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CLIENT-PERCEIVED THERAPISTEMPATHY AS A CORRELATE OF OUTCOME
Item Type text; Dissertation-Reproduction (electronic)
Authors Kalfas, Nicholas Soterios, 1945-
Publisher The University of Arizona.
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Xerox University Microfilms 300 North Zeeb Road Ann Arbor, Michigan 48106
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| KALFAS, Nicholas Soterios, 1945-i CLIENT-PERCEIVED THERAPIST EMPATHY AS A [ CORRELATE OF OUTCOME. >
j The University of Arizona, Ph.D., 1973 i Education, guidance and counseling i i i i I i
University Microfilms, A XEROX Company, Ann Arbor, Michigan
THIS DISSERTATION HAS BEEN MICROFILMED EXACTLY AS RECEIVED.
CLIENT-PERCEIVED THERAPIST EMPATHY
AS A CORRELATE OF OUTCOME
by
Nicholas Soterios Kalfas
A Dissertation Submitted to the Faculty of the
DEPARTMENT OF COUNSELING AND GUIDANCE
In Partial Fulfillment of the Requirements For the Degree of
DOCTOR OF PHILOSOPHY
In the Graduate College
THE UNIVERSITY OF ARIZONA
19 7 3
THE UNIVERSITY OF ARIZONA
GRADUATE COLLEGE
I hereby recommend that this dissertation prepared under my
direction by Nicholas Soterios Kalfas
entitled Client-Perceived Therapist Empathy as a Corre
late of Outcome
be accepted as fulfilling the dissertation requirement of the
degree of Doctor of Philosophy
B-g-p UJ . JLfjr io_, it73 Dissertation Director Date
After inspection of the final copy of the dissertation, the
following members of the Final EKamination Conimittee concur in
its approval and recommend its acceptance:*"
< 9 1 / / Q / 7 3
"V V'0(p
? / , ' / 7 1
This approval and acceptance is contingent on the candidate's adequate performance and defense of this dissertation at the final oral examination. The inclusion of this sheet bound into the library copy of the dissertation is evidence of satisfactory performance at the final examination.
STATEMENT BY AUTHOR
This dissertation has been submitted in partial fulfillment of requirements for an advanced degree at The University of Arizona and is deposited in the University Library to be made available to borrowers under rules of the Library.
Brief quotations from this dissertation are allowable without special permission, provided that accurate acknowledgment of source is made. Requests for permission for extended quotation from or reproduction of this manuscript in whole or in part may be granted by the head of the major department or the Dean of the Graduate College when in his judgment the proposed use of the material is in the interests of scholarship. In all other instances, however, permission must be obtained from the author.
SIGNED :•
ACKNOWLEDGMENTS
It would be impossible for one to complete a disser
tation or a doctoral program by oneself; many people share
in the process, some directly, some indirectly. It would
also be impossible for one to thank them all. I wish to
express my appreciation to:
Dr. Bill Hillman, whose friendship and advice have
been immeasurable.
Drs. Oscar Christensen, Phil Lauver, Dan Reschly,
and Darrell Sabers, who served on my committee and who were
of great help throughout my graduate program and in contrib
uting- to my personal growth.
Dr. Dave Cutler, Bernie Engelhard, Ralph Wetmore,
and the rest of the staff at the Air Force Hospital Mental
Health Clinic, Davis-Monthan Air.Force Base.
Dr. Larry Stewart, whose advice and guidance has
contributed to my professional growth.
Dr. Paul Danielson, whose patience and wisdom have
contributed to my maturity.
Dr. Sarah Dinham, who gave of her time to keep the
statistics straight.
Fellow doctoral students; Pete Attarian, Maxine
Ijams, Dave Mahrer, and many others whose support, friend
ship, and encouragement made a doctorate possible.
• • • xia
iv
And, most importantly, to my wife, Maureen, who has
lived with academia since she has known me. Her support,
in more ways than one, and encouragement have truly made the
attainment of this degree possible.
TABLE OF CONTENTS
Page
LIST OF TABLES vii
LIST OF ILLUSTRATIONS viii
ABSTRACT , ix
CHAPTER
I. INTRODUCTION 1
Statement of the Problem 6 Hypotheses 8
Hypothesis 1 8 Hypothesis 2 8 Hypothesis 3 9 Hypothesis 4 9 Hypothesis 5 9 Hypothesis 6 9
Definitions 10 Limitations of the Study 10 Summary 11
II. RESEARCH METHODOLOGY 13
General Design of the Study 13 Sources of Data 14 Characteristics of the Subjects and
the Counselors 15 Instrumentation 16
The Relationship Inventory 16 The Tennessee Self Concept Scale ... 17
Data Gathering Procedures 18 Data Analysis and Statistical Techniques . 19
Hypothesis 1 19 Hypothesis 2 20 Hypothesis 3 20 Hypothesis 4 20 Hypothesis 5 21 Hypothesis 6 21
Summary 22
v
vi
TABLE OF CONTENTS—Continued
Page
III. RESULTS AND DISCUSSION 24
Results 24 Hypothesis 1 24 Hypothesis 2 25 Hypothesis 3 25 Hypothesis 4 25 Hypothesis 5 26 Hypothesis 6 27
Empathy Scale Reliability 32 Discussion 33
IV. RECOMMENDATIONS AND SUMMARY 38
Recommendations 3 8 Summary 39
APPENDIX A: INTRODUCTORY LETTER ....... 41
APPENDIX B: SCATTERPLOTS OF EMPATHY SCALE SCORES SHOWING SPLIT-HALF RELIABILITY . . 42
SELECTED BIBLIOGRAPHY 45
LIST OF TABLES
Table Page
1. Descriptive Data for the Five Single Subjects on the Exact Probabilities of Their Patterns of Perceived Therapist Empathy, Outcome Change Scores, and Mean Change Scores of Perceived Empathy Between Interviews 28
2. Total Positive Pre-Test, Post-Test, and Change Scores of the Tennessee Self Concept Scale ... 34
vii
LIST OF ILLUSTRATIONS
Figure Page
1. Pattern of Perceived Therapist Empathy for Subject A 28
2. Pattern of Perceived Therapist Empathy for Subject B 29
3. Pattern of Perceived Therapist Empathy for Subject C 29
4. Pattern of Perceived Therapist Empathy for Subject D 30
5. Pattern of Perceived Therapist Empathy for Subject E 30
6. Pattern of Perceived Therapist Empathy for Subjects A, B, C, D, and E 31
7. A Comparison of Patterns of Perceived Therapist Empathy for Subjects A, B, C, D, and E, Corrected to Zero Initial Scale Score 36
8. Scatterplot of First Measures of Positive and Negative Empathy Scale Scores Showing Split-Half Reliability 42
9. Scatterplot of Last Measures of Positive and Negative Empathy Scale Scores Showing Split-Half Reliability 43
10. Combined Scatterplot of First and Last Positive and Negative Empathy Scale Scores Showing Split-Half Reliability 44
viii
ABSTRACT
Many studies have shown a relationship between meas
ures of empathy and measures of outcome with clients in
middle and long term therapy. The present study investiga
ted measures of client-perceived therapist empathy and self
concept outcome measures with clients in brief therapy at a
mental health clinic. The patterns of perceived therapist
empathy scores of select clients in a multiple single-case
format design were also investigated.
