Received 12/22/15

Revised 04/29/16
Accepted 04/30/16
DOI: 10.1002/johc.12043

Examining Conditions for

Empathy in Counseling:
An Exploratory Model
Hannah B. Bayne and Danica G. Hays
✦ ✦ ✦

The authors present a new multidimensional framework for empathy through the development
and analysis of the Conditions for Empathy in Counseling Scale. Exploratory factor analysis
led to retention of 6 factors related to counselor conceptualization of empathic processes. The
rationale, procedures, initial data, and implications for counseling are discussed.
Keywords: empathy, exploratory factor analysis, Conditions for Empathy Model,
Conditions for Empathy in Counseling Scale
✦ ✦ ✦

Empathy is often viewed as important for treatment outcomes, yet as a

construct it lacks consistency in definition and assessment (Elliott, Bohart,
Watson, & Greenberg, 2011; Gerdes, Segal, & Lietz, 2010; Neukrug, Bayne,
Dean-Nganga, & Pusateri, 2013). Depending on a researcher’s orientation,
empathy may be conceptualized a number of ways, and this can affect as-
sessment and interpretation of results by focusing on one component of
empathy (such as cognitive empathy) to the exclusion of another (such as
behavioral empathy; Gerdes et al., 2010; Pederson, 2009). Despite the lack
of standard definition and assessment, the overall concept of empathy is
widely viewed within counselor training as a desirable personal character-
istic, clinical skill, and component of client satisfaction (Clark, 2010a; Elliott
et al., 2011; Rogers, 1959). Therefore, given the many purported merits of
empathy within the counseling field, it is important to continue to explore
and clarify the nature of empathic practice. In this article, we discuss exist-
ing views of empathy in counseling and present a model to further clarify
components of empathic treatment. We then discuss initial formulation and
analysis of a scale for counselor empathy conceptualization.

EMPATHY IN COUNSELING AND RESEARCH

A broad review of previous definitions and models of empathy reveals an

array of conceptual frameworks for understanding empathic ability and
Hannah B. Bayne, Department of Pastoral Counseling, Loyola University Maryland; Danica G. Hays,
College of Education, University of Nevada Las Vegas. Correspondence concerning this article should
be addressed to Hannah B. Bayne, Department of Pastoral Counseling, Loyola University Maryland,
8890 McGaw Road, Columbia, MD 21045 (e-mail: hbbayne@loyola.edu).

© 2017 by the American Counseling Association. All rights reserved.

32 Journal of HUMANISTIC COUNSELING ◆ April 2017 ◆ Volume 56
practice. Despite this variety, definitions can largely be grouped along af-
fective, moral, cognitive, behavioral, and neurological dimensions (Clark,
2004; Stepien & Baernstein, 2006). Affective empathy, or emotive empathy,
involves identifying with the emotional expression or experience of another
person, in the sense that the counselor feels what the client feels or draws
on previous personal experiences to connect with the emotional content
of the client (Clark, 2004; Kohut, 2010; Stepien & Baernstein, 2006; Tudor,
2011). However, some researchers, such as Truax and Carkhuff (1967),
argued that experiencing the emotional content of a client is not ideal
and in fact could render a counselor less effective. There is also a debate
on whether counselors are truly engaging in empathy in these cases, or
whether sympathy or countertransference leads to the emotional reaction
to the client’s story (Clark, 2004, 2010a; Neumann et al., 2009).
A second definition, moral empathy, refers to a motivation to connect with
and understand another’s reality (Stepien & Baernstein, 2006; Zaki, 2014).
This definition suggests that a person must intentionally choose to act in
an empathic way for it to be fully expressed, and thus empathic connection
cannot be accidental in its application. Cognitive empathy, in turn, involves
the counselor’s ability to accurately understand client statements from
a more distanced and objective perspective (Stepien & Baernstein, 2006;
Watson, 2002). Next, behavioral empathy is the application of verbal and
nonverbal responses that convey understanding to a client. Historically,
behavioral empathy has been a strong focus in conceptualization and as-
sessment of empathy (Baumgarten & Roffers, 2003; Egan, 2010; Truax &
Carkhuff, 1967), as well as in counselor training, because it is more easily
observed and concrete than other forms of empathy (Bohart & Greenberg,
1997; Clark, 2010a; Stepien & Baernstein, 2006).
More recently, social neuroscience research suggests that observing an-
other person’s experience can create a vicarious response in the observer,
illuminating the same neural pathways. However, vicarious neural responses
do not assure a full realization of empathy in an interpersonal context, and
thus this line of research continues to explore which factors may affect
true expression of empathy in relationships (Singer & Lamm, 2009). These
studies have thus led to some debate as to whether empathy is an inherent
quality, or whether it is a distinct skill that must be taught and intentionally
applied within an interaction (Gerdes et al., 2010; Singer & Lamm, 2009).
Given the varied conceptualizations of empathy, it is not surprising that
empathy measures, likewise, differ greatly in operational definitions and
assessment methods. Previous measures of empathy include self-report,
observation, measurement of neural responses, and client ratings (Elliott
et al., 2011; Gerdes et al., 2010; Pederson, 2009). In a review of 206 studies
of empathy within medicine, Pederson (2009) found that 38 quantitative
assessments were used across studies, whereas 51 of the studies did not
even identify a method for evaluating empathy. Similar variability exists
within counseling, psychology, and social work research (Gerdes et al.,

