The impact of early empathy on alliance building ...

This article was downloaded by: [Alberta Pos] On: 09 May 2014, At: 09:12 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Psychotherapy Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/tpsr20

The impact of early empathy on alliance building, emotional processing, and outcome during experiential treatment of depression a

a

Ashley J. Malin & Alberta E. Pos a

Department of Psychology, York University, Toronto, ON, Canada Published online: 07 May 2014.

To cite this article: Ashley J. Malin & Alberta E. Pos (2014): The impact of early empathy on alliance building, emotional processing, and outcome during experiential treatment of depression, Psychotherapy Research, DOI: 10.1080/10503307.2014.901572 To link to this article: http://dx.doi.org/10.1080/10503307.2014.901572

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions

Psychotherapy Research, 2014 http://dx.doi.org/10.1080/10503307.2014.901572

EMPIRICAL PAPER

The impact of early empathy on alliance building, emotional processing, and outcome during experiential treatment of depression

ASHLEY J. MALIN & ALBERTA E. POS Department of Psychology, York University, Toronto, ON, Canada

Downloaded by [Alberta Pos] at 09:12 09 May 2014

(Received 14 February 2013; revised 28 February 2014; accepted 3 March 2014)

Abstract Objective: This study examined the relationships among the therapist process of expressed empathy during first sessions, clients’ post-session one alliance reports, clients’ later working phase emotional processing, and clients’ final reductions in depressive symptoms for 30 clients receiving short-term experiential therapy for depression. Method: The therapist process of expressed empathy was assessed using a new observer-rated measure: the measure of expressed empathy, which was demonstrated to be valid and reliable. Results: Results indicate that therapist expressed empathy in session one significantly affected the outcome, albeit indirectly. This indirect effect occurred through two direct effects on other important therapy processes that did directly predict client outcomes: (i) Therapist expressed empathy in first sessions directly and positively predicted client reports of first-session alliances; and (ii) therapist expressed empathy directly predicted observer-rated deepened client emotional processing in the working phase of therapy. Conclusions: Empirical support was provided for the theorized relationships in experiential theory amongst the variables examined. Keywords: empathy; working alliance; emotional processing; experiential therapy; depression

This study investigated the importance of the process of therapist expressed empathy during first sessions of experiential therapy to both small “o” (session processes) and large “O” (therapy) outcomes (Greenberg, 1986) during experiential treatment of depression. The relationships among therapist expressed empathy, clients’ session one reports of the alliance, clients’ working phase emotional processing (WPEP), and clients’ post-therapy reports of reductions in depressive symptoms were explored. Depression is currently the leading cause of disease burden in high-income countries, and is forecast to become the leading cause of disease burden worldwide by 2030 (Ferrari et al., 2013; World Health Organization, 2004). While interpersonal, cognitive-behavioural, and experiential psychotherapies are all empirically validated and equally effective short-term treatments for moderately depressed adults (Elkin et al., 1989; Goldman, Greenberg, & Angus, 2006; Greenberg & Watson,

1998; Shea & Elkin, 1996; Watson, Gordon, Stermac, Kalogerakos, & Steckley, 2003), their effects can be considered modest (Westen & Morrison, 2001). As such, all treatments should be improved. To accomplish this, researchers must establish how these treatments work. It is often currently argued that after client factors (Lambert, 1992), common, rather than specific, factors are responsible for the lion’s share of client change in all psychotherapies. Empathy and the working alliance are two suggested common factors (see Norcross, 2011; Greenberg & Watson, 2006). Emotional processing (EP) has been suggested as a third common factor across all treatments for depression (Greenberg & Pascual-Leone, 2006 for a review; Pos, Greenberg, & Warwar, 2009; Teasdale, 1999). Common factors, however, are specifically implemented within different models of treatment (Goldfried, 2004). Therefore, the presumption of common factors does not excuse researchers from the task of empirically validating

Correspondence concerning this article should be addressed to Ashley J. Malin, Department of Psychology, York University, 4700 Keele Street Toronto, ON M3J 1P3, Canada. Email: [email protected] © 2014 Society for Psychotherapy Research


2

A. J. Malin and A. E. Pos

mechanisms of change within particular effective treatments. Wampold (2001) has suggested that this requires us to demonstrate that a theoretically informed implementation of a particular common factor (such as alliance development) within a specific model of treatment (such as experiential therapy) occurs and can predict client improvement. An additional concern, particularly related to research on the alliance, is the frequent use of transtheoretical measures, such as the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989), to operationalize the alliance. This often causes us to ignore exploring variables contributing to the development of the alliance within particular approaches. Horvath and Bedi (2002) have suggested attention be paid to these factors that influence alliance development, especially what the therapist does in session (therapist process) to predict good alliance formation. This study tested experiential theory concerning change, in particular the importance placed on therapists expressing empathy to alliance building, facilitating EP, and final outcomes, during experiential therapy for depression.