The results of the present study show that in the
mental health clinic where it was conducted, utilizing cli
ents in brief therapy, no significant relationships were
found between client-perceived therapist empathy measures
taken at the first, middle, or last interviews, and outcome
measures. Differences were shown to exist between first,
middle, and last client-perceived therapist empathy meas
ures at the .01 level of confidence. Subsequent analysis
revealed that there were differences between the first and
middle measures, and even greater differences between the
first and last measures.
The results of the multiple single-case format in
vestigation revealed that client-perceived therapist empathy
measures varied from interview to interview with the great
est amount of variability in between-interview-scores
ix
X
occurring with those clients attaining negative outcome
change scores. In addition, measures of client-perceived
therapist empathy tended to be more favorable at the last
interview than the first regardless of outcome scores.
Because the evidence shown in the present study is
not consistent with previous findings, the investigator
proposes that future research efforts involve replication
of this study in other mental health clinics offering brief
therapy to their clients.
CHAPTER I
INTRODUCTION
Despite the many diverse theoretical orientations
in counseling and psychotherapy, empathy, on the part of the
counselor, is commonly stressed as an important dimension of
the therapeutic process (e.g., Fromm-Reichman, 1950; May,
1939; Rogers, 1957, 1959; Truax and Carkhuff, 1967; Tyler,
1969). Rogers' theoretical statements concerning the re
lationships among empathy, therapy process, and therapy
outcome are, perhaps, the best known. Empathy is treated
as a therapist condition which has a direct influence on
therapy process and outcome. Carkhuff (1969, pp. 82-83)
states, "empathy is perhaps the most critical of all helping
dimensions. Without empathy there is no basis for helping.
From it flows the appropriate and meaningful employment of
all other dimensions and ultimately the resolution of the
helpee's problems." In this vein, high levels of therapist
empathy at some point in therapy will presumably be respon
sible for client change. Following the reasoning of Rogers
and of Carkhuff, therapist empathy is directly related to
client change and counseling outcome.
The relationship between therapist empathy and out
come has been the subject of considerable research (e.g.,
1
2
Barrett-Lennard, 1962; Cartwright and Lerner, 1963; Dombrow,
1966; Lesser, 1961; Rogers et al., 1967; Truax and Carkhuff,
1967). The findings of these authors indicate a strong re
lationship between empathy and outcome. However, they leave
unanswered questions about what part empathy plays in out
come, at what time during the therapeutic relationship
empathy is most critical, and how the client's perception of
empathy during the therapeutic relationship is related to
outcome.
Empathy seems to be a necessary quality which per
vades other necessary therapist conditions. Buchheimer in
1961 identifies five dimensions of empathy (1968, p. 350):
(1) tone, an expressive and nonverbal dimension reflected when two people interact in expressive harmony and unity; (2) pace, or appropriate timing of counselor leads; (3) flexibility, or the counselor's ability to discard previously thought out tactics or goals if they do not fit the coun-selee's situation; (4) perception of the counse-lee's frame of reference, or the ability to abstract the core of the counselee's concern and to formulate it objectively and palatably so that he can elaborate; and (5) repertoire of leads, or the resourcefulness with which the counselor varies his leading in appropriate ways to apply to both manifest and dynamic content of the counselee's expression.
It appears that empathy is a multifaceted construct drawing
upon a variety of necessary therapist skills and conditions
not the least of which is the client's perception of these
conditions.
The measurement of empathy has been accomplished in
a number of ways: situational, predictive, tape-judged
3
ratings, and perceived empathy (by both therapist and
client). The method used by Kagan et al. (1967) is an
example representative of the situational approach. Their
Affective Sensitivity Scale measures the ability of a ther
apist to perceive and identify affective states in others.
Empathy, in this sense, is treated as a "trait," in that
therapists scoring high in the test situation are presumed
capable of greater empathy with their clients.
In the predictive measure approach (e.g., Cartwright
and Lerner, 1963), the therapist attempts to predict how the
client he is working with will respond on a personality in
ventory or other series of self-descriptive items. A corre
lation is computed between the therapist's predictions and
the client's self-descriptions, the higher the correlation,
the higher the level of therapist empathy.
