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Exploring Empathy: Part II

Misguided Empathic Attempts

It’s surprisingly easy to try too hard to express empathy, to completely miss your client’s emotional point, or otherwise stumble in your efforts to be empathic. Classic statements that beginning therapists often use, but should avoid, include {{34 Sommers-Flanagan,John 1989;}}:

1.  “I know how you feel” or “I understand.”

In response to such a statement, clients may retort: “No. You don’t understand how I feel” and would be absolutely correct. “I understand” is a condescending response that should be avoided. However, saying “I want to understand” or “I’m trying to understand” is perfectly acceptable.

2.  “I’ve been through the same type of thing.”

Clients may respond with skepticism or ask you to elaborate on your experience. Suddenly the roles are reversed: The interviewer is being interviewed.

3.  “Oh my God, that must have been terrible.”

Clients who have experienced trauma sometimes are uncertain about how traumatic their experiences really were. Therefore, to hear a professional exclaim that what they lived through and coped with was “terrible” can be too negative. The important point here is whether you are leading or tracking the client’s emotional experience. If the client is giving you a clear indication that he or she senses the “terribleness” of his or her experiences, reflecting that the experiences “must have been terrible” is empathic. However, a better empathic response would remove the judgment of “must have” and get rid of the “Oh my God” (i.e., “Sounds like you felt terrible about what happened.”).

The Evidence Base for Empathy

There’s a substantial body of empirical research addressing the relationship between empathy and treatment process and outcomes. This research strongly supports the central role of empathy in facilitating positive treatment outcomes.

In a meta-analysis of 47 studies including over 3,000 clients, Greenberg and colleagues (2001) reported a correlation of .32 between empathy and treatment outcome. Although this is not a large correlation, they noted, “empathy . . . accounted for almost 10% of outcome variance” and “Overall, empathy accounts for as much and probably more outcome variance than does specific intervention” (p. 381).

Elliot and colleagues (2011) also conducted a more recent meta-analysis. This sample included: “224 separate tests of the empathy-outcome association” (p. 139) from 57 studies including 3,599 clients. They concluded (based on a weighted r of 0.30) that empathy accounts for about 9% of therapy outcomes variance.

Based on their 2001 meta-analysis and an analysis of various theoretical propositions, Greenberg et al., identified four ways in which empathy contributes to positive treatment outcomes.

  1. Empathy improves the therapeutic relationship. When clients feel understood, they’re more likely to stay in therapy and be satisfied with their therapist.
  2. Empathy contributes to a corrective emotional experience. A corrective emotional experience occurs when the client expects more of the same pain-causing interactions with others, but instead, experiences acceptance and understanding. Empathic understanding tends to foster deeper and more trusting interactions and disclosures.
  3. Empathy facilitates client verbal, emotional, and intellectual self-exploration and insight. Rogers (1961) emphasized this: “It is only as I see them (your feelings and thoughts) as you see them, and accept them and you, that you feel really free to explore all the hidden nooks and frightening crannies of your inner and often buried experience” (p. 34).
  4. Empathy moves clients in the direction of self-healing. This allows clients to take the lead in their own personal change—based on a deeper understanding of their own motivations.

Although it’s always difficult to prove causal relationships in psychotherapy research, it appears that empathy contributes to positive treatment outcomes {{705 Duan 2002; 4508 Elliot 2011; 1047 Greenberg 2001;}}. In fact, some authors suggest that empathy is the basis for all effective therapeutic interventions: “Because empathy is the basis for understanding, one can conclude that there is no effective intervention without empathy and all effective interventions have to be empathic” (Duan et al., 2002, p. 209).

Concluding Thoughts on Empathy

Empathy is a vastly important, powerful, and complex interpersonal phenomenon. People express themselves on multiple levels, and due to natural human ambivalence, can simultaneously express conflicting meanings and emotions. Greenberg and associates (2001) captured the challenges of being empathic with individual clients when they wrote:

Certain fragile clients may find expressions of empathy too intrusive, while highly resistant clients may find empathy too directive; still other clients may find an empathic focus on feelings too foreign. Therapists therefore need to know when—and when not—to respond empathetically. Therapists need to continually engage in process diagnoses to determine when and how to communicate empathic understanding and at what level to focus their empathic responses from one moment to the next. (p. 383)

The preceding description of how it’s necessary to constantly attune your empathic responding to your individual client probably sounds daunting . . . and it should. When we add cultural diversity to the empathic mix, the task becomes doubly daunting. Nevertheless, we encourage you to embrace the challenge with hope, optimism, and patience. It’s only by sitting with people as they struggle to express their emotional pain and suffering that we can further refine our empathic way of being. Like everything, empathic responding takes practice, something Rogers (1961) recommended over 50 years ago.