Empathy Empathy is a basic relational process (Elliott & Greenberg, 2007; Goleman, 1995; Rogers, 1959) and an important component of emotional intelligence. It is also a core relationship condition experiential therapists employ to establish the alliance and to support EP (Pos, Greenberg, & Elliott, 2008). Defined by Rogers (1959) as the ability to accurately perceive the internal frame of reference of another, including their emotional components and meanings, empathy is a complex higher-order construct. This means that therapists must utilize a full range of cognitive and emotional functions while responding empathically to clients. Therapist behaviours shown to significantly relate to client perceptions of empathy include: Therapists’ non-verbal behaviours [maintaining eye contact, having a concerned expression, and maintaining a forward lean or head nodding to convey an understanding (D’Augelli, 1974; Tepper, 1973; Watson, 2001)]; therapists’ speech characteristics [having similar rates of speech and vocal tones as their clients, responding just ahead of their clients, and not interrupting (Barrington, 1961; Elliott, Bohart, Watson, & Greenberg, 2011; Greenberg & Elliott, 1997)]; therapists’ response modes [conveying a sense of interest, having an equal level of emotional involvement as their clients, not conveying detachment or boredom (Caracena & Vicory, 1969; Tepper, 1973), use of emotion words (Barrington, 1961), provision of

exploratory responses rather than general advice (Barkham & Shapiro, 1986), and clearly communicated messages (Bohart & Greenberg, 1997; Caracena & Victory, 1969)]. Therapists’ characteristics such as being non-judgemental, attentive, and open to discussing any topic also have been shown to be important (Myers, 2000). Empathy and Alliance Formation Experiential theory assumes that therapists’ provision of empathy is the foundation upon which the alliance is constructed. Experiential therapists are directed from the first moments of therapy to engage in and provide an empathically attuned relationship for the purpose of promoting safety and facilitating alliance development (Greenberg & Watson, 2006; Pos et al., 2008; Rogers, 1975). In fact, significant positive associations between empathy and the working alliance have been found across a number of therapeutic approaches. Salvio, Beutler, Wood, and Engle (1992) found moderate-to-large correlations between clients’ ratings of empathy and the alliance, both measured after session 20 for clients receiving various types of therapy for depression. Horvath (1981) and Mosely (1983) both found moderateto-large correlations between clients’ ratings of empathy and the alliance after the third session of various types of therapy. Finally, Wing (2010) found a significant moderate correlation between observer ratings of therapist empathy and alliance formation for clients receiving psychodynamic psychotherapy. The present study, however, tests experiential theory concerning the particular importance of first-session therapist empathy to initial alliance building or later therapy processes and outcome. The importance of first-session alliances during experiential therapy for depression has been highlighted by Pos et al. (2009) who found that even after controlling for growth in the alliance and deepening of EP across therapy, clients’ reports of the alliance after first sessions directly predicted all outcome measures. Therefore, alliance-related factors operating within the very first hour of experiential therapy appear to be important for clients’ final outcomes. A long-held assumption that three to five sessions are required to develop an alliance has resulted in the majority of alliance research not adequately examining alliance development in initial sessions nor the potential ramification of first-session alliances to later processes and final outcomes (see Horvath & Bedi, 2002 for a review). Support for examining first-session alliances is offered by dynamic systems theory that argues that initial conditions within any process set the course for its later developmental trajectory (van Geert, 1996). Furthermore, experiential theory

Psychotherapy Research (Greenberg & Watson, 2006) and recent experiential process research (Pos et al., 2009; Wong & Pos, 2014) suggest that alliance building in the initial hour can considerably influence therapy process and outcome. Therefore, for both empirical and theoretical reasons the importance of examining first sessions and empathic process in first sessions is underlined.


Empathy and EP Experiential theory also assumes that EP is a core change process in experiential therapy (PascualLeone & Greenberg, 2007; Pos, Greenberg, Goldman, & Korman, 2003; Pos et al., 2009). Within experiential psychotherapy, adaptive EP is seen as involving an integration of cognitive and affective components (Greenberg, 2002) and consisting of a series of stages (Pos et al., 2003; Pos & Greenberg, 2007). Clients learn to approach, be aware of and tolerate contact with emotions, cognitively orient to and make meaning of emotional information, and finally transform emotion by accessing adaptive emotional resources (Pos & Greenberg, 2007). Through this process, new emotional reactions and meanings can emerge that can be integrated into cognitive–affective meaning structures and subsequently change them (Pos, Greenberg, & Goldman, 2005). Experiential therapists are taught that providing an empathically attuned relationship from the start of therapy will facilitate clients’ EP by helping them feel safe enough to move their attention away from interpersonal concerns towards engaging fully in the therapy task of approaching their feelings (Pos, 2006; Watson, Goldman, & Vanaerschot, 1998). Developmental researchers also agree that therapist empathy can facilitate EP and believe that it does so by helping to heal empathic failures that were experienced during childhood (Paivio & Laurent, 2001). Although the relationship between therapist empathy and later EP is assumed to exist, it has not yet been empirically tested. Some evidence of this relationship was found by Steckley (2006) who demonstrated that clients who perceived their therapists as being empathic experienced structural changes in their internal models of self and other, and treated themselves and others less negatively (were less destructive, controlling, oppressing, critical, rejecting, careless, and neglecting) by the end of therapy. All of these positive self-changes were also associated with more favourable treatment outcomes (Steckley, 2006). Empathy and Outcome The alliance and EP have already been demonstrated to be robust predictors of psychotherapy outcome in