Judged tape ratings (e.g., Carkhuff, 1969; Truax and
Carkhuff, 1967) make use of independent judges to rate the
level of therapist empathy present in the interview. This
is typically accomplished by the use of audio tapes. The
judges listen to segments of a client-counselor verbal
interaction and rate the counselor's responses in regard to
level of therapist empathy present on a five point scale of
which the following is illustrative: Level 1, the thera
pist's responses either do not attend to or detract signif
icantly from the expressions of the client; Level 3, the
therapist's responses are interchangeable with the client's
1
in that they express essentially the same affects and mean
ings; Level 5, the therapist's responses add significantly
to the feelings and meanings of the client in such a way as
to express accurately feelings and meanings which the client
himself is unable to express clearly, or, in the event of
ongoing deep self-exploration by the client, the therapist
is fully with the client in his deepest moments (Carkhuff,
1969).
Perceived empathy is the therapist's or the client's
perception of the counselor's empathy in the relationship.
Rogers (1962) states that unless the client perceives this
condition in the relationship, it does not exist in his per
ceptual world and thus cannot be effective. A measure of
the amount of empathy in a relationship is the Barrett-
Lennard (1962) Relationship Inventory. The Relationship
Inventory attains a measure of one person's perception of
the empathy of another person in a relationship.
In each method described the level of therapist
empathy may be thought of as a direct influence in the coun
seling relationship, and, as such, is a variable influencing
the outcome of the counseling relationship. The methods
mentioned, however, do not yield measures which are equal
in their relationship with outcome. Empathy, as a process
measure, is thought of as an indicator of the efficacy of
counseling since measured levels of empathy have been found
to have a positive relationship with outcome. The strength
5
of this relationship varies with the measures used.
Shertzer and Stone (1968, p. 512) state "outcome is directed
toward assessing the final product of counseling and usually
focuses upon such issues as which techniques work best with
which counselees, whether counseling was successful, and
whether counseling effects were lasting." Rogers (1961, p.
36) describes the change that takes place in the client
during counseling as outcome, stating, "that in such a rela
tionship the individual will reorganize himself at both the
conscious and deeper levels of his personality in such a
manner as to come with life more constructively, more intel
ligently, and in a more socialized as well as a more satis
fying way." In this vein an outcome measure can be one
which is sensitive to the client's level of self-esteem.
Tying together a process variable, such as a measure
of empathy, and an outcome variable or variables has gener
ally proven to be quite frustrating. The relationship,
while found to exist, has not been defined clearly. The
importance of clarifying the relationship lies in under
standing key features of the counseling relationship as well
as lending itself to improving counselor training. Kurtz
and Grummon (197 2) suggest that a strong relationship exists
between empathy and therapy outcomes and show that client-
perceived empathy is best related to outcome. If the
client's perceptions do not change, and are formed early in
the relationship, then the client's early perceptions of the
level of therapist offered empathy could very well be pre
dictive of outcome. Some previous studies have shown that
no relationship exists between the client's perception of
therapist empathy early in the counseling relationship and
outcome (e.g., Cartwright and Lerner, 1963; Kurtz and
Grummon, 1972), while others would imply that this predic
tive relationship does exist (e.g., Kiesler, Mathiew, and
Klein, 1967; Rogers et al., 1967). Because of conflicting
reports it is difficult to ascertain whether levels of
client-perceived empathy change during the counseling rela
tionship.
The literature has often been more confusing than
clarifying in its treatment of client-perceived therapist
empathy. Typically, too few measures of client-perceived
empathy have been attained during the counseling relation
ship and linearity of data has seemingly been assumed. This
appears to be a deficiency in design. The implications of
client-perceived therapist empathy in counseling and its
relationship to counseling outcome need to be clarified.
Statement of the Problem
While counselors today operate from many different
theoretical viewpoints, it is commonly agreed that therapist
empathy plays an important part in the counseling relation
ship. How the client perceives therapist empathy would seem
7
to have a great deal to do with the efficacy and the rapid
ity with which the counseling relationship becomes effec
tive as a change agent for the client.
Kurtz and Grummon (19 72) report a relationship be
tween client perceptions of therapist empathy and a variety
of outcome measures including the Tennessee Self Concept
Scale (Fitts, 1965), MMPI ratings, and therapist evaluations.
Client-perceived therapist empathy, according to Kurtz and
Grummon (1972), appears to be the best correlate of counsel
ing outcome, which suggests that the client acts either
productively or not depending on his perceptions of the
therapist in the counseling relationship.
Previous studies have shown that client perception
of therapist empathy correlates highly with outcome vari
ables. These studies, however, typically assessed client
perceptions of therapist empathy at only two or three points
during the counseling relationship and then correlated these
findings with outcome measures. Conflicting reports as to
the stability of the client's perceptions of therapist empa
thy over time have also appeared. It would seem that a
stronger research design was necessary in order to ascertain
how these variables relate to each other. Specifically,
more frequent measurement of client-perceived therapist em
pathy during the period of the counseling relationship would
result in a more meaningful understanding of the process and
stability of client perceptions of therapist empathy over
8
time. The purpose of this study was to explore the rela
tionship between client perceptions of therapist empathy and
counseling outcome in a specific setting, utilizing crisis
intervention and/or brief therapy, and to explore client-
perceived therapist empathy and its role in this setting.
More specifically, this study sought to explore the follow
ing research questions: What was the relationship between
client-perceived therapist empathy and counseling outcomes?
How did client-perceived therapist empathy vary during the
counseling relationship?
Hypotheses
In order to answer the research questions stated
above, the following hypotheses were tested.
Hypothesis 1
There is a relationship between the mean level of
client-perceived therapist empathy, as measured by the Em
pathy Scale of the Relationship Inventory,, and counseling
outcome, as measured by a change in the Total Positive score
of the Tennessee Self Concept Scale.
Hypothesis 2
There is a relationship between the initial measure
of client-perceived therapist empathy, as measured by the
Empathy Scale of the Relationship Inventory, and counseling
9
outcome, as measured by a change in the Total Positive score
of the Tennessee Self Concept Scale.
