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Introduction
Across psychotherapeutic approaches, therapist empathy has been identified as an important nonspecific factor in treatment (Elliott, Bohart, Watson and Greenberg, 2011; Luborsky, Singer and Luborsky, 1975) and found to exert medium-sized but variable effects on client outcomes (Bohart, Elliott, Greenberg and Watson, 2002; Elliott et al., 2011). Definitions of therapist empathy have varied (Bohart and Greenberg, 1997), though they generally have emphasized the therapist's ability to understand the client's experience and communicate this understanding to the client (Rogers, 1957; Truax and Carkhuff, 1967). The expression of therapist empathy within sessions is considered a complex process (Bohart et al., 2002; Greenberg and Rushanski-Rosenberg, 2002) comprised of several components: affective (relating and responding to the client's emotions with similar emotions); cognitive (the intellectual understanding of client experiences; Duan and Hill, 1996; Gladstein, 1983); and attitudinal as demonstrated by warmth and acceptance (Greenberg and Rushanski-Rosenberg, 2002). Other components include the ability to set aside one's own views to enter the client's world without judgment or prejudice (Rogers, 1975), and attunement to momentary changes in the client's presentation, meaning, or concerns (Thwaites and Bennett-Levy, 2007; Watson, 2002; Watson and Prosser, 2002).
A review of behavioral correlates of therapist empathy suggests that therapists may demonstrate empathy in session in several ways, including: 1) communicating with an interested, concerned, expressive tone of voice; 2) demonstrating a level of emotional intensity similar to the client's; and 3) reflecting clients' statements, nuances in meaning, or unsaid but implied meanings back to them (Watson, 2002). While often considered an interactional process between therapist and client (Barrett-Lennard, 1981), therapist empathy seems to vary more between therapists than to fluctuate within therapists across the clients they treat (Truax et al., 1966). Therefore, most discussions of therapist empathy have focused on therapists' behaviors and experiences rather than their clients' reactions to the therapists per se.
Therapist empathy assessment methods include therapist self-report ratings (Barrett-Lennard, 1962; King and Holosko, 2011), client ratings (Barrett-Lennard, 1962; Mercer, Maxwell, Heaney and Watt, 2004; Persons and Burns, 1985), written analogue tasks (Miller, Hedrick and Orlofsky, 1991), and observer ratings (Elliott et al., 1982; Truax and Carkhuff, 1967; Watson, 1999). Therapist self-reports have been shown to be unreliable, with therapists over-rating their empathy as compared to...