3

experiential therapy for depression (Pos, Greenberg, Goldman, & Korman, 2005; Pos et al., 2009). Empathy also has been demonstrated to be a moderately strong predictor of and to account for approximately 9% of the variance in psychotherapy outcome across many models of intervention (Elliott et al., 2011). Furthermore, empathy has been demonstrated to account for as much or more variance in outcome than specific psychotherapeutic interventions (Bohart, Elliott, Greenberg, & Watson, 2002). Other variables such as expressing understanding, being attentive, and being openly receptive to clients’ perspectives have also been associated with successful outcomes (Henry, Schact, & Strupp, 1986; Watson, Enright, & Kalogerakos, 1998) and are identified as important to perceived empathy.

Empathy Measures Therapist empathy has been measured by client reports, therapist reports, assessing therapist and client perceptual congruence of therapist empathy, or by observer ratings of expressed empathy (Elliott et al., 2011; Watson & Prosser, 1999/2002). Research has consistently shown that client-rated measures are the best predictors of psychotherapy outcome, followed closely by observer-rated measures (Elliot et al., 2011; Watson & Prosser, 1999/ 2002), with therapist-rated measures being the least predictive (Bohart et al., 2002; Elliott et al., 2011). Degree of therapist and client perceptual congruence has been found to be unrelated to psychotherapy outcome (Elliott et al., 2011). The Barrett-Lennard Relationship Inventory (BLRI; Barrett-Lennard, 1986) is the best known and most widely used client-rated measure of therapist empathy that assesses clients’ perceptions of empathy, as operationalized by Rogers (1957; Elliott et al., 2011). Using this measure, clients rate the extent to which they experience the therapist as genuine, prizing, or empathic during the therapy session. Two early observer-rated empathy measures designed by Truax and Carkhuff (1967) and Carkhuff and Berenson (1967) also widely used in the past have been criticized for not adequately reflecting client-centred (CC) conceptions of empathy as an attitude and for focusing exclusively on empathic reflections (Lambert, De Julio, & Stein, 1978; Watson & Prosser, 1999/2002). In the present study, we employed a relatively new observer-rated measure: The measure of expressed empathy (MEE; Watson & Prosser, 1999/2002). It differs from other measures in that it is based on the behavioural correlates of empathy identified in previous research (Barrington, 1961; Bohart & Greenberg, 1997; Caracena & Victory, 1969; D’Augelli, 1974; Elliott et al., 2011;

4


Greenberg & Elliott, 1997; Tepper, 1973; Watson, 2001) and evaluates both therapists’ verbal and nonverbal behaviour, including speech characteristics and response modes. Unlike client-rated measures, such as the BLRI that assesses clients’ global perceptions of empathy, the MEE measures specific components of expressed empathy (Watson & Prosser, 1999/2002). Due also to the fact that we were interested in testing theoretical assumptions concerning observable (not perceived) therapist behaviours that relate to later client reports and experiences, the MEE was assumed to be an optimal measure of therapists engaging in the process of expressing empathy.


Current Study The hypotheses of the current study are summarized as follows: (i) Since the experiential assumption is that therapist empathy in session one is a key therapist process, the first hypothesis is that therapist expressed empathy in session one will positively predict post-session one client-rated alliance scores. (ii) Another experiential assumption is that therapist empathy is directly essential to facilitating EP. Therefore, hypothesis two is that therapist expressed empathy in first sessions will positively predict EP in the working phase of therapy. Finally, our last hypothesis concerns empathy’s relationship to outcome. Given that therapist empathy in session one is assumed to facilitate two important change processes (i.e., the formation of the working alliance and later EP) that predict outcome in this therapeutic modality, and that therapist empathy measured later on in therapy has been found to be predictive of outcome, we expected that therapist expressed empathy measured in session one would directly predict outcome as well.

Research Design and Method Participants Due to the exploratory nature of the present study, the sample consisted of 30 clients with the lowest (LA) and highest post-session one alliance (HA) ratings selected from a larger sample of 74 clients who received short-term (16–20 sessions) treatment in two York University trials of experiential psychotherapy for depression (Goldman et al., 2006; Greenberg & Watson, 1998). Both trials compared the effectiveness of two experiential treatments: CC therapy and emotion-focused therapy (EFT). All subjects met criteria for major depressive disorder on the Structured Clinical Interview (SCI; Spitzer, Williams, Gibon, & First, 1989) for the Diagnostic