Journal of HUMANISTIC COUNSELING ◆ April 2017 ◆ Volume 56 33

2010): Self-report measures are common and tend to measure empathy
along affective or cognitive dimensions, although low correlation has
been found between these two constructs (Elliott et al., 2011; Gerdes et al.,
2010). Empathy has also traditionally been measured by observer ratings,
such as methods popularized by Truax and Carkhuff (1967), as a means to
rate observed empathic behavior. Client ratings represent another form of
empathy assessment and rely on clients’ perspectives of empathic content
as well as perceived impact on the therapeutic process (Elliott et al., 2011).
These differences in both conceptualization and assessment of empathy
indicate that there may be multiple constructs or lenses through which to
view the empathic process.
Despite these differences in definition and assessment measures, previous
research has nearly universally highlighted the importance of empathy and
the beneficial outcomes of an empathic approach (Bohart, Elliott, Greenberg,
& Watson, 2002; Clark, 2010a; Elliott et al., 2011; Gerdes et al., 2010; Rogers,
1959; Watson, Steckley, & McMullen, 2014). The general construct of empathy
has been linked to increased adherence to treatment, greater satisfaction with
the therapeutic relationship, and efficacy in treatment outcomes (Elliott et al.,
2011; Hojat, 2007; Neumann et al., 2009; Watson et al., 2014). Interpretations
of previous research and theoretical models of counseling posit that empa-
thy offers a client a nonjudgmental space for further reflection, as well as
modeling the potential for self-acceptance to facilitate client change (Bohart
et al., 2002; Frankel, Rachlin, & Yip-Bannicq, 2012; Rogers, 1959; Watson et
al., 2014). Empathy is also linked to a more comprehensive understanding
and conceptualization of clinical concerns, which can therefore lead to more
responsive and targeted treatments (Neumann et al., 2009).

THE CONDITIONS FOR EMPATHY MODEL

Empathy’s varied definitions, coupled with evidence of clinical importance,

demonstrate that the broader concept may need further clarification to
enhance understanding as well as the intentional application of empathy
within counseling. Although current research on empathy within counseling
is limited, research within the medical field has contributed substantially
to the current study of empathy both in theory and in practice (Hojat, 2007;
Mercer & Reynolds, 2002; Neumann et al., 2009; Norfolk, Birdi, & Walsh,
2007; Spiro, Curnen, Peschel, & St. James, 1993).
We previously developed the Conditions for Empathy Model in
medicine to better understand how empathy is applied in a clinical
setting (Bayne, Neukrug, Hays, & Britton, 2013). This grounded theory
study of physician empathy identified various components that may
affect empathic quality and expression. The components of empathy
that make up this model include considerations such as physician
qualities, barriers to empathic connection, levels of empathy, and
impact on treatment (see Figure 1). These components influence how
and to what degree empathy is expressed within the physician–patient

34 Journal of HUMANISTIC COUNSELING ◆ April 2017 ◆ Volume 56

 Physician Qualities
Medical Ability/ Conceptualization
Personal Traits Motivation Flexibility
Experience of Empathy

Internal Barriers

Internal Threats Ego Burnout Sympathy

Physician Processes

External Barriers

Managed Care/ Acute/High-Pressure Time/Volume of Medical School

Medical System Scenarios Patients Admissions/Training

Initial Empathy
Skills: Listening,
Customer Service Treating the Disease
Body Language, etc.

Genuine Empathy

Caring/Compassion Understanding Accurate Reflection Treating the Person

Patient Role in Physician Empathy

Level of Similarity or
Receptivity Trust
Understanding Vulnerability

Results of Empathy
Compliance/ Lower Individualized
Engaged Patient Relationship
Success Malpractice Treatment

FIGURE 1
The Conditions for Empathy in Medicine Model’s Initial Seven-Factor
Structure Based on a Grounded Theory Study of Physicians
Note. Each bolded theme contains three or more subthemes that relate to it. Physician processes are
bracketed to demonstrate that the first five themes involve processes experienced and/or controlled
by the physician. The additional two themes involve the patient’s role in the process as well as po-
tential outcomes that involve both the patient and the physician. From “A Comprehensive Model for
Optimizing Empathy in Person-Centered Care,” by H. Bayne, E. Neukrug, D. Hays, & B. Britton, 2013,
Patient Education and Counseling, 93, p. 211. Copyright 2013 by Elsevier. Reprinted with permission.

relationship. The sequential steps of the model progress through (a)

personal qualities of physicians, including compassion, motivation to
connect, level of experience and competency, and how they person-
ally conceptualize empathy as a skill (Physician Qualities); (b) the

Journal of HUMANISTIC COUNSELING ◆ April 2017 ◆ Volume 56 35

role of internal and external barriers, including emotional distancing,
exhaustion, and sympathy (Internal Barriers) and managed care re-
strictions, crises, and high volumes of patients (External Barriers); (c)
movement toward initial and genuine empathy, including microskills
and nonverbal qualities (Initial Empathy) and a more compassionate
connection between the physician and the patient to understand both
the disease or condition and the whole person (Genuine Empathy);
and (d) an impact on treatment based on patient attributes, including
receptivity, degree of similarity to the physician, or perceived sense of
vulnerability (Patient Role in Physician Empathy) as well as adherence
to treatment goals and more accurate identification of relevant clinical
issues (Results of Empathy; Bayne et al., 2013).
Although formed through interviews of medical professionals, the
model seems to parallel certain components of empathy in counseling,
such as counselor qualities and motivation, issues of burnout, impact
of the client on the process, and potential impacts on treatment (see
Bachelor, 1988; Clark, 2010a; Elliott et al., 2011; Nelson, Klein, & Irvin,
2003; Schumann, Zaki, & Dweck, 2014; Stebnicki, 2007; Watson, 2002;
Zaki, 2014). The model also extends the concept of empathy beyond
that of a skill or attribute to identify components of empathic practice
and process that involve both internal and external factors (Bayne et
al., 2013). Therefore, the overlap in concepts from previous empathy
research in counseling and the findings of this study present some
similarities and warrant an analysis of the model’s suitability within
the counseling profession.
Our intent for the present study, then, was to explore more closely how
the Conditions for Empathy Model might fit within a counseling framework.
We posited that a deeper understanding of the process and conditions for
empathy in counseling might clarify how to enhance empathic care as well
as further the conceptualization of empathy as a multifaceted process. We
developed an initial scale from the model, the Conditions for Empathy in
Counseling Scale (CES), and addressed the following research questions
using a sample of counseling students, practitioners, and educators:

Research Question 1: To what extent does the factor structure of the CES
align with the Conditions of Empathy Model, using exploratory
factor analysis (EFA) procedures?
Research Question 2: Does the CES have strong internal consistency?
Research Question 3: Is there a significant relationship between the CES
and the Interpersonal Reactivity Index (IRI; Davis, 1980), indicating
support for convergent validity?
Research Question 4: Is there a significant relationship between demo-
graphic variables (i.e., length of time in practice, direct service and
counseling experience, work setting, and gender) and the CES,
indicating evidence of criterion-related validity?