Hypothesis 3
There is a relationship between the middle measure
of client-perceived therapist empathy, as measured by the
Empathy Scale of the Relationship Inventory, and counseling
outcome, as measured by a change in the Total Positive score
of the Tennessee Self Concept Scale.
Hypothesis ^
There is a relationship between the final measure of
client-perceived therapist empathy, as measured by the Empa
thy Scale of the Relationship Inventory, and counseling
outcome, as measured by a change in the Total Positive score
of the Tennessee Self Concept Scale.
Hypothesis 5
There are no differences between the initial, middle,
and final measures of client-perceived therapist empathy
during the entire counseling relationship as measured by the
Empathy Scale of the Relationship Inventory.
Hypothesis 6
There is no increase in the level of client-perceived
therapist empathy as the counseling relationship continues
over time as measured by the Empathy Scale of the Relation
ship Inventory.
10
Definitions
For the most part, the meanings of terms used in
this study are those commonly held. However, definitions of
some terms are clarified below.
Client-Perceived Therapist Empathy: Refers to therapist
offered empathy which a client perceives, as measured by
the Empathy Scale of the Barrett-Lennard Relationship In
ventory .
Empathy: Refers to the condition in a counseling re
lationship which, in Rogers' (1957, p. 98) words is "to
sense the client's own private world as if it were your
own, but without ever losing the 'as if' quality....'*
Outcome: Refers to the change in the Total Positive
score as measured by the Tennessee Self Concept Scale.
Limitations of the Study
This study has several limitations, the first of
which was its focus. That is, only client-perceived thera
pist empathy was utilized as a measure of empathy, and only
the Tennessee Self Concept Scale was used as an outcome
measure. This, however, seemed to be justified in review
ing the work of Kurtz and Grummon (197 2) since they showed
a high relationship between these two measures. The data
11
were collected in the field, thus precluding many of the
control conditions necessary for truly rigorous experimental
design.
Counselee variables such as readiness for counseling
and severity of the problem were not controlled. The cli
ents did, however, volunteer for inclusion in the study and
were selected according to sex and whether or not a problem
of a personal nature was described.
Counselor variables also were under little control
and were dictated by the setting. Counselor length of ex
perience, counseling style, confidence, and reputation as
well as training were not controlled.
Summary
Although many studies have shown a positive corre
lation between measures of empathy and outcome, questions
still remain concerning empathy and its dimensions. Client-
perceived therapist empathy has been shown to be most highly
correlated with outcome, yet questions still remain concern
ing the stability of these perceptions and the levels of
perceived empathy over the course of the counseling rela
tionship. This study dealt with the variables of client-
perceived empathy and outcome with the intent of exploring
this relationship in a brief therapy or crisis intervention
setting. It replicated, in part, some of the work done by
Kurtz and Grummon (1972), Rogers et al. (1967), and others;
but focused the investigation on the variable of client-
perceived therapist empathy over time.
CHAPTER II
RESEARCH METHODOLOGY
The research methodology is discussed in this chap
ter. The first section presents the general design of the
study. Succeeding sections include a discussion of sources
of data, characteristics of the subjects and the counselors,
instrumentation, data gathering procedures, and statistical
techniques. A final section summarizes the chapter.
General Design of the Study
This study was basically descriptive in nature, and
was divided into two parts. Part one, which included hy
potheses 1 through 5, primarily investigated the relation
ship of client-perceived therapist empathy and outcome, and
the stability of these perceptions during the course of the
relationship. A correlational design was utilized for hy
potheses 1 through 4, and a one-way analysis of variance
design for hypothesis 5.
Part Two, which included hypothesis 6 of the study,
was an investigation of client-perceived therapist empathy
over time. Five subjects were utilized in a multiple
single-case format design (Bergin and Strupp, 197 0) with
data represented through demographic and ideographic methods.
13
14
Sources of Data
The setting for this study was the Mental Health
Clinic, Air Force Hospital, Davis-Monthan Air Force Base,
Tucson, Arizona. The Mental Health Clinic was staffed by a
psychiatrist, a psychiatric social worker, and by psychia
tric technicians. Basic emphasis was on crisis intervention
which, in process, was similar to the non-directive or
client-centered model. In addition, the clinic dealt with
psychiatric evaluations and in supplying information for
processing discharges.
The clients using the Mental Health Clinic were
active duty personnel, dependents, and retired servicemen.
The clients used for the study were twelve males who re
ferred themselves to the clinic due to problems of a per
sonal nature. Generally, a client was seen for an intake
interview by one of the clinic staff members and then was
either followed in the clinic on a brief therapy or crisis
intervention basis or referred to a community agency. When
the client was followed in the clinic, the counselor follow
ing him established a counseling relationship with the cli
ent and, it was assumed for the purposes of this study,
helped him with his problem.
Between the process of intake and being seen by the
counselor, the client was approached and was asked if he
would be willing to participate in a study in which he would
be requested to fill out a one hundred item inventory before
and after the counseling relationship, and a sixteen item
questionnaire after each counseling session (see Appendix A
for introductory letter). The results of the clients' re
sponses to the inventories and the questionnaires were not
made known to the counselors while the study was being con
ducted.
Characteristics of the Subjects and the Counselors
The clients used in this study were twelve male
adults who expressed concerns of a personal nature. They
were either active duty or retired servicemen, or their
dependents. They sought counseling through the Mental
Health Clinic, whose primary function was to deal thera
peutically with clientele experiencing personal problems of
any type.
As specified in the preceding section, the six
counselors were regular personnel of the Mental Health Clin
ic. Only male counselors were used to limit the population
of both counselors and clients to males. Generally, when
dealing with clients with personal problems, the counselors
were trained to adopt a non-directive or client-centered
approach which paralleled the theoretical foundations of the
study.
16
Instrumentation
The instruments used to collect the data for this
study consisted of (a) the Relationship Inventory Empathy
Scale, and (b) the Tennessee Self Concept Scale.