and Statistical Manual of Mental Disorders (DSM-III-R; APA, 1987). All 30 clients completed treatment. For information on the original screening, assessment, and treatment procedures, see Greenberg and Watson (1998) and Goldman et al. (2006). The inclusion criteria were: A score of 16 or greater on the Beck Depression Inventory (BDI-LF; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), a score greater than 50 on the Global Assessment of Functioning on the DSM-III-R, and being between the ages of 18 and 65 at the time of assessment. Exclusion criteria were: Current drug or alcohol abuse; bipolar or psychotic disorder, current eating disorder, antisocial or borderline personality disorder; recent suicide attempts; a past history of incest; the loss of a significant other in the past year; or involvement in an ongoing violent relationship. These criteria assured that severely depressed, functionally impaired subjects were excluded (Elkin et al., 1989). Clients (n = 18) in the HA group ranged in age from 26 to 55 (M = 38.89, SD = 9.88) and clients in the LA group (n =12) ranged in age from 31 to 63 (M = 48.92, SD = 10.22). Clients in the HA group were 75% (n = 9) female and 25% (n = 3) male, while those in the LA group were 72.2% (n = 13) female and 27.8% (n = 5) male. No significant differences were found between HA and LA groups in terms of marital status, gender, or type of therapy received (CC or EFT). Significant differences between HA and LA groups in age and education status were found. Clients in the HA group were younger (M = 38.89, SD = 9.88) versus the LA group (M = 48.92, SD = 10.22), p = .01, and tended to have higher education statuses than those in the LA group, p < .05. However, since age or education did not predict any therapy process measures they were not included as predictors in any analyses. Therapists There were 16 therapists in this study: 4 males and 12 females. Twelve were clinical psychology doctoral students (2 male, 10 female), two (one male and one female) were psychiatrists, and three (two male and one female) were psychologists. Two therapists had clients in both HA and LA groups, while eight therapists had clients in the HA group only and six therapists had clients in the LA group only. Therapists received 40 hr of manual-based training, supervision by licensed psychologists, and adherence monitoring. Treatments Two experiential therapies were used: CC therapy (Rice, Greenberg, & Watson, 1994; Rogers, 1957,

Psychotherapy Research


1975) and EFT (Greenberg, Rice, & Elliott, 1993; Greenberg & Watson, 2006). Clients were randomly assigned to treatment. For both approaches, the primary goal during the first three sessions is for therapists to provide empathic attunement to promote the formation of a strong therapeutic alliance and facilitate a deepening of clients’ EP (Pos et al., 2008). Thus, therapy process does not differ between CC and EFT within the first three sessions. The core goal of both therapies is to deepen the client’s emotional and experiential processing. Adherence was measured and achieved in both conditions (see the original outcome reports Goldman et al., 2006; Greenberg & Watson, 1998). CC therapy. This therapy followed a manual based on Rogers (1957, 1975; Rice et al., 1994). In CC therapy, therapists provide the necessary facilitative relationship conditions: Unconditional positive regard, empathy, and congruence. Following the clients’ internal track, therapists communicate empathy, facilitate exploration, encourage symbolization of core meaning, and increase emotional awareness. Emotion-focused therapy. In this therapy, therapists, after session three and within the context of a CC relationship, use marker-guided, processdirective interventions intended to promote optimal EP. Specific emotional problem markers are used to determine matched interventions. Four interventions used in the study were: Two-chair dialogue for selfevaluative conflict; empty-chair dialogue for unfinished business with a significant other; focusing on an unclear felt sense (Gendlin, 1997); and systematic evocative unfolding for problematic or confusing (to the client) affective reactions. Currently, there are two manuals for the use of this therapy for depression (Greenberg et al., 1993; and Greenberg & Watson, 2006). Process Measures Measure of expressed empathy. This is an observer-rated measure of therapist-communicated empathy that evaluates therapists’ verbal and nonverbal behaviours, speech characteristics, and response modes (Watson & Prosser, 1999/2002). It consists of 10 dimensions that are rated on a 9-point Likert scale (from 0 = “never” to 8 = “all the time”) based on the percentage of time that the behaviour was present during the rated segment. A global empathy score is calculated as the average of the 10 subscale ratings. Internal consistency for the scale, as assessed by scale developers, is high (α = .88). Construct validity is provided by a large and