36 Journal of HUMANISTIC COUNSELING ◆ April 2017 ◆ Volume 56

 Research Question 5: Is there a significant relationship between the CES
and a tendency to respond in a socially desirable manner, as mea-
sured by a short form of the Marlowe–Crowne Social Desirability
Scale (MCSDS; Crowne & Marlowe, 1960; Fischer & Fick, 1993)?

METHOD

Participants and Procedure

Our study used an electronic survey upon institutional review board ap-
proval. We obtained 411 participants (401 with usable data) by posting
to counseling electronic mailing lists, contacting program leaders from
programs accredited by the Council for Accreditation of Counseling and
Related Educational Programs, and e-mailing national and regional repre-
sentatives of the American Counseling Association’s membership divisions.
We obtained participants from a range of counseling work settings and
levels of experience (i.e., 0–40 years of clinical experience; M = 6.8 years,
SD = 8.55); our primary criterion for participation was the possession of a
professional counselor identity demonstrated by enrollment in a counseling
program or possession of a degree in counseling or a related profession.
Table 1 provides participant demographic information.

Instruments and Scale Development

CES. We developed an initial scale to capture the components of the Con-

ditions for Empathy Model (Bayne et al., 2013). Questions were adjusted
to fit the language of the counseling profession (i.e., physician changed to
counselor, patient changed to client, reference to counseling instead of medi-
cal treatment). The 55-item initial scale included a brief description of each
primary category of the model and consisted of the following categories:
Counselor Attributes (12 items), Internal Barriers (nine items), External
Barriers (six items), Initial Empathy (five items), Genuine Empathy (six
items), Client Role in Counselor Empathy (seven items), and Results of
Empathy (10 items). Each category was based on one of the seven factors
of the original model (see Figure 1), and there were one or two questions
for each subcategory.
Six experts reviewed the scale and provided feedback on item content
and how well they believed each item reflected the intended construct
per category. Reviewers were identified based on expertise (through
publication record) in empathy and/or scale development. All reviewers
were doctoral-level counselor educators (n = 5) or psychologists (n = 1).
There were two male and six female reviewers ranging in age from 30
to 75 years. We adjusted 32 items based on the reviewers’ suggestions,
including (a) adding an item to assess how perceived value conflicts relate
to empathy, (b) adding neutral scaling points, (c) deleting two items due

Journal of HUMANISTIC COUNSELING ◆ April 2017 ◆ Volume 56 37

 TABLE 1
Participant Demographics
Variable n %
Gender
Female 322 81
Male 76 19
Transgender 1 0
Race/ethnicity
White/European American 324 81
African American 31 8
Hispanic/Latino 16 4
Multiracial 14 4
Asian American 4 1
Native American 2 1
Other 8 2
Highest education level
Bachelor’s degree 145 37
Master’s degree 177 45
Educational specialist degree 6 2
Doctoral degree 67 17
Primary professional role
Student 211 53
Practitioner 115 29
Faculty member 57 14
Postdoctoral/postgraduate fellow 8 2
Director/supervisor 8 2
Primary specialization
Mental health counselor 116 29
School counselor 17 4
College counselor 26 7
Counseling resident 18 5
Graduate not currently accruing hours for counseling licensure 23 6
Current practicum and internship student 130 32
Student with no clinical experience 38 12
Other (e.g., social worker, psychologist) 22 6

Note. Mean age was 37.34 years (SD = 12.59, range = 20–70).

to redundancy, and (d) performing minor edits. We agreed with all the
suggestions and adopted a final scale of 54 items for EFA, maintaining
the primary categories of the original model for a proposed seven-factor
structure. Participants were asked to rate each item using a 6-point Lik-
ert scale (ranging from 1 = disagree to 6 = agree) with a selection between
each point label to allow participants to express their level of agreement
along a continuum rather than as a fixed response. The EFA survey also
contained 16 reverse-scored items.
IRI. We used the IRI (Davis, 1980) to provide initial evidence of convergent
validity for some elements of the CES, particularly those components in-
tended to measure empathic understanding and personal conceptualization
of the counselor. The IRI was selected because of its widespread use as a
measure of empathy, as well as its multidimensional framework for assessing
empathy along four distinct factors (Cliffordson, 2002; Davis, 1980; Pederson,