The Relationship Inventory
The Relationship Inventory was originally developed
by Barrett-Lennard (1962) to assess perceptions of selected
therapeutic attitudes expressed by the counselor in the
counseling relationship, and to give operational expression
to the conditions of therapy postulated by Rogers (1957).
The Empathy Scale, which was used in this study, is from the
1964 revision of the Relationship Inventory which was im
proved and shortened.
The psychometric characteristics of the Relationship
Inventory seemed to be well within the limits of acceptable
test construction. During the initial development of the
Relationship Inventory (Barrett-Lennard, 1962) a content
validation was made to ascertain how safely items could be
regarded as either positive or negative expressions of the
variables they were designed to represent. Five judges
classified each item as a positive or negative indicator of
the variable in question according to given definitions.
There was perfect agreement among the judges in classifying
the items on all except four items, three of which were
eliminated from the questionnaire. Split-half reliabilities
17
between .83 and .95 for the four scales, and test-retest
correlations over a six-month interval from .61 to .81 were
reported by Hollenbeck (19 61).'
The Empathy Scale of the Relationship Inventory was
used to attain the client's perceptions of the therapist's
empathy. This scale consists of sixteen statements such as
"He tries to see things through my eyes," and "He under
stands my words but not the way I feel." The client indi
cates three degrees of agreement or disagreement with each
statement, with no neutral position provided. Barrett-
Lennard (19 69) reported a test-retest reliability of .86
with the Empathy Scale using an interval ranging from two to
six weeks. Stewart (197 0) reported a split-half reliability
of .57 with the Empathy Scale using deaf subjects, which may
have caused the relationship to be lower than what might
have been attained with normal hearing subjects.
The Tennessee Self Concept Scale
The Total Positive score of the Tennessee Self Con
cept Scale was used in this study to provide a measure of
client self-concept. This instrument reportedly has excel
lent psychometric characteristics, and Ashcroft and Fitts
(19 61*) have shown that the scale was sensitive to change in
psychotherapy. Suinn (197 2, p. 369) stated .
the TSCS ranks among the better measures combining group
discrimination with self-concept formation." Bentler
18
(1972, p. 366) stated that the test-retest reliability
correlations had been reported in the high . 80's and that
the TSCS has remarkably high correlations with other meas
ures of personality functioning. He further stated "...
it seems safe to conclude that the scale overlaps suffi
ciently with well known measures (of personality) to con
sider it a possible alternative for these measures in
various applied situations."
The Total Positive score reflects the client's
level of self-esteem and Fitts (1965) considers it to be the
single most important score derived from the scale. The
difference score between pre- and post-counseling testing
with the TSCS was used as the counseling outcome score.
Data Gathering Procedures
Each client-counselor dyad yielded an outcome meas
ure consisting of the difference between pre- and post-
counseling testing of the client on the Tennessee Self Con
cept Scale, and client-perceived therapist empathy measures
consisting of a Relationship Inventory Empathy Scale score
after each counseling session. The Tennessee Self Concept
Scale was completed by each client after the intake inter
view but prior to the first counseling interview as well as
after termination of counseling. The net change made on the
Total Positive scores was used as the measure of change in
the client, or in other words, as a measure of outcome.
19
The client also responded to the Empathy Scale of
the Relationship Inventory after each counseling interview.
The Empathy Scale score after each interview provided a
measure of how empathic the client perceived the therapist
to be during that interview. In addition, the mean of these
scores taken together provided an overall measure of client-
perceived therapist empathy.
Data Analysis and Statistical Techniques
The data were analyzed and tested for significance
according to the procedures outlined below. The Relation
ship Inventory and the Tennessee Self Concept Scale are both
Likert type instruments and were thus assumed to yield in
terval data. However, it was not felt that all the assump
tions necessary to use parametric statistics could be met
and it was therefore decided to use nonparametric methods.
Hypothesis 1
Mean client-perceived therapist empathy scores as
measured by the Empathy Scale of the Relationship Inventory
were correlated with outcome scores consisting of the change
in the Total Positive score of the Tennessee Self Concept
Scale. Analysis consisted of application of a Spearman
rank correlation (rs). The Spearman rs is perhaps the best
statistic based on ranks according to Siegel (1956). "The
20
efficiency of the Spearman rank correlation when compared
with the most powerful parametric correlation, the Pearson
r, is about 91 percent (Siegel, 1956, p. 213)."
Hypothesis 2
The initial measure of client-perceived therapist
empathy as measured by the Empathy Scale of the Relationship
Inventory was correlated with outcome scores consisting of
the change in the Total Positive score of the Tennessee Self
Concept Scale. Analysis consisted of application of a
Spearman rs.
Hypothesis 3
The middle measure of client-perceived therapist
empathy as measured by the Empathy Scale of the Relationship
Inventory was correlated with outcome scores consisting of
the change in the Total Positive score of the Tennessee Self
Concept Scale. Analysis consisted of application of a
Spearman rs.
Hypothesis 4
The last measure of client-perceived therapist empa
thy as measured by the Empathy Scale of the Relationship
Inventory was correlated with outcome scores consisting of
the change in the Total Positive score of the Tennessee Self
Concept Scale. Analysis consisted of application of a
Spearman rg.
21
Hypothesis 5
A Kruskal-Wallis one-way analysis of variance was
used to test this hypothesis. The first, middle, and last
measures of client-perceived therapist empathy as measured
by the Empathy Scale of the Relationship Inventory were test
ed for differences. According to Siegel (1956), the effi
ciency of the Kruskal-Wallis test, when compared with the
most powerful parametric test, the F test, is 95.5 percent.
At this time, however, there was no published post
hoc test available for the Kruskal-Wallis test. Therefore,
a one-way analysis of variance was used to attain data for
the Tukey post hoc test. The first, middle, and last sam
ples were tested with the Tukey to determine the location of
any differences.
