September has been quiet for this blog as it included family traveling as well as immersion into the 6th edition revision of Clinical Interviewing. While re-working Chapter 7 (Evidence-Based Relationships), we developed three new case examples. As with all case examples, these are inspired by real cases of our own or of other professionals, but also include plenty of fictional components. The fictional components allow for concise articulation of specific learning goals, while preserving anonymity.

On a related note, one highly-esteemed reviewer of the 5th edition commented—repeatedly—that the text was filled with “bloat.” This was helpful feedback, albeit difficult. Ouch! And so we are striving in the 6th edition to consistently de-bloat everything:). What fun! Don’t worry; we’re still hydrating (this is exactly the sort of commentary that gets us into bloating trouble)

Here are the Case Examples.

Case Example: 7.1

Congruence across Cultures

Cultural identity has many dimensions (Collins, Arthur, & Wong-Wylie, 2010). In this example, during an initial clinical interview with an African American male teenager, the clinician is using congruence or authenticity across several different cultural domains.

Client: This is stupid. What do you know about me and my life?

Clinician: I think you’re saying that we’re very different and I totally agree with you. As you can probably guess, I’ve never been in a gang or lived in a neighborhood like yours. And you can see that I’m not a Black teenager and so I don’t know much about you and what your life is like. But I’d like to know. And I’d like to be of help to you in some way during our time together.

This clinician is being open and congruent and speaking about some of the obvious issues that might interfere with the clinician-client relationship. It would be nice to claim that this sort of openness always results in clinician-client connection, but nothing always works. However, as researchers have reported, there’s a tendency for congruence to facilitate improved treatment process and it also appears to contribute to positive outcomes, at least in a small way (Kolden et al., 2011; Tao, Owen, Pace, & Imel, 2015).

Case Example 7.2:

Intermittent Unconditional Positive Regard and Parallel Process

Michelle is a 26-year-old graduate student. She identifies as a White Heterosexual female. After an initial clinical interview with Hugo, a 35-year-old who identifies as a male heterosexual Latino, she meets with her supervisor. During the meeting she expresses frustration about her judgmental feelings toward Hugo. She tells her supervisor that Hugo sees everyone as against him. He’s extremely angry toward his ex-wife. He’s returning to college following his divorce and believes his poor grades are due to racial discrimination. Michelle tells her supervisor that she just doesn’t get Hugo and that she thinks she should refer him instead of having a second session.

Michelle’s supervisor listens empathically and is accepting of Michelle’s concerns and frustrations. The supervisor shares a brief story of a case where she had difficulty experiencing positive regard toward a client who had a disability. Then, she asks Michelle to put herself in Hugo’s shoes and imagine what it would be like to return to college as a 35-year-old minority person. She has Michelle imagine what might be “under” Hugo’s palpable anger toward his ex-wife. The supervisor also tells Michelle, “When you have a client who views everyone as against him, it’s all the more important for you to make an authentic effort to be with him.” At the end of supervision Michelle agrees to meet with Hugo for a second session and to try to explore and understand his perspectives on a deeper level. During their next supervision session, Michelle reports great progress at experiencing intermittent unconditional positive regard for Hugo and is enthused about working with him in the future.

One way to enhance your ability to experience unconditional positive regard is to have a supervisor who accepts your frustrations and intermittent judgmental-ness. If the issues that arise in therapy are similar (or parallel) to the issues that arise in supervision, it’s referred to as parallel process (Searles, 1955). This is one reason why when you get a dose of unconditional positive regard in supervision, it may help you pass it on to your client.

Case Example 7.6

Mutual Empathy – A Feminist Relationship Factor

Chantelle, a 25-year-old woman attending community college, came to the student health service for counseling. She was intermittently tearful as she described her abusive childhood. Her counselor, a 25-year-old female counseling intern, listened, paraphrased, offered feeling reflections, and stayed connected with the client through the stories and tears. At one point, the client expressed hate for herself and then described repeated scenarios where she felt coerced into providing sexual favors for males in her household in order to have access to transportation and food. With tears of empathic resonance in her eyes the therapist said, “I have this image of you in prison and the men in control only hand you the keys to temporarily go out on leave if they shame you by giving them sexual gratification.”

The client noticed her counselor’s emotion. In response she had a powerful emotional outpouring. Later, when asked about what was helpful in her work with the counseling intern, the client identified her counselor’s tears. She said that her mother and sisters always minimized and humiliated her for “complaining” about living in a home where she had food and shelter. For the client, the whole idea and experience of someone else having an empathic emotional response to her shame and self-revulsion played a big role in her healing.