38 Journal of HUMANISTIC COUNSELING ◆ April 2017 ◆ Volume 56

2009). The IRI is a self-report scale consisting of 4 seven-item subscales:
Empathic Concern (EC), Personal Distress (PD), Perspective Taking (PT),
and Fantasy (FS). The first two subscales, EC and PD, contain items aimed
at measuring emotive empathy, whereas the PT subscale addresses cognitive
empathy components. The FS subscale measures an individual’s ability to
use fantasy or imagination to extend beyond his or her own perspective.
Participants answer each item along a 5-point Likert-type scale, indicating
whether the item does not describe me well (1) or describes me very well (5).
Each subscale receives its own score, further stressing that empathy is a
multidimensional construct. Overall reliability of the IRI as tested by Davis
(1980) is sufficient across each of the subscales, with internal reliabilities
ranging from .71 to .77 and test–retest reliabilities ranging from .62 to .71.
The subscales and multidimensional factor structure of the IRI have also
been tested extensively and show moderate to high correlation with other
empathy constructs (Cliffordson, 2002; Davis, 1983).
MCSDS. Because empathy is considered a desirable construct within the
counseling profession, we determined that participants may respond to sur-
vey questions based on socially desirable responses. We therefore included
the 10-item Short Form X1 version of the MCSDS (MCSDS-X1; Crowne &
Marlowe, 1960) to screen for participants who were more inclined to provide
socially desirable responses (Fischer & Fick, 1993). The MCSDS measures
socially desirable responding through a 33-item scale consisting of true/false
statements. Statements such as “I like to gossip at times” or “I have never
deliberately said something that hurt someone’s feelings” assess the degree to
which participants might be inclined to align responses toward what is socially
desirable rather than their true feelings or practices. Several briefer versions
of the scale have been developed and tested, with the MCSDS-X1 identified
as the scale of choice because of its length (10 items), high correlations with
the original scale, and high internal consistency (α = .79; Fischer & Fick, 1993).

RESULTS

EFA

Research Question 1 related to investigating the factor structure of the

54-item CES using a principal axis extraction followed by a promax
rotation, given the interdependent conditions of empathy (Bayne et al.,
2013). The Kaiser–Meyer–Olin test statistic for sampling adequacy was
good (.74) and the Bartlett’s test of sphericity was significant (p < .001),
indicating that the data were suitable for factor analysis. Communalities for
the scale ranged from .22 to .63 (M = .41). We extracted six factors based on
examination of the scree plot (Cattell, 1966; Costello & Osborne, 2005; Pett,
Lackey, & Sullivan, 2003) and factors having eigenvalues 1.00 or greater;
this accounted for 27.27% of the variance. Using .30 as the factor loading
criteria, 29 of the 54 items loaded on one of the six initial factors (see Table 2).

Journal of HUMANISTIC COUNSELING ◆ April 2017 ◆ Volume 56 39

 TABLE 2
Rotated Factor Structure and Total Variance
Explained for the Conditions for Empathy Scale
Extracted Sums of Squared Loadings
Factor No. of Items Eigenvalue % Variance Cumulative %
1. Empathy in Treatment 8 4.73 8.75 8.75
2. Client Variables 6 4.01 7.42 16.17
3. Barriers to Empathy 4 2.33 4.32 20.49
4. Person of the Counselor
Variables 6 1.40 2.60 23.09
5. Initial Empathy 2 1.26 2.34 25.42
6. Empathy in the
Counselor–Client Dyad 3 1.00 1.85 27.27

Items that loaded at less than .30 for all factors were excluded from the
instrument (Costello & Osborne, 2005; Pett et al., 2003). Items 8 and 10
each cross-loaded on two factors and were placed on Factors 1 and 6,
respectively, based on theoretical assumptions of the original model
(Bayne et al., 2013; Pett et al., 2003). Table 3 provides the rotated factor
structure, communalities, and item means and standard deviations for
the revised CES.

Evidence of Reliability and Validity

We determined evidence of reliability and validity for the CES by comput-

ing internal consistency estimates and examining the association between
the CES and IRI scales (Davis, 1980) and select demographic variables. To
address Research Question 2, we calculated Cronbach’s α for the 29-item
CES scale, and findings indicated adequate reliability for the sample size
(see Ponterotto & Ruckdeschel, 2007). Cronbach’s α for the total scale was
.81, with reliability estimates for the initial factors at α = .73 (Factor 1), α =
.61 (Factor 2), α = .65 (Factor 3), α = .59 (Factor 4), α = .29 (Factor 5), and α
= .30 (Factor 6). On the basis of the reliability estimates for the six factors,
we determined that a total score is recommended over separate scores for
each subscale.
To provide initial evidence of convergent validity for the CES (Research
Question 3), we then compared the 29-item CES with the total and subscale
scores from the IRI (Davis, 1980). We first present scoring information for
the CES and IRI. The mean and standard deviation for the CES based on
the EFA sample was 4.10 and 0.35, respectively, indicating that respondents
endorsed higher levels of empathy overall. The mean and standard devia-
tion IRI subscale scores are as follows: PT (M = 22.31, SD = 3.78), EC (M =
22.31, SD = 3.47), FS (M = 18.16, SD = 5.54), and PD (M = 8.16, SD = 4.44).
Pearson correlation coefficients demonstrated significantly positive cor-
relations (p < .01) between the CES and each subscale of the IRI, with the
exception of the PT subscale (r = .09, p = .09). This suggests strong convergent

40 Journal of HUMANISTIC COUNSELING ◆ April 2017 ◆ Volume 56


TABLE 3
Rotated Factor Structure, Communalities, and CES Item Means and Standard Deviations