5

significant correlation (r = .66, p < .01) with client ratings of empathy, as measured by the BarrettLennard Relationship Inventory (BLRI; BarrettLennard, 1962), a well-validated client-rated measure of empathy, and the fact that it is based on empirically validated behavioural predictors of empathy. The 10 therapist expressive dimensions assessed by the MEE are: (i) Vocal concern: The extent to which the therapist’s voice has a soft resonance with a grounded open quality; (ii) vocal expressiveness: The extent to which the expressiveness in the therapist’s voice varies appropriately in energy, colour, and pitch to respond to the nature of the client’s subject matter; (iii) vocal matching: The degree to which the therapist’s vocal response quality appropriately matches and/or holds the intensity of emotion that the client is experiencing; (iv) warmth and interpersonal safety: The degree to which the therapist communicates an atmosphere of warm safety through soft expressiveness, smiling, and eye contact; (v) responsive attunement: The extent to which the therapist tracks and responds to the client’s moment-to-moment experience (including facial and/ or non-verbal behaviours that may differ from verbal content); (vi) look of concern: The extent to which the therapist appears caring, engaged, and involved (not bored or disinterested); (vii) responsiveness/following: The extent to which the therapist adjusts responses to follow the client’s track rather than lead session content; (viii) understanding experience: The degree to which the therapist generally communicates sensitive understanding of the significance of the client’s inner world of emotional meaning relating to events being discussed; (ix) understanding cognitive meaning: The degree to which the therapist conveys accurate understanding of the client’s cognitive meaning framework by following and understanding both their client’s narratives as well as the client’s idiosyncratic construals explicit or implicit in these narratives; (x) therapist genuineness/acceptance: The extent to which the therapist communicates that they value and prize the client and appears sincere, authentic, and genuine (Watson & Prosser, 1999/2002). Working alliance inventory. This is a 36-item measure of the therapeutic alliance rated on a 7-point Likert scale composed of three subscales that each assesses the client–therapist bond, client– therapist agreement on the tasks, and goals of therapy (Horvath & Greenberg, 1986, 1989). The internal consistency of the entire scale is reportedly high (.87–.93) as is it for the individual subscales (.92 for Bond, .90 for Task, and .89 for Goal; Horvath & Greenberg, 1986, 1989). There is a short-form (12-item) version with comparable

6



psychometric properties (Tracey & Kokotovic, 1989). Client-rated short forms were used in this study. The experiencing scale. This scale measures the degree to which clients orient to, symbolize, and use internal felt experience to inform problem–solving (Klein, Mathieu-Coughlan, & Kiesler, 1986). Ratings are given on a 7-point ordinal rating scale and are assigned to segments of psychotherapy based on grammatical, expressive, paralinguistic, and content distinctions indicative of different degrees of experiencing. Ratings from 1 to 4 describe the progressive movement of orientation from external to internal referents, while ratings from 5 to 7 describe the progressive use of experienced inner perspectives in affective problem-solving. Inter-rater reliability coefficients have been reported to range from .76 to .91, and rating or re-rating coefficients of .80 have been reported (Pos et al., 2009). This scale was applied to emotion episodes (EEs; narrative segments within which clients described real or imagined emotional experiences; see Pos et al., 2009) in this study.

Session Outcome Measures General session evaluation questionnaire. The General Session Evaluation Questionnaire (GSEQ; Watson & Greenberg, 1996) consisted of five 7-point Likert items: Three taken from Orlinsky and Howard’s (1975) therapy-session evaluation measure (inter-item reliability was .75), and two items tapping a factor reflecting task helpfulness (Elliott, 1985) in therapy (inter-item was reliability .83; Warwar, 1995). These questions asked: (i) How clients globally felt about the session that had occurred, (ii) the degree to which they found their therapist helpful, (iii) the degree of progress they felt they were making as a result of the session, (iv) the degree to which they experienced a change or shift as the result of the session, and (v) the degree to which they felt they wanted to take a new course of action as a result of the session. Client task-specific measure. The client taskspecific measure (CTSM) tracks post-session progress on the main tasks of treatment (Greenberg & Safran, 1991; Greenberg et al., 1993). It consists of 12 items that are rated by clients on a 7-point Likert scale. Three items each are related to: Self-critical processes, problematic reactions, unfinished business with a significant other, and experience of the therapist’s client-centredness, respectively.

Outcome Measures The beck depression inventory. This is a 21-item self-report inventory designed to measure severity of depression (Beck, 1972; Beck et al., 1961). Higher scores reflect greater severity of depression (range = 0–63). Beck, Steer, and Garbin (1988) report validity coefficients ranging from .66 to .86, and internal consistency coefficients ranging from .73 to .93. Outcome scores for the BDI in this study were clients’ residual gain scores calculated from the larger combined York 1 and 2 samples. Analyses were also duplicated using post-therapy BDI scores.

Procedure Defining alliance groups. The sample of 74 participants from the original two randomized controlled trials was rank-sorted from LA to HA session-one WAI scores. A WAI score of 5 or above, indicating that clients are at a minimum “often” agreeing with WAI items, was the criterion for a high alliance (Pos & Thompson, 2010). Thirteen clients had low alliances with mean WAI scores below 5, and 18 clients had WAI scores of above 5. The WAI scores in the HA group ranged from 5.42 to 7.00 (M = 6.11, SD = .50), and WAI scores in the LA group ranged from 3.58 to 4.67 (M = 4.19, SD = .37). Scoring EP. EP ratings used in this study were archival from Pos et al.’s (2009) study. EP was measured as experiencing during EEs (EE-EXP; see Pos et al., 2009). EEs (Greenberg & Korman, 1993) are segments of psychotherapy in which clients speak about having experienced emotion in response to a real or imagined situation (see Greenberg & Korman, 1993; Pos et al., 2003). Reliability between raters for sampling EEs was excellent. Pos et al. (2009) reported that raters agreed 92% of the time on the identified EE and its protocol. EP in the present study was defined as average modal (most frequently expressed) EEEXP across all EEs from the working-phase sessions from Pos et al.’s (2009) study. These were two sessions between the fourth and fourth to last sessions (on average between sessions 8 and 10) which clients had reported as having been the most helpful. Helpfulness was defined as that session having resulted in the most progress, the highest degree of shift or change (on the GSEQ), and the highest degree of task resolution (on the CTSM). The average interrater reliability reported for EE-EXP ratings was excellent (weighted Cohen’s Kappa reported = .79; Pos et al., 2009).

