Is Low Therapist Empathy Toxic?

» Posted by on Feb 6, 2014 in Alpha Blog | 0 comments

by Steven Bengis, David S. Prescott, and Joan Tabachnick



How important is the ability of a therapist to demonstrate client empathy and attunement to the therapeutic outcome?


The Research

In 2012, Theresa Moyers and William Miller reviewed studies in the alcohol and substance abuse addiction fields to determine the relevance of demonstrated therapist empathy with adult clients. The measured outcome was a reduction in observable addictive behaviors in the clients. For this paper, Moyers and Miller defined accurate empathy from a Rogerian perspective as a:

“commitment to understanding the client’s personal frame of reference and the ability to convey this heard meaning back to the client via reflective listening….the process encompasses the accurate understanding of both cognitive and emotional aspects of the client’s experience as well as attunement to the unfolding experience of a client during a treatment session.”

Study after study has found that, more than any variance in therapeutic approach, client perceptions of therapist empathy (and similar qualities observed by researchers during sessions) are directly correlated with more positive outcomes. The results of many of the studies were startling. For example, beginning in the 1980’s studies were demonstrating results that showed the number of drinking days were at least four times higher when the client was treated by low-empathy therapists (Valle, 1981). Other studies found that clients would have had better outcomes with a self-help book than a low-empathy therapist, while high-empathy therapists were far superior to bibliotherapy. The trends of these results have continued to the present, show variability between therapists having more to do with outcomes than differences between clients (Baldwin et al, 2007).

Given the importance then of empathy, the authors question whether agencies shouldn’t pre-screen counselors for empathy as a part of the hiring process. Although no paper-and-pencil measure can do this reliably, the authors have developed a procedure in which the applicants submitted a 20-minute work sample of a conversation on one of two topics: “What it was like growing up in my home?” or “How I came to the work in this field.” Successful candidates needed to make one reflective statement for every open-ended question they asked. Their results indicate that even this rudimentary process will predict later performance in actual treatment sessions.

The authors conclude that: 1) High-empathy counselors appear to have higher success rates regardless of their therapeutic practice; 2) Pre-screening therapists for empathic skills (as well as training them in how to be empathic) may contribute to better treatment outcomes.

Obviously, more research is needed on the therapist qualities, especially with adolescents who have sexual behavior problems.

Implications for Professionals

Although in the NEARI Press newsletter, we typically choose articles that focus on adolescents and not adults, these findings are vital to consider in work with sexually abusive adolescents. This review, like others, has found that a client’s perception of his/her therapist’s ability to listen, reflect, and attune has as much to do with treatment outcomes, resistance to treatment interventions, and a willingness to remain in treatment as does any technique to which the therapist may be wedded. Further, advising and teaching may increase resistant behavior (one study indicated a 70% increase in resistance using a directive vs. a client-centered approach) while confrontation, shaming or authoritarian approaches can result either in no change in clients or adverse outcomes. The available research suggests that when faced with resistant clients or those who are failing to make progress, perhaps an honest assessment of our ourselves and our own compassionate, reflective, and empathic capabilities may be equally important to moving through resistance as any discussion of our clients.

Implications for the Field

The vast majority of both research and professional discourse (e.g., workshops in conferences, list serve discussions and published articles) tend to focus on the identification of risk factors, best treatment techniques, the variability in client typologies, etc. Until quite recently, too little attention has been paid to the therapeutic and healing qualities of the therapist administering a range of either assessment or treatment protocols. While we are looking at whether cognitive-behavioral, multi-systemic, or other approaches lead to better treatment outcomes, perhaps it is time to encourage research that would explore client outcomes related to feeling heard, understood, listened to, and engaged as partners in the “recovery/healing” process. Our clients enter treatment with a high degree of shame and resistance. In this regard (especially true for adults), the parallels to the addiction work referenced in the above research are compelling. The field of motivational interviewing has begun to explore these very factors. Given the impact of treatment failures, we must understand all the variables that contribute to such failures, including the professional limitations of the therapist. This article is a “must read” for all of us.


One of the largest determinants of client outcomes is the counselor who provides treatment. Therapists often vary widely in effectiveness even when delivering standardized manual-guided treatment. In particular, the therapeutic skill of accurate empathy originally described by Carl Rogers has been found to account for a meaningful proportion of variance in therapeutic alliance and addiction treatment outcomes. The authors propose emphasis on empathic listening skills as an evidence-based practice in the hiring and training of counselor to improve outcomes.


  • Moyers, T.B., & Miller, W.R., (2012, October 1), Is Low Therapist Empathy Toxic? Psychology of Addictive Behaviors, 27, 878-884.