Factor/Item 1 2 3 4 5 6 h2 M SD
Factor 1: Empathy in Treatment
8. Empathy includes becoming emotionally involved with a client.a –.14b –.03 –.14 –.13 .02 –.09 .49 4.61 1.38
24. Being empathic helps me when working with clients in crisis.a –.35b .26 .10 –.08 .02 .21 .39 1.83 0.95
34. Having empathy allows me to accurately understand my client. .46b .05 .03 .09 –.08 –.08 .43 4.88 0.95
45. My clients are more engaged when I am empathic toward them. .50b –.14 .07 .26 .09 .03 .40 5.24 0.78
47. Understanding my clients helps me establish goals that the client is more
likely to follow through with. .32b –.09 –.02 .12 .03 .02 .50 5.33 0.78
50. Clients are more satisfied with treatment when I am empathic. .64b –.13 –.02 .12 –.05 .01 .47 5.21 0.84
51. I am more satisfied with my work when I am empathic with clients. .69b –.06 .00 .17 .02 –.18 .63 5.17 0.91
53. I can better customize treatment when I fully understand a client. .37b .15 .04 .29 .06 .08 .50 5.20 0.81
Factor 2: Client Variables
15. A client’s diagnosis helps me establish empathy with more accuracy than
any other factor of treatment. –.06 .38b –.01 –.05 –.14 .18 .29 2.13 1.17
22. I do not believe that managed care affects my ability to be empathic with
clients.a –.29 .31b .31 .03 .02 –.08 .47 3.21 1.59
23. It is not always feasible to be empathic with a client in crisis because other
more pressing interventions are needed. –.17 .37b .18 .06 –.15 .34 .46 2.79 1.39
37. I can focus on my client’s needs only after I understand who they are as a
person. .11 .44b .13 .08 –.04 .13 .36 3.31 1.35
38. I can only be empathic to the degree my client is willing to connect with me. –.23 .65b .24 .26 –.19 .20 .58 2.61 1.32
41. I can only establish empathy with a client who has trust in the therapeutic
process. –.19 .73b .11 –.04 –.21 .23 .58 2.24 1.22
Factor 3: Barriers to Empathy
13. It may be difficult for me to be empathic if I am uncomfortable with certain
session content. –.11 .11 .40b .12 .03 .25 .34 3.52 1.34
17. It is difficult to be empathic when I am exhausted. –.03 .04 .69b .09 .09 .08 .53 4.14 1.23
25. It is difficult for me to be empathic when seeing a large volume of clients. –.09 .14 .72b .03 –.01 .19 .58 3.07 1.42
26. I am less likely to be empathic during sessions when there are time
constraints. .02 .20 .52b .17 –.07 .13 .35 2.61 1.35
(Continued)

41
42
TABLE 3 (Continued)
Rotated Factor Structure, Communalities, and CES Item Means and Standard Deviations

Factor/Item 1 2 3 4 5 6 h2 M SD
Factor 4: Person of the Counselor Variables
1. My personality guides the way I interact with clients. .08 .01 .13 .43b –.01 .20 .32 4.83 0.94
6. The more clients I see, the more I am able to understand client perspectives. .13 .05 –.01 .57b .09 .11 .43 4.58 1.22
9. I know I am empathic when I can remain nonjudgmental while understanding
the client’s perspective. .28 .04 –.03 .36b –.11 –.15 .46 4.92 1.10
32. I am able to be empathic when I care about my client. .21 .07 .10 .44b –.14 .02 .43 4.94 1.11
44. I am more compassionate toward clients who I perceive as being vulnerable
in some way. .05 .04 .28 .46b –.23 .10 .41 3.62 1.41
52. I develop better therapeutic relationships with my clients when I understand
them. .24 .13 .09 .39b .03 .07 .46 5.21 0.86
Factor 5: Initial Empathy
7. As I become a more competent counselor, my ability to be empathic remains
the same as it was when I was first learning.a –.07 –.06 .12 .02 .69b .07 .56 4.30 1.32
28. Actively listening to my clients is sufficient for them to feel as though I am
being empathic.a .13 –.29 –.17 –.14 .44b –.18 .43 4.32 1.29
Factor 6: Empathy in the Counselor–Client Dyad
10. I cannot empathize with a client if I have not had a similar experience.a .16 –.43 –.24 .00 .17 –.32b .40 5.56 0.65
11. It is hard to empathize with a client who has a different culture or set of
values than I do.a .08 –.25 –.18 –.05 .06 –.52b .35 4.84 1.13
43. It is easier to develop empathy for a client who is similar to me in some way. .00 .07 .16 .20 .04 .64b .52 3.98 1.34
Note. CES = Conditions for Empathy in Counseling Scale.
a
Reverse-scored item. bValue represents items that belong to that factor.
validity evidence for the subscales of EC (r = .20, p = .000), FS (r =.28, p
= .000), and PD (r = .15, p = .004). Given that the IRI purports to measure
multiple dimensions of empathy, it stands to reason that the PT subscale
is not as closely related to the six-factor structure of the CES, whereas the
FS, EC, and PD subscales do correlate with the underlying factor structure
of the final CES. Within the IRI, PT appears to assess a more general ability
to take on the perspective of others, whereas related questions in the CES
concern the process of perspective taking specifically within the therapeutic
setting. It is difficult to speculate as to how these differ, but any difference
may account for the lack of significance between PT and CES scores.
With respect to Research Question 4, we conducted a four-way analysis
of variance along various demographic variables and scores on the CES to
examine main and interaction effects for gender, length of time in clinical
practice, work setting, or whether the individual had ever received per-
sonal counseling. Levene’s test for equality of error variance was found to
be nonsignificant, F(281, 72) = 1.29, p = .102. There were no main effects
between CES scores and gender, F(1, 72) = 3.31, p = .07, ηp2 = .04; length of
time in practice, F(125, 72) = 1.12, p = .30, ηp2 = .66; work setting, F(11, 72)
= 0.88, p =.57, ηp2 = .12; or personal experience with counseling, F(1, 72) =
0.17, p = .68, ηp2 = .002.

CES and Social Desirability

Participants responding in a socially desirable manner or pattern can ob-

scure interpretation of an assessment’s underlying structure as well as its
relationship with other variables (van de Mortel, 2008). Thus, examining
for significance in the relationship between social desirability scales and
an assessment can help to detect if this particular response set is confound-
ing other findings. To address Research Question 5, we examined Pearson
correlation coefficients for the final CES and the MCSDS-X1. The CES was
not significantly correlated with the MCSDS-X1 (r = .95, p = .81), indicating
that participants were not prone to selecting socially desirable responses
and thus may have been more likely to honestly assess themselves across
the CES items.