And this is the end of the case examples. Comments–excluding comments about bloating–are always welcome.

Just because I know you all want in on the new introductory comments for Chapter 3 of the 6th edition of Clinical Interviewing.

And just because I’m wondering if my reference to Csikszentmihalyi’s fish cutter is too enigmatic.

Here’s the text; note it’s a draft with incomplete citations and likely grammar challenges.

Chapter 3

One vision for this chapter (and the next two) is to identify, describe, and illustrate every technical skill that therapists might employ during a clinical interview. We hope to do this so clearly that you can easily acquire and practice these skills. If we accomplish this vision, then you’ll know how to help clients:

• Talk openly about themselves, their problems, and their hopes;
• Have insights or new ideas about what they can do to manage their problems and achieve their personal goals; and
• Begin engaging in positive behavior change.

Other scholars and practitioners have referred to clinical interviewing technical skills as facilitative behaviors, helping skills, microskills, counseling behaviors, and more.

As we focus like a laser on skill-building, we also feel a troubling discomfort. This discomfort stems from our awareness that the great Carl Rogers would NOT AGREE IN THE LEAST with what we’re writing. Rogers would vehemently disagree because, for him, the special ingredients that make therapy work were NOT techniques or skills or behaviors. Instead, he repeatedly and emphatically claimed that successful therapy (even one-session clinical interviews) were all about therapist ATTITUDE—and the subsequent development of a “certain type of relationship” (Rogers, 1942, 1957, 1961; more on this in Chapter 6).

It’s always difficult to argue with Carl Rogers. His gentle, caring, and reflective voice keeps urging us to abandon skill development in the service of empathy training. And his point is exceptionally valuable, essential, and profound (we hope we’re making our thoughts on this clear). Many contemporary therapists, academics, and others don’t understand the essence of what Carl Rogers wrote and said about person-centered therapy. Too often his ideas are dumbed down to reflection skills (e.g., paraphrasing and reflection of feeling). The consequence of this dumbing down is that far too many helping professionals-in-training end up learning parroting skills. And we should note that parroting skills—unless emanating from an actual parrot and not a human counselor—are universally annoying and not particularly therapeutic.

As we open this chapter, we cannot in good conscience risk having you conclude that all you need to do is learn a couple dozen behavioral skills to become a good therapist or clinical interviewer. Rogers was right; that’s just not how it works.

Adopting a Therapeutic Attitude

Back in the 1940s, 50s, and 60s, Rogers repeatedly wrote about his core conditions or counselor attitudes. The conditions he viewed as necessary and sufficient to establish a therapeutic relationship were congruence, unconditional positive regard, and empathic understanding. If he were alive today, he would probably cringe at the modern emphasis on teaching therapeutic behaviors or skills, noting that nothing clinicians do can be therapeutic unless the clinician experiences and expresses the attitudes of congruence, unconditional positive regard, and empathic understanding. For the most part, research on counseling and psychotherapy has borne out his claims. As you’ll see, even contemporary neuroscience research is also broadly supportive of Rogers’s ideas.

Neurogenesis refers to the birth of neurons and is the biggest revelation in recent brain research. Although neurogenesis primarily occurs during pre-natal brain development, the so-called new brain research emphasizes adult neurogenesis; this is the discovery that humans can generate new neurons (brain cells) throughout the lifespan and not just during prenatal brain development). When adult neurogenesis happens, new neurons are integrated into existing neuro-circuitry.

From our perspective, the adult neurogenesis revelation is neither new nor particularly revelatory. For example, over 25 years ago, it was demonstrated that repeated tactile experiences produced functional reorganization in the primary somatosensory cortex of adult owl monkeys (Jenkins et al., 1990). This finding and subsequent research supporting neurogenesis essentially articulates a common sense principle that counselors and psychotherapists have utilized for decades. That is: Whatever behavior you rehearse, practice, or repeat, is likely to strengthen your skills in that area; and then, whatever skills you repeatedly practice will lead to you developing a brain that allows you to demonstrate these skills more efficiently. This is probably why Mihaly Csikszentmihalyi’s (1990) famous fish-cutter became able to experience optimal “flow” while fileting fish. It’s also how Carl Rogers became so adept at empathic understanding. For you, it’s the explanation and prescription for how you will become more like Carl Rogers than Csikszentmihalyi’s famous fish-cutter.