7

Psychotherapy Research


MEE training. Six MEE raters (graduate students and clinical faculty) received 40 hr of training from MEE experts and Jeanne Watson, the scale developer, from the University of Toronto. Interclass correlation coefficients between trained raters and experts for ratings on 13 five-min video segments were used to establish reliability, and ranged from .89 to .99 (excellent). MEE rating procedure. As required by the MEE manual, the 31 videos of first sessions were each segmented into 5-min time bins for rating (i.e., 1-hr video = 12 five-min time bins). For the present study, the raters who were most reliable with the MEE experts from the training phase independently and fully rated all 5-min time bins within a session video on each of the 10 scale dimensions. Disagreements were discussed. Consensual ratings were obtained and used in the analysis. Rater’s preconsensual ratings were used to establish reliability. Coding procedure. In order to arrive at sessionlevel empathy ratings for the MEE dimensions, the ratings for all time bins for each dimension across the session were averaged. A total empathy score was then calculated as an average of the dimension scores.

Results The Measure of Expressed Empathy Inter-rater reliability. Inter-rater agreement for total MEE scores was excellent, intraclass correlation coefficient (ICC) = .85, and ranged from good to excellent for each of the dimensions, ICCs = .62–.82 (Portney & Watkins, 2000; Shrouf & Fleiss, 1979). Internal consistency. Cronbach’s alphas for each of the 10 subscales and total MEE scores were calculated. Internal consistency for the MEE total score was high, α = .98, and ranged from good to excellent (α = .72 to α = .99) for the individual dimensions. Factors. Two factor analyses were conducted to confirm that the MEE constructs were loaded onto a single factor (empathy). One employed the maximum likelihood method and the other employed a principle components analysis. Neither analysis yielded significant sub-factors amongst the 10 dimensions, indicating one overall expressed empathy factor.

Therapist Expressed Empathy Mean ratings and standard deviations of observer ratings of therapist expressed empathy measured as a total MEE score as well as by subscale scores are presented in Table I. Consistent with expectations driven by the experiential therapy model, the mean global rating of therapist expressed empathy as well as mean ratings for all 10 MEE dimensions across therapists was in the high range (>6 or rated as occurring over 75% of the time). Therapist dimensions of “looking concerned” and “responsiveness” had the highest average ratings and lowest standard deviations, indicating that these therapist behaviours were rated as the ones most consistently present. The dimensions of “matching” and “attunement” had the lowest average ratings and highest standard deviations, indicating that experiential therapists varied most on providing these empathic dimensions.

Hypothesis One: Session one Therapists’ Expressed Empathy Will Significantly Relate to Clients’ Post-Session Alliance Reports Hypothesis one was supported. An independent samples t-test indicated significant differences in therapist expressed empathy between the high (HA) versus low alliance (LA) groups, t(28) = 3.15, p < .01. Therapists in the LA group were rated significantly lower on average total expressed empathy (M = 6.44, SD = .53) than those in the HA group (M = 6.93, SD = .32; Table II) The relationships among ratings on both total MEE and dimensions of the MEE during session one and clients’ post-session one alliance reports can be found in Table III. Due to the exploratory nature of this study, the Pearson correlations were not corrected for family-wise error and should be interpreted accordingly. Higher session-one therapist global MEE scores related to clients reporting more positive therapeutic alliances with their therapist by Table I. Subscale and total scale means of the MEE. MEE dimension

Mean

SD

Max

Min

MEE total Vocal concern Vocal expressiveness Matching Warmth/safety Attunement Looking concerned Responsiveness Understanding experience Understanding meaning Genuineness/valuing

6.74 6.73 6.62 6.58 6.68 6.59 6.93 6.82 6.82 6.80 6.81

0.48 0.46 0.48 0.59 0.55 0.68 0.33 0.40 0.54 0.56 0.52

7.00 7.48 7.50 7.48 7.58 7.53 7.43 7.46 7.48 7.60 7.63

3.58 5.00 5.36 4.75 5.03 4.61 5.78 5.67 4.72 5.11 5.56

Note. N = 30.