 Even though that last section was titled, Concluding Thoughts, Part III is coming soon:)

Excerpt from The Initial Psychotherapy Session with Adolescent Clients

Adolescent clients are known for their tendency to push their psychotherapist’s emotional buttons. For example:

Therapist:     I want to welcome you to therapy with me and I hope we can work together in ways you find helpful.

Client:          You talk just like a shrink. I punched my last therapist in the nose (client glares at therapist and awaits a response).

If psychotherapists are not aware of how they are likely to react to emotionally provocative situations (such as the preceding) and prepared to respond with empathy, validation, and concession, they may not be well-suited to working with adolescent clients (Sommers-Flanagan & Richardson, 2011).

Nearly all adolescents have quick reactions to therapists and unfortunately these reactions are often negative, though some may be unrealistically positive (Bernstein, 1996). Adolescents may bristle at the thought of an intimate encounter with someone whom they see as an authority figure. Having been judged and reprimanded by adults previously, adolescents may anticipate the same relationship dynamics in psychotherapy. Therapists must be ready for this negative reaction (i.e., transference) and actively develop strategies to engage clients, lower resistance, and manage their own countertransference reactions (Sommers-Flanagan & Sommers-Flanagan, 2007).

And later in the article . . .

Based on clinical experience, we recommend opening statements or questions that are like invitations to work together. Adolescent clients may or may not reject the invitation, but because adolescent clients typically did not select their psychotherapist, offering an invitation is a reasonable opening. We recommend an invitation that emphasizes disclosure, collaboration, and interest and that initiates a process of exploring client goals. For example,

I’d like to start by telling you how I like to work with teenagers. I’m interested in helping you be successful. That’s my goal, to help you be successful in here or out in the world. My goal is to help you accomplish your goals. But there’s a limit on that. My goals are your goals just as long as your goals are legal and healthy.

The messages imbedded in that sample opening include: (a) this is what I am about; (b) I want to work with you; (c) I am interested in you and your success; (d) there are limits regarding what I will help you with. It is very possible for adolescent clients to oppose this opening in one way or another, but no matter how they respond, a message that includes disclosure, collaboration, interest, and limits is a good beginning.

And finally, photo that includes me and my professional coauthor.


Rita’s Children’s Book for Adults

In case you didn’t know, my wife Rita is an exceptionally creative person. She’s the source of many, if not most, of my good ideas, which I often steal from her in ways that couples do . . . in that she’ll say something and then because I spend time in my own mind thinking about it, later I’ll forget she was the source of the idea and unintentionally claim it as my own. For example, she had this great idea for a children’s book for adults about baby corporations that end up in a daycare with the rest of the human babies. In this case, I remember it was her idea, but it’s so good that occasionally, I slip into thinking that maybe we thought of it at the same time. . . or maybe I inspired her to think of it. . . or maybe I’d like a little credit even though I don’t deserve any.

All this is a way for me to say that Rita did the impressive thing of taking her idea and turning it into reality. Just 2 days ago she published an electronic version of her children’s book for adults online through Amazon. It’s only $0.99 and so feel free to check it out and “Like” it on Amazon or write a review on it (like I did:) or share it . . . Here’s the link:—Thrive-ebook/dp/B00B1K0ZQ2/ref=sr_1_35?s=books&ie=UTF8&qid=1358486158&sr=1-35&keywords=rita+sommers-flanagan


New Publications

This past month I’ve had a few published pieces that may be of interest. First, thanks to Jim Overholser of Case Western University, I had the honor of being the editor of a special issue for the Journal of Contemporary Psychotherapy. Here’s a link to the “Intro to the Special Issue” written with Nick Heck, who’s currently in South Carolina doing his pre-doc internship in clinical psych.

 In this intro piece we also describe the several other very cool articles that take a look at how we can best connect with diverse clients during initial clinical interviews.

I also wrote part one of a “miracle question” blog for the ACA blogsite. Check it out at:

Here’s my grandson Davis in his Chicken Suit, providing writing inspiration.


Office Clutter and Decor

I’m in Connecticut hanging out with Rita, Chelsea, Seth, and my twin grandkids . . . and doing a little writing editing for the forthcoming 5th edition of Clinical Interviewing. Just edited the following section where I reveal a bit about my dream-life. The unconscious is a funny thing. (see

Office Clutter and Decor

We all have stuff that we drag around with us in our lives. Some of this stuff is disorganized, messy and unsightly. Other stuff is more interesting and pleasing to the psyche or the eye.

One of us (John) sometimes dreams that he’s preparing for a therapy session and just before it begins, he notices that his office is a complete mess. There are piles of dirty clothes, books, CDs, and papers strewn around the room. At the last minute, he dashes around the room stuffing papers and clothes under his desk in anticipation of his client’s arrival. Unfortunately, the cleaning never gets quite finished, and when the client comes into the room there’s an obvious and embarrassing mess to explain.