DISCUSSION

Empathy is significantly linked with various treatment outcomes across

disciplines (Elliott et al., 2011; Hojat, 2007; Neumann et al., 2009; Watson et
al., 2014); however, additional research is warranted given its multidimen-
sional nature and the challenges in operationalizing and assessing empathy
(Cliffordson, 2002; Davis, 1980; Pederson, 2009). Although there are various
conceptualizations of empathy (Gerdes et al., 2010; Pederson, 2009; Stepien
& Baernstein, 2006), less is known about empathy as a process or the factors
that may enhance or impede its application. The present study provides an

Journal of HUMANISTIC COUNSELING ◆ April 2017 ◆ Volume 56 43

initial analysis of the Conditions for Empathy Model and its application
with a counseling population. Components of the model that were retained
following EFA include counselor conceptualizations of empathy and ac-
knowledgment of situational variables that may affect the full expression
of empathy within a clinical encounter.
Upon completion of EFA, the factor structure of the CES was best rep-
resented by a six-factor solution. Because of the exploratory nature of the
results, labels for these factors are tentative and are founded in the language
of the original theoretical model (Pett et al., 2003). The six factors capture
aspects within each of the seven components of the Conditions for Empathy
Model (Bayne et al., 2013). However, even though items from all seven fac-
tors were retained, the items fell on different factors within the six-factor
structure of the EFA. To compare the theoretical loadings with the actual
placement of items on the six-factor structure, we present an examination
of each factor in the following discussion.

Exploratory Factor Loadings

Factor 1. In this study, the items for Factor 1 appear to delineate counselor
perceptions of the benefits of empathy within treatment, including client
engagement, satisfaction, and adherence. Items also reflect participant ac-
knowledgment of definitions of empathy related to accurate understanding,
and the distinction of empathy from sympathy. Therefore, we named this
factor Empathy in Treatment. The eight items within this factor thus serve
to clarify the counselor’s views of empathy’s definition and role within
the therapeutic process. This factor seems most similar to Factor 7 within
the theoretical model, Results of Empathy, which describes the impact of
empathic care as resulting in engaged patients, compliance and success
with treatment, lower malpractice, enhanced clinical relationships, and
more individualized and responsive treatment.
Factor 2. In this study, items loading on Factor 2 appear to be related to
counselor perceptions of client variables that can affect the expression of,
or effectiveness of, empathy in the therapeutic setting. The importance of
the client’s willingness to connect and develop trust with the counselor
falls within this factor. This is similar to the factor Patient Role in Physi-
cian Empathy within the original model, which includes patient receptivity
and trust as essential facilitative components of successful empathic care.
However, Factor 2 diverges from the original model in that two items (“A
client’s diagnosis helps me establish empathy with more accuracy than any
other factor of treatment” and “I do not believe that managed care affects
my ability to be empathic with clients”) both loaded positively on this factor.
Each of these items was hypothesized to be negatively weighted based on
the theoretical model, such that physicians believed that diagnoses at times
circumvented the opportunity to be fully empathic, and that managed care
restrictions greatly affected the ability to be empathic with a patient. In this

44 Journal of HUMANISTIC COUNSELING ◆ April 2017 ◆ Volume 56

study, these items loaded positively on Factor 2, potentially indicating that
participants consider diagnosis as useful in the formation of empathy, and
managed care may not be as much of a barrier as in the medical field. If
true, this could fit within the reconceptualization of empathy posited by
Clark (2010b), who suggested that sources of knowledge (including diag-
nostic criteria) can enhance empathic understanding. Given the six items
identified for this factor, we provide a tentative label of Client Variables,
because these items seem to describe characteristics of clients (e.g., willing-
ness to trust and connect with the counselor, level of crisis, diagnosis) that
participants identify as affecting the empathic process.
Factor 3. The four items loading onto Factor 3 seem to correspond with
counselor perspectives of potential limitations to empathic care. Items such
as “It is difficult for me to be empathic when I am exhausted” or “I am
less likely to be empathic during sessions when there are time constraints”
demonstrate how empathy can be influenced by external factors. We tenta-
tively label this factor Barriers to Empathy. In the original model, physicians
identified many barriers to empathy, and therefore these processes were
broken into two separate factors: Internal Barriers (consisting of things such
as physician burnout or overidentification with the client’s emotions through
sympathy) and External Barriers (consisting of managed care restrictions,
crisis situations, sheer volume of patients, and medical training that did
not prioritize a focus on empathic care). The barriers retained within this
factor are notably all limitations within the person of the counselor, such
as personal fatigue or discomfort with session content.
Factor 4. Items loading onto Factor 4 seem to relate to the counselor’s
view of the source of empathy toward clients. The counselor’s personality
is attributed to how he or she interacts with clients, and perceived client
vulnerability is seen as a compassion-enhancing factor. Other items on
this factor include the counselor’s awareness of when and how empathy
is activated (i.e., “I know I am empathic when I can remain nonjudgmental
while understanding the client’s perspective,” “I am able to be empathic
when I care about my client,” and “I develop better therapeutic relation-
ships with my clients when I understand them”). The value of experience
on empathy development was also acknowledged (“The more clients I
see, the more I am able to understand client perspectives”). This factor is
tentatively labeled Person of the Counselor Variables because the items re-
flect personality, experience, and counselor conceptualizations of empathy.
This factor is similar to the initial factor in the theoretical model, Physician
Qualities, in the identification of personal traits (such as personality and
conceptualizations of empathy), as well as the Genuine Empathy factor,
which identifies genuine care, compassion, and accurate understanding as
essential for a deeper empathic understanding.
Factor 5. The two items on Factor 5 deviate from the expected direction
of the theoretical model; thus, this factor is difficult to interpret. Another
issue is that it is ideal for retained factors to have at least three items