Hypothesis 6
Five subjects with a minimum of six counseling in
terviews each were studied demographically and ideographi-
cally in a multiple single-case format design (Bergin and
Strupp, 1970) for changes in client-perceived therapist
empathy as measured by the empathy scale of the Relationship
Inventory during the course of the counseling relationship.
This hypothesis was tested using the Fisher exact probability
test (Siegel, 1956).
In addition, a split-half reliability study of the
Empathy Scale using scores attained following the first and
22
last counseling sessions was conducted. The statistical
technique used was that suggested by Cronbach (19 60, p. 141).
According to Cronbach, this procedure produces results simi
lar to those produced by the Spearman-Brown formula.
Summary
The subjects of this study consisted of twelve adult
active duty, retired servicemen or their dependents who
sought counseling at the Mental Health Clinic at Davis-
Monthan Air Force Base, Tucson, Arizona. The counselors
used in the study were male personnel of the Mental Health
Clinic.
The Empathy Scale of the Relationship Inventory,
which was designed to assess client perceptions of the coun
seling relationship variable of empathic understanding, was
administered to the clients following each counseling inter
view.
The Tennessee Self Concept Scale was administered to
the clients before the counseling relationship began and
after termination. The amount of change between the two
administrations in the Total Positive score was used as a
measure of outcome.
A split-half reliability study was conducted to
determine the reliability of the Empathy Scale as it was
used in this study. For this purpose, client scores
23
attained following the first and last counseling sessions
were split into equivalent halves and analyzed.
Analysis of the data involved correlating mean,
first, middle, and last perceived empathy scores with out
come. It also included a one-way analysis of variance study
with a subsequent post hoc test of the first, middle, and
last counseling,session perceived empathy scores to deter
mine if and where the scores differed. Last, a multiple
single-case format design was utilized to study the vari
able of client-perceived therapist empathy over time.
CHAPTER III
RESULTS AND DISCUSSION
The study was designed to explore the relationship
between client-perceived therapist empathy at various stages
during a brief therapy or crisis intervention counseling
relationship, and outcome. Client-perceived therapist empa
thy at various stages during the counseling relationship was
analyzed for differences and the perceived therapist empathy
patterns of five single subjects was studied. Twelve sub
jects' outcome scores, as measured by a change in the Total
Positive score of the Tennessee Self Concept Scale, and
perceived empathy.scores, as measured by the Empathy Scale
of the Relationship Inventory, were utilized to make these
comparisons.
Results
Hypothesis 1
The Spearman rank-order correlation (r_), used to b
test the relationship between outcome scores and the mean of
client-perceived therapist empathy scores, yielded a corre
lation coefficient of .10 which was not statistically
significant. The assertion stated in hypothesis 1 of a re
lationship between outcome scores and the mean of client-
perceived therapist empathy scores, was not supported by
these data.
24
25
Hypothesis 2
The Spearman rank-order correlation (rs), used to
test the relationship between outcome scores and the first
measure of client-perceived therapist empathy scores, yield
ed a correlation coefficient of .40 which was not statisti
cally significant. The assertion stated in hypothesis 2 of
a relationship between outcome scores and the first measure
of client-perceived therapist empathy scores, was not sup
ported by these data.
Hypothesis 3
The Spearman rank-order correlation (rs), used to
test the relationship between outcome scores and the.middle
measure of client-perceived therapist empathy scores, yield
ed a correlation coefficient of -.2M- which was not statisti
cally significant. The assertion stated in hypothesis 3 of
a relationship between outcome scores and the middle measure
of client-perceived therapist empathy scores, was not sup
ported by these data.
Hypothesis 4
The Spearman rank-order correlation (r„), used to b
test the relationship between outcome scores and the last
measures of client-perceived therapist empathy scores, yield
ed a correlation coefficient of -.0 3 which was not statisti
cally significant. The assertion stated in hypothesis •+ of
26
a relationship between outcome scores and the last measure
of client-perceived therapist empathy scores, was not sup
ported by these data.
Hypothesis 5
The Kruskal-Wallis one-way analysis of variance,
used to determine if there were differences between the
first, middle, and last measures of client-perceived thera
pist empathy, yielded an H=10.64-39 which was statistically
significant at the .01 level of confidence. The assertion
stated in hypothesis 5 of no differences between the first,
middle, and last measures of client-perceived therapist em
pathy scores, was not supported by these data.
At the time of this study there were no published
post hoc tests for the Kruskal-Wallis one-way analysis of
variance. Therefore, a one-way analysis of variance with a
Tukey post hoc test was used to determine the nature of the
differences. The one-way ANOVA yielded an F=6.5277 which
was significant at the .005 level of confidence. The Tukey
yielded a q=-6.1069 between the first and middle measures of
client-perceived therapist empathy which was significant at
the .005 level of confidence. The Tukey yielded a q=-2.4944
between the middle and last measures of client-perceived
therapist empathy which was significant at the .01 level of
confidence. Between the first and last measures of client-
27
percieved therapist empathy, the Tukey yielded a q=~8.6013
which was significant at the .001 level of confidence.
While it could not be presumed that a nonparametric
post hoc test would yield results at the same levels of
confidence as the Tukey, it would seem safe to assume that
there is a significant difference between first and middle
measures of client-perceived therapist empathy, and an even
greater difference between first and last measures of client-
perceived therapist empathy.
Hypothesis 6
Five subjects were studied in a multiple single-case
format design to determine whether there was an increase in
the level of client-perceived therapist empathy as the coun
seling relationship continued over time. Each subject's
pattern of perceived therapist empathy is presented in
Figures 1 through 6, while descriptive data are presented in
Table 1. The nature of the multiple single-case format de
sign precluded statistical testing in the traditional sense.