8

A. J. Malin and A. E. Pos with clients’ WPEP. Therapist “vocal expressiveness” and “understanding experience” had the largest relationships with WPEP. A hierarchical regression analysis determined whether client-rated alliance after session one could predict clients’ WPEP once the early alliance was controlled. These results are presented in Table IV. In the full final model, neither therapist expressed empathy nor client-rated session-one alliance independently predicted clients’ WPEP. The overall model containing both variables was not significant, F(2, 27) = 2.7, p = .11. There was a trend (p = .07) however, for therapists’ MEE scores predicting clients’ WPEP scores. Another hierarchical regression tested the possibility that the two empathic dimensions with the strongest relationships with WPEP might independently predict WPEP once the early alliance was controlled. A combined score for “vocal expressiveness” and “understanding experience” was used in this analysis. Results are presented in Table V. The overall model was significant, F(2, 27) = 4.37, p < .05, and the combined score of these two MEE dimensions did significantly and independently predict clients’ WPEP, accounting for 24% of the variance. Clients’ post-session one WAI ratings did not significantly predict WPEP in this regression.

Table II. Therapist ratings on the MEE as a function of WAI group. Alliance group

Mean MEE

SD

Max

Min

6.44

0.53

7.32

5.16

6.93

0.32

7.37

6.31

LA group (mean WAI = 4.19, SD = 0.37) HA group (mean WAI= 6.11, SD = 0.50)


Note. N = 30. LA, low alliance; HA, high alliance.

the end of that session (r(28) = .54, p < .01). Higher therapist scores on each of the 10 MEE dimensions were also significantly and moderately positively correlated with post-session one WAI scores. Therefore, higher ratings on all 10 therapist behavioural dimensions related to significantly higher clientrated post-session one alliances. Therapist matching, warmth/safety, and attunement had the largest correlations with the WAI scores, while therapists’ look of concern had the smallest correlation with the WAI scores.

Hypothesis Two: Therapists’ Expressed Empathy in Session One Will Relate to Clients’ Working Phase Emotional Processing Hypothesis two was also supported. Pearson correlations between therapists’ session-one expressed empathy and clients’ WPEP are also presented in Table III. Therapists rated by observers as higher on total expressed empathy in session one were more likely to have clients with deeper modal EE-EXP during the working phase of therapy. All but two dimensions (“responsiveness” and “understanding meaning”) showed significant positive relationships

Hypothesis Three: Therapist’s Expressed Empathy in Session One will Directly Predict Outcome Hypothesis three was not supported. Pearson correlations of the relationships between therapists’ expressed empathy in session one, session-one alliance, WPEP, and outcome on the BDI are presented

Table III. Pearson correlations among session-one expressed empathy, post-session one working alliance and WPEP. Process variables (1) WPEP (2) WAI (3) MEE total (4) Vocal concern (5) Vocal expressiveness (6) Matching (7) Warmth/safety (8) Attunement (9) Looking concerned (10) Responsiveness (11) Und. experience (12) Und. meaning (13) Genuine/valuing

2

3

4

5

6

7

8

9

10

11

12

13

.44*

.44* .54** .92 – – – – – – – – – –

.39* .45* .92 .89 – – – – – – – – –

.49* .46* .98 .89 .91 – – – – – – – –

.39* .55** .99 .91 .94 .98 – – – – – – –

.42* .55** .96 .80 .83 .95 .94 – – – – – –

.39* .54** .84 .85 .80 .77 .82 .69 – – – – –

.39* .40* .77 .64 .67 .68 .73 .72 .66 – – – –

.35 .49* .97 .91 .86 .93 .94 .93 .82 .78 – – –

.46* .51** .95 .81 .78 .92 .91 .97 .75 .72 .94 – –

.36 .52** .93 .86 .85 .92 .93 .90 .73 .54 .86 .88 –

.40* .46* .92 – – – – – – – – – –

Note. N = 30. WPEPm = average modal experiencing during emotion episodes during working phase sessions; working phase = sessions identified by clients as the most helpful on session measures; MEE dimensions: Vocal concern, vocal expressiveness. Matching, warmth/ safety, attunement, looking concerned, responsiveness. Und. experience, und. meaning, genuine/valuing. WAI, Working Alliance Inventory; MEE, measure of expressed empathy. *p < .05; **p < .01. When not corrected for family-wise error, simple Pearson r > .39 is significant at p = .05, r > .54 is significant at p = .01.

9

Psychotherapy Research Table IV. Hierarchical regression predicting WPEP with therapist expressed empathy and the working alliance. Variables Step 1 Therapist expressed empathy Step 2 Therapist expressed empathy Working alliance S1

Total R2

▵R2

F change

df

.19

.19

6.52*

1, 28

β

.44* .19

.00

.19

1, 27 .39 .09

Note. Therapist expressed empathy, measured by MEE. Working alliance formation, measured by WAI. WPEP, measured by EXP scale. *p < .05.


empathy in session one significantly contributed to more favourable psychotherapy outcomes by contributing to two other therapy processes.