Journal of HUMANISTIC COUNSELING ◆ April 2017 ◆ Volume 56 45

(Costello & Osborne, 2005; Pett et al., 2003) for instrument development.
However, because this study is exploratory in nature and we are therefore
not advocating the adoption of this scale without further review and test-
ing, we have retained the six-factor model as the most parsimonious and
can therefore attempt to speculate on the meaning of the fifth factor. One
of the items, “As I become a more competent counselor, my ability to be
empathic remains the same as when I was first learning,” was originally
developed as the reverse-scored item to measure the concept of experience
as a means to enhance empathy. In the original model, more senior physi-
cians indicated that their ability to be empathic improved as they became
more comfortable and fluent in other areas of treatment, and as years of
experience assisted them in better understanding patients as well as the
importance of utilizing empathy within clinical interviews. It is interest-
ing that another item related to this concept loaded positively on Factor 4
(“The more clients I see, the more I am able to understand client perspec-
tives”). It could be that counselors in this study view understanding of
client perspectives, which they acknowledge as improving with experience,
as different than empathic ability, which these results indicate counselors
believe does not change over time.
The second item in Factor 5, “Actively listening to my clients is suffi-
cient for them to feel as though I am being empathic,” was also intended
to be a negatively weighted item but loaded positively on this factor.
In the original model, physicians indicated that there were two levels
of empathic skill and behavior: Initial Empathy, which consisted of the
minimal skills needed to connect with a patient (including active listen-
ing), and Genuine Empathy, which suggested a deeper level of care and
concern that was both more genuine in its application and also more ef-
fective. In this study, however, participants largely expressed agreement
that active listening is sufficient for empathy. This may reflect the strong
emphasis on active listening in the microskills training approach that is
the basis of most counselor skills training courses (Ridley, Kelly, & Mol-
len, 2011). However, there is some doubt as to whether active listening
skills are sufficient for empathic connection. Andres-Hyman, Strauss, and
Davidson (2007) stated,
These techniques serve merely as the trappings of accurate empathy, positive regard,
nonpossessive warmth, and congruence or genuineness. . . . Distilling these multi-
dimensional factors into a handful of somewhat superficial strategies only begins to
capture what it takes to truly understand and reflect another person’s perspective
and subjective experience. (p. 81)

Empathy may, therefore, be a more complex process. The responses from

participants in this study, however, demonstrate that empathy is still
viewed by many as a component of effective active listening skills. We
will draw from the original model to tentatively label this factor Initial
Empathy, because both items acknowledge a foundational component of

46 Journal of HUMANISTIC COUNSELING ◆ April 2017 ◆ Volume 56

empathy that can be sufficiently applied regardless of experience level or
more advanced application of skills.
Factor 6. Finally, Factor 6 consists of three items, two of which load
negatively on the factor. Two of these items, “I cannot empathize with a
client if I have not had a similar experience” and “It is hard to empathize
with a client who has a different culture or set of values than I do,” load
negatively and indicate the ability to empathize with clients who are dif-
ferent from the counselor, thus also supporting the concept that empathy
involves the “as if” quality of taking on a client’s perspective without
needing to fully feel or think as they do (Rogers, 1957). Still, the third item
loading on this factor, “It is easier to develop empathy for a client who is
similar to me in some way,” acknowledges that although empathy allows
counselors to transcend differences, similarities can still enhance or ease
the process by which they relate to their clients. This factor can therefore
be labeled Empathy in the Counselor–Client Dyad to reflect participants’
perspectives of the relational impacts of counselor and client identities. This
factor corresponds with some of the concepts in the Patient Role in Physi-
cian Empathy factor in the original model, which indicates that degree of
similarity between patient and physician can enhance physician empathy.

Summary of the Exploratory Model

This exploratory analysis thus preserves many of the concepts from the
original model, yet not all factors were retained and item loadings resulted
in the need to hypothesize new factor labels. Although this is an acceptable
practice (Pett et al., 2003), these labels should be seen as theoretical in nature
and tentative placeholders pending more substantial analysis of each fac-
tor. The resulting 29-item CES indicated adequate reliability as a total scale
and thus consistently evaluated multiple components of empathy among a
sample of participants with professional identities within counseling and
related professions. The CES yielded strong content and construct validity
alongside the constructs of the IRI, which measures multiple dimensions
of empathy. However, full criterion-related validity cannot be supported
without further development of the scale.
There were no interaction effects based on various demographics of coun-
selors, counselors-in-training, and related professionals. This was surprising,
given that previous research has found differences in empathy across gender
(Neumann et al., 2009; Schulte-Ruther, Markowitsch, Shah, Fink, & Piefke,
2008), and the original model would suggest that empathy might be affected
by level of experience and training (Bayne et al., 2013). The lack of effects across
these variables could be related to the fact that the scale in its entirety assesses
counselor-perceived conceptualization and limitations of empathy in addition
to qualities of the empathic counselor. Qualities of empathy such as perspective
taking or emotional connection, as measured by previous instruments such as
the IRI, may vary more considerably along demographic variables than when

Journal of HUMANISTIC COUNSELING ◆ April 2017 ◆ Volume 56 47

empathy is viewed through a broader and more dimensional perspective of
conceptualization, limiting and enhancing factors, and treatment implications.
Further study is needed to explore these effects.