Research on the neuroscience of emotions is in its infancy. Consequently, you should take everything we write about it here (and that anyone writes about it anywhere) with a grain of salt. With that caveat in mind, let’s look at how modern brain science might support ideas for training yourself to be like Carl Rogers.

Researchers have recently been developing theories about what’s happening in different brain regions during an empathic experience. To summarize a large body of research, it appears that various brain regions and structures are especially activated when individuals have an empathic response. One particularly important brain structure involved in empathy experiences, self-regulation, and other behaviors linked to being helpful and compassionate is the insula.

More specifically, it appears that compassion meditation (aka lovingkindness meditation) is associated with neural activity and structural development (or strengthening) of the insula (or insular cortex). Researchers have reported that individuals who are highly experienced with compassion meditation have a thicker insula and that when they view or hear someone in distress they experience more neural activity in that brain region than individuals without much compassion meditation experience (Hölzel, Carmody, Vangel, Congleton, Yerramsetti, Gard, & Lazar, 2011). Other researchers have reported meta-analyses and other reviews indicating that during cognitive-emotional perception, regulation, and response, several brain structures are activated and the relationships among them are highly complex and integrated. In describing the role of the anterior insular cortex in empathic responding, Mutschler, Reinbold, Wankerl, Seifritz, and Ball (2013) wrote:

Accumulating evidence indicates a crucial role of the insular cortex in empathy: in particular the anterior insular cortex (AIC)—a brain region which is situated in the depth of the Sylvian fissure and anatomically highly interconnected to many other cortical regions (p. 1).

At the risk of oversimplifying a complex neurological process, it appears generally safe to conclude that compassion meditation and other human activities related to empathic experiencing may contribute in some way to the thickening of the insula and subsequently enhance empathic responsiveness.

Overall, at this early stage, it’s difficult for anyone to definitively declare how individuals can develop their brains to become more empathic. It’s tempting to conclude that, if you want to improve your empathic abilities, then you should engage in rigorous training to strengthen and grow your insula (and some of its empathy and self-regulation cohort like the middle cingulate cortex and pre-supplementary motor area; Kohn, Eickhoff, Scheller, Laird, Fox, and Habel, 2014). This brings to mind silly images of you engaging your insula in a series of cross-fit type workouts focusing particularly on its anterior muscular structure. Although the analogy and our knowledge about what’s really happening in the brain break down rather quickly, we nevertheless believe it makes sense for you to participate in a “training regime” that includes the following general steps:

1. Commit yourself to the intention of becoming a person who can listen to others in ways that are accepting, empathic, and respectful.

2. Similar to how meditators develop a meditation practice, develop an empathic listening practice. This could involve any form of regular interpersonal experience where you devote time to using the active listening skills described in this chapter. As you engage in this practice it is important to have listening with compassion as your primary goal.

3. Engage in the active listening, multicultural, and empathy development activities sprinkled throughout this text, offered in your classes, and that you obtain from additional outside readings.

4. When you watch television, read literature, and obtain information via technology, let yourself linger on and experience the emotions triggered during these normal daily activities.

5. Reflect on these experiences and then . . . repeat . . . repeat . . . and repeat some more.

Rogers wrote in very personal ways about his core conditions for counseling and psychotherapy. In the following lengthy quotation, he’s discussing obstacles that prevent most people from allowing themselves to step into another’s shoes and experience empathic understanding. Reading this excerpt (and following the preceding five steps and contemplating Multicultural Highlight 3.1) is part of our prescription for helping you adopt an empathic orientation toward individuals with whom you will work.

I come now to a central learning which has had a great deal of significance for me. I can state this learning as follows: I have found it of enormous value when I can permit myself to understand another person. The way in which I have worded this statement may seem strange to you. Is it necessary to permit oneself to understand another? I think that it is. Our first reaction to most of the statements which we hear from other people is an immediate evaluation or judgment, rather than an understanding of it. When someone expresses some feeling or attitude or belief, our tendency is, almost immediately, to feel “That’s right”; or “That’s stupid”; “That’s abnormal”; “That’s unreasonable”; “That’s incorrect”; “That’s not nice.” Very rarely do we permit ourselves to understand precisely what the meaning of his [or her] statement is to him [or her]. I believe this is because understanding is risky. If I let myself really understand another person, I might be changed by that understanding. (Rogers, 1961, p. 18; specific italics from the original are missing here)

All this makes me want to ask: How will you work to be more like Carl Rogers today?