in Table VI. Both post-session one WAI and working phase EE-EXP scores were significantly and positively correlated with BDI residual gain scores, while therapists’ MEE scores were not. Therefore, no direct relationship between therapist expressed empathy in session one and outcome for depressive symptoms was indicated. Indirect prediction. Since expressed empathy was directly related to client-rated alliances and clients’ WPEP, and both of these processes directly predicted outcome, one remaining question was whether the alliance and EP variables mediated significant indirect effects of expressed empathy on outcome. These concurrent indirect effects were explored using path analysis using AMOS (Arbuckle, 2007) and Sobel tests. Therapist expressed empathy was found to significantly affect outcome through two indirect effects: One on post-session one WAI ratings, Sobel z = −2.14, p = .02, and the other on WPEP scores, Sobel z = −1.79, p = .04. The final path diagram of processes predicting outcome is shown in Figure 1. Given the sample size, we ran bootstrap analyses as suggested by Preacher and Hayes (2008) which yielded similar results (estimates remained unaffected). The hypothesized, AMOS model also had good fit statistics (see Table VII for fit statistics with acceptable values). Therefore, high therapist expressed

Discussion Experiential therapists are mandated to provide empathic attunement from the first moments of therapy in order to facilitate both positive working alliances and clients’ EP. This study is the first to test experiential assumptions concerning empathy’s role in strengthening the early therapy alliance, clients’ EP, and outcomes in experiential treatment for depression. Therapist Expressed Empathy and Early Alliance Formation Consistent with experiential theory and as originally hypothesized, therapist empathy expressed during the first session as rated by observers directly predicted clients’ post-session one alliance reports. Clients who had therapists rated as more empathic in first sessions tended to rate their working alliance with their therapist more favourably. This was true for specific empathic dimensions as well as global empathy operationalized as an average of 10 empathic dimensions. “Vocal matching,” “therapist warmth and interpersonal safety,” and “responsive attunement” are the empathic behaviours that were most positively associated with session one alliance formation. These empathic behaviours are also identified in infant and neuropsychological literatures as important to the development of emotional regulation capacities (Porges, 2004; Schore, 2001; Stern, 2000). Therefore, it may be that these therapist behaviours in particular help clients emotionally regulate from the first moments of therapy, and may also be especially important to quickly building a therapeutic relationship. Since the alliance as measured by the WAI is operationalized as feeling bonded with the therapist, and also as agreeing on tasks and goals of therapy, a question might be whether empathy contributed especially to one of

Table V. Hierarchical regression predicting WPEP with two dimensions of therapist expressed empathy and the working alliance. Variables

Total R2

▵ R2

F change

Step 1 Vocal expressiveness + Understanding experience Step 2 Vocal expressiveness + Understanding experience Working alliance S1

.24

.24

8.90*

1, 28

.24

.00

.12

1, 27

df

β

.49** .46* .07

Note. Vocal expressiveness + understanding experience, combined MEE variable. Working alliance formation, measured by the WAI. Working phase emotional processing, measured by EXP scale. *p < .05; **p < .01.

10


Table VI. Pearson correlation matrix relating therapist expressed empathy, the working alliance, WPEP and outcome.

Table VII. Summary of goodness of fit indices for the path analysis model.

Variables

1

2

3

4

Model

MEE total WAI WPEPm BDIres

– – – –

.54** – – –

.44* .30 – –

−.26 −.52** −.49** –


MEE, measure of expressed empathy; WAI, working alliance inventory; WPEPm, modal working phase EE-EXP score; BDIres, BDI residual gain score. *p < .05; **p < .01.

these subscales of the WAI; however, expressed empathy did not relate more strongly to any subscale in the present study. This may be the result of how related the experience of a safe bond and agreement on EP as both task and goal of therapy are in an experiential approach. In another model of therapy (dynamic therapy perhaps), therapist expressed empathy might relate more strongly to the experience of the therapy bond (Gelso & Carter, 1985).

Therapist Expressed Empathy and WPEP This study also tested the experiential assumption that empathy contributes to an environment in which clients can turn their inward attention towards processing their emotional experiences. Clients with therapists rated as more empathic in the first session were those who were processing their emotions significantly better, approximately eight sessions later. This is important given that WPEP has been found to be the most important direct predictor of outcome in experiential therapy for depression (Pos

.43** MEE_S1

WAI_S1

–.37*

. 54***

.38 –.41** WPEPm

BDI

Figure 1. Final model predicting BDI residual gain scores. MEE_S1, therapist scores on the measure of expressed empathy in session 1; WPEPm, modal working phase emotional processing scores on the EXP scale; WAI_S1, clients’ post-session one ratings on the working alliance inventory; BDI, residual gain scores on the BDI. Signiﬁcant indirect effect of MEE on BDI outcome through post-session one WAI ratings, Sobel z = −2.14, p = 0.02, and signiﬁcant indirect effect of MEE on BDI outcome through working phase emotional processing scores, Sobel z = −1.79, p = .04. *p < .05; **p < .01; ***p < .001.

BDI

p for χ2

RMSEA

CFI

SRMR

.534

.00

1.00

.020

Note. Good fit indicated by a chi-square p value greater than .05, a root-mean-square error of approximation (RMSEA) value less than or equal to .05 (.95 very good fit), and a standardized root-mean-square residual (SRMR) less than .05 (