However, the Fisher exact probability test was used to deter
mine the exact probability of occurrence of each subject's
pattern of perceived therapist empathy. The median of each
subject's perceived empathy scores and the mid-point of the
counseling relationship were used to classify the Empathy
Scale scores in their appropriate cells. Inspection of the
data in Table 1 as well as Figures 1 through 6 leads to the
28
Table 1. Descriptive Data for the Five Single Subjects on the Exact Probabilities of Their Patterns of Perceived Therapist Empathy, Outcome Change Scores, and Mean Change Scores of Perceived Empathy Between Interviews
Subject Code
Exact Probability
of Occurrence
Outcome Change Scores
Mean Change Scores Between
Interviews
A . 0500 19 3.1667
B . 5000 6 4.3333
C .2286 -18 6.2500
D .4500 -22 10.5000
E .4500 -46 7/5000
E m 32 P a 28 t h 24 y
20 S c 16 a 1 12 e
8 S c 4 o r 0 e s
3 4 5 6 7
Interview Number
10
Figure 1. Pattern of Perceived Therapist Empathy for Subject A
32
2 8
24
2 0
16
12
8
4
0
;ur
38
34
30
2 6
22
18
14
10
6
1 2 3 7 8 9 10 5 6
Interview Number
2. Pattern of Perceived Therapist Empathy for Subject B
10 1 2 3 9 4 5 6 7 8
Interview Number
3. Pattern of Perceived Therapist Empathy for Subject C
10
36
32
2 8
21
20
16
12
8
re
21
20
16
12
8
1
0
-1
- 8
1.
1 2 3 1 5 6 7 8 9 1 0
Interview Number
Pattern of Perceived Therapist Empathy for Subject D
1 2 3 6 10 5
Interview Number
5. Pattern of Perceived Therapist Empathy for Subject E
31
44
40
36
32
2 8
24
2 0
16
12
8
4
0
-4
- 8
-12
-16
Figure
Legend:
E m P a t h y
S c a 1 e
S c o r e s
, ^ - C
1 2 3 4 5 6 7 8 9 1 0
Interview Number
6. Pattern of Perceived Therapist Empathy for Subjects A, B, C, D, and E
Subjects with positive outcome change scores
Subjects with negative outcome change scores
32
conclusion that client-perceived therapist empathy varied
from interview to interview and tended to increase from the
initial measure to the last measure. Therefore, hypothesis
6, that there is no increase in the level of client-
perceived therapist empathy as the counseling relationship
continues over time, did not appear to be substantiated by
the evidence obtained.
Empathy Scale Reliability
The split-half reliability study of the first and
last Empathy Scale measures using the statistical technique
suggested by Cronbach (1960, p. 141) yielded reliability
coefficients of .37 and .46 respectively. The positive and
negative halves of the Empathy Scale, as suggested by
Barrett-Lennard (19 69), were used for these analyses. These
results are quite low, since Stewart (19 70) attained a
split-half reliability coefficient of .57 using the same
procedure. Inspection of Figures 8 through 10 (Appendix B)
shows what appears to be an indication of a differential
acquiescence response set of a portion of the sample. It
could be speculated that these reliability coefficients
would approach acceptable levels if not for the suspected
acquiescence response set.
An odd-even split-half reliability procedure was
then done using the same statistical technique. The odd-
even procedure on the first and last measures of the Empathy
Scale yielded reliability coefficients of .75 and .70 re
spectively. The odd-even procedure yielded more homogeneous
halves and thus suggest a greater split-half reliability.
Discussion
In contrast to many previous finding (e.g., Barrett-
Lennard, 1969; Cartwright and Lerner, 1963; Kagan et al.,
1967; Kiesler et al. , 1967; Kurtz and Grummon, 1972; Rogers
et al. , 1967; Truax and Carkhuff, 1967) that strong relation
ships consistently exist between therapist empathy and coun
seling outcome, the findings of the present study suggest
that client-percieved therapist empathy scores varied from
interview to interview, tended to be more favorable at the
last interview than the first regardless of outcome scores,
that there was no relationship evidenced between client-
perceived therapist empathy scores and outcome scores, and
that there was no relationship evidenced between client-
perceived therapist empathy scores and outcome scores. It
is felt that the scores attained in this study are psycho-
metrically acceptable. The odd-even split-half reliability
scores attained on the Relationship Inventory Empathy Scale,
in addition to the previous research yielding reliability
and validity data on this instrument, tend to maintain con
fidence in the present data. Similarly, reliability and
validity data attained from previous research on the TSCS
tended to maintain confidence in the present data. Table 2
34
Table 2. Total Positive Pre-Test, Post-Test, and Change Scores of the Tennessee Self Concept Scale
Subject Code
Pre-Test Scores
Post-Test Scores
Change Scores
6 320 358 38
34 322 354 32
16 297 316 19
35 398 413 15
41 342 348 6
37 368 374 6
32 358 360 2
25 354 354 0
4 338 320 -18
3 399 377 -22
24 357 333 -24
28 366 320 -46
shows Total Positive pre-test, post-test, and change scores
for the TSCS. The Total Positive Scale of the TSCS has a
mean of 345.57 and a standard deviation of 30.70.
The present study, which was conducted at an Air
Force Hospital Mental Health Clinic, utilized subjects who
made use of the clinic for either crisis intervention or
brief therapy on a walk-in or appointment basis. With this
specific population and in this specific setting there was
no relationship evidenced between mean client-perceived
empathy scores arid outcome scores. No relationships were
found between first, middle, or last client-perceived thera
pist empathy scores and outcome scores. The lack of any
significant relationship between client-perceived
empathy scores and outcome scores would appear to be either
a function of the small sample obtained or to be unique to
the population utilizing the clinic. From the evidence
attained it would appear that client-perceived therapist
empathy, as it was measured in the present study, accounted
for only a small percentage of the variance of outcome as
measured by the Total Positive scores of the TSCS.