Those of you inclined toward dream interpretation may quickly assume that John has excessive psychological baggage that leaks out during therapy sessions and personal needs to be addressed and de-cluttered. Although this interpretation may well be true, John also has the more concrete problem of keeping his office neat and tidy (although he strongly denies keeping dirty clothes strewn about his office). The main point is, of course, to be intentional, disciplined, and tasteful in your office décor and clutter management.

To whatever degree you wish, your office can represent your personality and your values. You can consciously arrange your office more or less formally, more or less chic, and more or less self-revealing. It’s important to strive for an office that a wide and diverse range of individuals may find comforting. For example, therapists working with Native American clients may want tasteful Native American art or handicrafts in their office—although multiculturally sensitive art is no substitute for adequate multicultural awareness, exposure, study, training, and supervision.

Want to Help with Professional Referencing?

Hi All.

I’ve got a writing project going and could use some help with specific tasks and so I’m posting this “job description” and instructions for applying.

Job Description

• Working from a PC platform (sorry, Macs haven’t worked well for this) and using PsycInfo, identify citations/references (books and articles) to use in the 2013 revision of Clinical Interviewing
• Compile these references in an organized electronic chapter-by-chapter library using RefWorks
• Meet with me in person or over the phone to discuss the references as needed
• Insert the references into the chapters using RefWorks
• Edit the reference lists to be perfectly compliant with APA format
• Available to work up to 5 hours a week from now until Feb 1 (this will likely be quite variable with zero hours some weeks and more other weeks)
• Interest in making $15/hour for this work
• If you don’t have direct experience in this area but you’re capable and motivated, depending on other factors, I may be happy to pay you for the first few hours as you learn how to do this

Application Instructions

Email me at a short letter/note expressing your interest and any experience you have with the items on the preceding job description list.


Tomorrow’s Election and Confirmation Bias

Confirmation bias is one of the most ubiquitous psychological phenomena on planet Earth. If you don’t know what it is, you should learn. And if you do know what it is, you should start paying even more attention to it. It’s everywhere and it affects everyone.

I think the all-time best description of confirmation bias is captured by an old Yogi Berra story. One day, when a player on Yogi’s team was called out on a close play at second base in a crucial game, Yogi went charging onto the field to protest the call. The umpire explained that he, unlike Yogi, was an objective observer and that he, unlike Yogi, had been only about 5 feet from the play, while Yogi had been over 100 feet away, seated in the dugout. When Yogi heard the umpire’s logic, he became EVEN MORE ANGRY than before and snapped back, “Listen ump, I wouldn’t have seen it, if I hadn’t believed it” (adapted from Leber, 1991).

There’s little doubt about the relevance of confirmation bias for tomorrow’s election. Liberal bloggers and pollsters see data suggesting an Obama victory while conservative media personalities counter-predict a Romney landslide.

As in the Yogi Berra example, confirmation bias explains why two presumably objective individuals can observe the same incident and draw starkly differing conclusions. After all, it’s impossible to suspend our personal beliefs and rely exclusively on logical data. We all naturally interpret and spin the data. Republicans look at recent economic figures and claim they’re caused by failed economic policies. Democrats look at the same data and note that Obama inherited a dismal economic situation and that we’d be far worse off if he hadn’t provided a stimulus and increased government spending.

The confirmation bias is everywhere all at once. If I were to wake up one morning believing abortion is murder, immigrants are illegals, and gays are sinful—my perceptions and behaviors would follow . . . and I’ll be more inclined to view individuals with darker skin as intruders who threaten my lifestyle, I’ll reject the mainstream media as having a liberal bias, and believe deeply that Fox News offers fair and balanced reporting.

But if somehow a miracle occurs and I wake up the next day believing women have the right to make their own medical choices, that many immigrants are just seeking a better life like my Italian forebears, and that gay-ness is a natural biological disposition—you can imagine how I might feel when I turn on my radio and accidentally listen to the Glen Beck show. It’s likely that I’ll pick a art his statements and question the source and validity of his facts.

My point is not to claim that one side has all the correct answers and if you think that, you’ve been drinking far too much Kool-Aid. Instead, my point is that we should all look at ourselves and question our biases. In fact, as you read this blog your response to the words on the screen will be affected by confirmation bias . . . and to the extent that you find yourself agreeing with or debating my position will likely have more to do with you and your beliefs and personal history than the accuracy or truthfulness of this blog.

As a final example, let’s look at the potential Presidential election outcome tomorrow. If you’re a liberal and Romney is elected you’ll be more likely to wonder if Tagg’s ownership of Ohio voting machines and voter suppression had more to do with the outcome than Romney’s desirability or credibility. On the other hand, if you’re a conservative and Obama wins, you may be inclined to blame it on voter fraud or an ignorant electorate. And if I’m correct and confirmation bias is ubiquitous, you may already be preparing your explanation for tomorrow’s election outcome.

Remember these words: “I wouldn’t have seen it, if I hadn’t believed it” and try your best to cope with tomorrow’s results—either way.