Implications

This study represents an initial step toward applying a multidimensional theoreti-

cal model of empathic conditions to the counseling setting. Primarily, this study
sought to expand an understanding of the multiple components of empathic
practice within counseling, based on a model originally developed within the
medical field. Instead of viewing empathy along one dimension (as a personal
quality or an applied skill), this model and the resulting CES assessment include
contextual processes that may either enhance or limit the expression of empathy
within the therapeutic setting. This is significant in that a counselor can possess
a full understanding of empathy and be skilled in applying it, yet still be limited
by personal or contextual variables such as client factors or fatigue/burnout.
Likewise, counselors who are limited in their understanding of empathy may
struggle to form empathic connections because of emotional enmeshment or
differential treatment of clients who are similar to the counselor.
Although more research is needed on the CES as an assessment tool, each
of the initial factors and the items contained therein could be useful to ex-
plore as discussion points within counselor training. For example, the effects
of empathy on the counseling process highlight the benefits of prioritizing
empathy within the counseling relationship. These items could be discussed
within clinical supervision to stress the importance of developing an empathic
practice. In addition, the client, barriers, and counselor variable items can be
useful within supervision discussions to acknowledge circumstances when
empathy is difficult to maintain or is complicated by additional variables.
Supervisors and counselor educators can help counselors-in-training brain-
storm ways to combat such limiting factors, as well as how to be attuned to
these factors and their potential impact on a session.
The CES also represents a step toward an assessment of the complex
process of empathy. This complexity is evident by the numerous conceptu-
alizations of empathy that currently exist, and we present one framework
for how empathy might be affected by various processes and conditions.
A broader understanding of empathy can influence how it is taught and
also how it is perceived in clinical practice. Rather than teaching empathy
only as a set of skills, whether minimally in the form of active listening or
more fully in the form of specific counselor interventions, it can be captured
as a process requiring knowledge, self-awareness, and skilled application.

Limitations and Future Research Directions

It is important to acknowledge the limitations associated with this study

in order to inform any application of the results or the use of the CES.

48 Journal of HUMANISTIC COUNSELING ◆ April 2017 ◆ Volume 56

First, it is again worth repeating that this study was an initial, exploratory
inquiry into whether the proposed theoretical model could be applied, in
whole or in part, to the counseling profession. The results, as discussed
earlier, demonstrate some initial support for certain components of the
model, but also indicate that the factor structure of empathy in counseling
may look different than in the medical field. Regarding the CES as a scale,
additional research is needed before it is more widely used to evaluate
the role of empathy in counseling process and outcome. Of particular im-
portance is establishment of further psychometric properties of the scale,
including test–retest reliability. Comparisons with other existing measures
of empathy may also further clarify the constructs represented by the CES
and highlight the various dimensions of empathy within the scale. In ad-
dition, although this study included participants across a broad range of
professional identities and experience, recruitment efforts were primarily
focused within counselor education, and thus the samples reflect a heavier
emphasis on these perspectives. Further research could use recruitment
strategies to focus on additional perspectives and professional roles in
related disciplines. Other demographic variables may also be interesting
to explore, such as primary theoretical orientation or variations in training.
In addition, previous research in the medical field has indicated that levels
of empathy decrease throughout training (Hojat et al., 2004); therefore,
although no significant effect was discovered based on level of experience
within this study, perhaps future analysis could utilize the CES to explore
whether conceptualizations of empathy change in response to certain com-
ponents of counselor training or within a training program.
One limitation concerns the fact that recruitment was conducted through
e-mails, electronic mailing lists, and counselor education program faculty.
Therefore, individuals electing to participate in either phase of the study
were likely more proactive in engaging within professional communi-
ties (such as via an electronic mailing list or enrollment in a counseling
program) and likely already had a personal or professional interest in
empathy that encouraged their participation. These factors could certainly
have influenced the results in that participants may reflect counselors
or counselors-in-training who already have more advanced conceptu-
alizations of empathy, and/or who have learned to prioritize empathy
despite contextual or counselor-related variables. Average scores on the
CES, then, could vary in other populations and could indicate differing
conditions for empathy in other counseling settings. Although this study
did include some counselors who identified primarily as practitioners,
it would be interesting to see the CES applied across multiple treatment
and practice settings.
Another limitation is that the Conditions for Empathy Model contains
components of empathic practice that do not correspond with any cur-
rent assessment of empathy. Therefore, we were limited in our ability to
explore construct validity of each component of the scale. The IRI, due to

Journal of HUMANISTIC COUNSELING ◆ April 2017 ◆ Volume 56 49

its multidimensional approach to empathy, was a best fit for this initial
psychometric evaluation, yet further inquiry should attempt to explore
additional components of the CES that may not be fully captured within
the related constructs of the IRI.
It is also a significant limitation that the selected model only explains
27% of the variance. To achieve an adequate amount of variance, close to
17 factors would have to be selected, which is too large to be meaningful
(Pett et al., 2003). One explanation of this limitation is that the items may
have been poorly constructed, and thus future research could attempt to
rewrite items to better reflect the intended underlying constructs. Another
explanation could be that the complexity of the original model results in
an overly cumbersome assessment, requiring a large number of factors
to represent the model as a whole. The original model consisted of seven
proposed factors with a total of 29 subcategories, and items for the scale
were crafted to capture each of these components. If each subcategory re-
flected different constructs, it could then be possible that the scale itself is
attempting to measure something far too complex. To clarify how each of
these constructs may relate to empathy, future research should break the
model into smaller parts to examine each in more depth, utilizing existing
measures of empathy to cross-validate related constructs. If empathy truly
is a multidimensional process, then it stands to reason that a comprehensive
model may indeed be rather complex and robust. There is a need for future
studies to distinguish which components of the model are indeed related to
the process of empathy, which may be related constructs worth additional
exploration, and which are superfluous categories that should be removed.

CONCLUSION

Our study provides preliminary analysis of a model of conditions for empa-

thy in counseling. The EFA revealed a six-factor model that meets acceptable
reliability and validity standards based on the assessed population. Although
the CES was unable to capture suitable variance of examined empathy in
counseling, it identifies several factors that may be part of a multidimen-
sional understanding of empathy and therefore warrants future research
and examination of related constructs. Further research is needed in the as-
sessment and exploration of scale properties, although this study represents
an important first step in conceptualizing empathy as a process within the
counseling setting. The CES can be used as a broader conceptualization of
empathic processes and can also be used to monitor understanding and self-
awareness of empathy within counselor training and supervision.

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a0037679

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