The evidence obtained from the subjects in the
multiple single-case format design suggests that client-
perceived therapist empathy as measured by the Empathy Scale
varied from interview to interview. It was noted that those
subjects with negative TSCS Total Positive change scores
had greater mean change scores between interviews (Table 1),
and thus displayed greater varied scores between interviews.
Figure 7 compares the patterns of perceived therapist empa
thy for subjects A through E corrected to a zero initial
scale score. The disparity of the perceptual patterns be
tween subjects A and B, and subjects C, D, and E is evident
in this figure. This exact probabilities of the distribu
tion of the patterns of perceived therapist empathy of
subjects A through E appear in Table 1. There do not appear
to be any discernible patterns in these probabilities. The
36
r ' ' \ ' \ i y > i '•
/ \
1 2 3 4 5 6 7 8 9 1 0
Interview Number
Figure 7. A Comparison of Patterns of Perceived Therapist Empathy for Subjects A, B, C, D, and E, Corrected to Zero Initial Scale Score
Legend: Subjects with positive outcome change scores
Subjects with negative outcome change scores
37
perceptual patterns of those subjects with negative outcome
change scores, however, tended to have distributions of
patterns of perceived therapist empathy closer to a chance
distribution although this observation may be an artifact of
the small sample.
The mean score on the Empathy Scale for client per
ceptions of therapist empathy after the third interview was
19.7 (SD = 8.2). This compares with Kurtz and Grummon's
(1972) findings in which a mean of 15.3 (SD = 12.3) was re-
porte At post-testing, the mean client-perceived thera
pist eh,; ithy score was 22.3 compared to the Kurtz and
Grummon (1972) post-therapy score of 19.3.
CHAPTER IV
RECOMMENDATIONS AND SUMMARY
Recommendat ions
The present study was designed to explore the rela
tionships between client-perceived therapist empathy and
counseling outcome in a brief therapy or crisis intervention
counseling relationship. It was also designed to explore
the patterns of client-perceived therapist empathy in a mul
tiple single-case format design. The results of the present
study must be interpreted with regard to the limited size of
the sample.
The first and most obvious recommendation for future
studies is the replication of this study in other similar
settings. In this respect more data could be attained in
other mental health clinics with clients in brief therapy.
This replicative effort would help increase the generali-
zability of the results.
The present results indicated the usefulness of the
multiple single-case format design in studying the patterns
of perception of clients in a counseling relationship. Rep
licative efforts, then, might focus on the multiple single-
case format design aspect of the present study in order to
further explore the patterns of perceived therapist empathy
38
39
of other clients in brief therapy in other mental health
clinics.
Future studies might also involve all four of the
Relationship Inventory scales with a more detailed analysis
so that more of the variance in outcome might be accounted
for. Simultaneously, more than one outcome measure might be
utilized. This would serve as a validity and reliability
check on each of the measures and perhaps provide a more
sophisticated approach to ascertaining outcome.
Summary
In previous studies, most of which were conducted in
relatively long term therapy situations, measures of thera
pist empathy have consistently been highly related to meas
ures of outcome. Unlike the previous studies, the present
study did not show relationships between measures of client-
perceived therapist empathy and measures of outcome.
Common patterns of perceived therapist empathy were
found with clients in the multiple single-case format de
sign. Client-perceived therapist empathy scores varied more
from interview to interview with those clients attaining
negative change scores.
Future research efforts would best be directed to
wards replicating the multiple single-case format design
section of this study. These efforts would aid in increasing
the generalizability of results if conducted in other mental
health clinics with clients in brief therapy.
APPENDIX A
INTRODUCTORY LETTER
The following letter was given to each subject after
he indicated that he was willing to participate in the study.
Dear Sir:
Presently a research study on counseling process is being conducted here at the base hospital mental health clinic. This letter is to acquaint you with your role in the study.
First of all, personal information, including your name, will be kept in strictest confidence. While your name need necessarily be used during the study for record keeping purposes it will not be used in the final report. Information attained during the study will not be made available to your counselor.
Your role in the study is a most important one. It will not, however, be demanding. Before your first appointment you will be asked to fill out a questionnaire called the TENNESSEE SELF CONCEPT SCALE. This scale measures your attitude about yourself and will take about 2 0 minutes to complete. You will be asked to fill out this questionnaire again after your last appointment.
After each appointment, including the first and last one, you will be asked to fill out a questionnaire called the RELATIONSHIP INVENTORY. This scale measures your attitude about your counselor during the immediately preceding appointment and will take about 5 minutes to complete.
If you have any questions or concerns please do not hesitate to contact me. I can be reached here at the clinic, Ext. 3848 or 4198; or at The University of Arizona at 884-3217.
With many thanks,
Nicholas S. Kalfas
41
APPENDIX B
SCATTERPLOTS OF EMPATHY SCALE SCORES
SHOWING SPLIT-HALF RELIABILITY
P 0 s 1 t i v e
E m P a t h y
S c a 1 e
S c o r e s
24
20
16
12
8
4
0
-4
- 8
-12
Figure 8.
-8 -4 0 4 8 12 16 20
Negative Empathy Scale Scores
24
Scatterplot of First Measure of Positive and Negative Empathy Scale Scores Showing Split-Half Reliability. (n=12)
42
43
P 0 s 1 t i v e
E m P a t h y
S c a 1 e
S c o r e s
24
2 0
16
12
0
-4
- 8
-12
Figure 9,
-8 -4 0 4 8 12 16 20
Negative Empathy Scale Scores
24
Scatterplot of Last Measure of Positive and Negative Empathy Scale Scores Showing Split-Half Reliability. (n=12)
44
P 0 s 1 t i v e
E m P a t h y
S c a 1 e
S c o r e s
24
20
16
12
8
4
0
-4
- 8
-12
Figure 10.
-8 -4 0 4 8 12 16 20
Negative Empathy Scale Scores
24
Combined Scatterplot of First and Last Positive and Negative Empathy Scale Scores Showing Split-Half Reliability. (n=24)
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