Tag Archives: Empathy

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Writing

Neurogenesis and Ideas for Training Your Brain to Listen with Empathy

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To start, I should say that I generally dislike pop-psych articles and promotional efforts that include cute sayings like, you can “Train (or re-wire) your Brain.” Most of you know this about me, partly because I like to make pithy comments about how, in fact, our brains actually don’t have any wires.

Despite overuse of the “wiring” analogy, I’m all-in on the principle that our behavior influences our brain structure, function, including a vast array of neurochemicals, hormones, and yada, yada, yada. In the following excerpt from our forthcoming Clinical Interviewing text, we provide a brief scientific commentary and recommendations for what we might oversimplify as “empathy training.”

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Neurogenesis refers to the birth of neurons and is one of the biggest revelations in brain research. Although neurogenesis primarily occurs during prenatal brain development, humans and other mammals generate new neurons (brain cells) throughout the life span (Jenkins et al., 1990). When adult neurogenesis occurs, new neurons are integrated into existing neurocircuitry.

Over 30 years ago, researchers 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 underscore a commonsense principle: Whatever behavior you practice or repeat is likely to stimulate neural growth and strengthen skills in that area. This is our explanation and prescription for how you can become more like Carl Rogers.

Multiple brain regions are activated during an empathic experience. Kim and colleagues (2020) summarized the complexity of what’s happening in the brain during empathic or compassionate responding, “Our analysis of sixteen fMRI studies revealed activation across seven broad regions, with the largest peaks localized to the Periaqueductal Grey, Anterior Insula, Anterior Cingulate, and Inferior Frontal Gyrus” (p. 112). In a similar review, Sezer and colleagues (2022) wrote:

Mindfulness-mediated functional connectivity changes include (1) increased connectivity between posterior cingulate cortex (DMN) and dorsolateral prefrontal cortex (FPN), which may relate to attention control; (2) decreased connectivity between cuneus and SN, which may relate to self-awareness; (3) increased connectivity between rostral anterior cingulate cortex region and dorsomedial prefrontal cortex (DMN) and decreased connectivity between rostral anterior cingulate cortex region and amygdala region, both of which may relate to emotion regulation; and lastly, (4) increased connectivity between dorsal anterior cingulate cortex (SN) and anterior insula (SN) which may relate to pain relief. (https://doi.org/10.1016/j.neubiorev.2022.104583)

If we focus in (somewhat inappropriately) on a particular brain structure, the anterior insula or insular cortex, a small structure residing deep within the fissure that separates the temporal lobe from the frontal and parietal lobes, seems particularly linked to empathy experiences, self-regulation, and other compassionate counseling-type responses (Chen et al., 2022).

Compassion meditation (aka lovingkindness meditation) is also associated with neural activity and structural development (or thickening) of the insula. Individuals who engage in regular compassion meditation have thicker insula, and when they view or hear someone in distress, they show more insula-related neural activity than individuals without compassion meditation experience (Hölzel et al., 2011). Other researchers have conducted meta-analyses and written reviews indicating that several brain structures are activated during cognitive-emotional perception, regulation, and response, and the relationships among them are highly complex (Kim et al., 2020; Pernet et al., 2021).

To oversimplify a complex neurological process, it appears generally safe to conclude that compassion meditation and other human activities related to empathy may contribute in some way to the thickening of the insula and development of other brain processes that enhance empathic responsiveness.

Although our knowledge about what’s actually happening in the brain is limited, these findings imply that you should engage in rigorous training to strengthen and grow your insula—as well as some of its empathic and self-regulating buddies like the posterior cingulate cortex, dorsolateral prefrontal cortex, rostral anterior cingulate cortex region, and dorsomedial prefrontal cortex (Sezer et al., 2022). This “training regimen” might contribute to you becoming more empathic and therefore, more therapeutic. In addition to practicing mindfulness or lovingkindness meditation, such a regimen could include:

  1. Committing to the intention of becoming a person who listens to others in ways that are accepting, empathic, and respectful.
  2. Developing an empathic listening practice. This would involve regular interpersonal experiences where you devote time to using active listening skills described in this chapter. As you practice, it’s important to have listening with compassion as your primary goal.
  3. Engaging in the active listening, multicultural, and empathy development activities sprinkled throughout this text, offered in your classes, and obtained from additional outside readings.
  4. When watching videos/television/movies, reading literature, and obtaining information via technology, lingering on and experiencing emotions that these normal daily activities trigger.
  5. Reflecting on these experiences and then… repeating… repeating… and repeating them over time and across situations

Rogers wrote in personal ways about his core conditions for counseling and psychotherapy. Contemplating his perspective is part of our prescription for developing an empathic orientation toward the variety of 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 [the] statement is to him [or her or them]. 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; italics in original)

As always, send me your thoughts on this content, as well as any ideas for improvement. Thanks and happy Friday!

Counseling and Psychotherapy Theory and Practice, Personal Reflections

We Don’t Always Have to Get Along, But Let’s Strive to NOT Hurt Each Other: Lessons from Alfred Adler

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ShoesUnless you’re in my Counseling and Psychotherapy Theories class and studying for your first exam, you probably don’t know much about Alfred Adler. Hence, this post–which happens to simultaneously be part of a study guide for Counseling Theories and part of what we need more of in American discourse.

Adler was a popular psychiatrist in the early 1900s. He was Freud’s contemporary. He wrote about Gemeinschaftsgefühl. But like lots of Adlerian things, Gemeinschaftsgefühl has been overlooked. Adler believed humans were naturally predisposed to work together, cooperatively, in community, with empathy, and positive social feelings. Lydia Sicher, an Adlerian follower, captured his ideas with one of the best professional journal article titles of all time: A Declaration of Interdependence.

Interdependence and Gemeinschaftsgefühl are so natural that, unless we’re broken in some way, we cannot stop ourselves from experiencing empathy; we cannot stop ourselves from helping others in need.

If you know something about Freud, or if you read Chapter 2 of the textbook, you probably recall that Freud was rather competitive. From his conflicts with Janet to his “booting” Adler out of the Psychoanalytic Society, Freud seemed focused on proving himself and holding a dominant position over others. In Freudian psychosexual terms, we might think of this as a fixation at the phallic developmental stage. From an Adlerian perspective, Freud’s behavior represents an excessive striving for superiority. Think about that as you think about contemporary American politics. Might there be an excessive striving for superiority in politics? I often wonder, if you’re already in a position of dominance, why is it necessary to “put down” others as they strive to have their voices heard?

The explanations for this consistent phenomenon across all political parties might be Freudian or they might be Adlerian. Either way, it’s important to learn something about how Adler’s responses to competition and superiority issues were much different than Freud’s. Even as a youth, Adler didn’t obtain gratification from dominating others. Mosak and Maniacci (1999) described a story about what was perhaps Adler’s one and only physical conflict:

Adler became embroiled in a conflict with a classmate, and a fight broke out. Adler struck the boy, and hurt him. He vowed not to fight again (p. 2).

Consider this. It appears Adler won the fight. He hurt the other boy. But instead of obtaining gratification from dominating or hurting someone else and wanting to repeat that behavior, he vowed never to fight again.

I share this story because it captures some of Adler’s theory of individual psychology. Perhaps because he already felt useful and as if he belonged, Adler obtained no additional gratification from having physical power over another. Instead, his aggressive outburst appeared to activate his social interest and compassion. He discovered he did not want to hurt other people. We could all use a little more Adler in our psyches. Not wanting to hurt others would generally be helpful in friendships, romantic relationships, and when conflict occurs. We can always argue and debate over ideas—but how about if we do that with respect and without any intent or motivation to hurt the other person?

In the anecdote about his fight, Adler is clearly not motivated or pulled toward proving his superiority. In another Adler anecdote, his biographer, Phyllis Bottome, described him as “very ordinary.” She wrote:

[He was] a very ordinary 57-year-old man who simply possessed a deep and abiding interest in the lives of ordinary people (Bottome, 1962 #234).

On that note, let’s review the theory and practice of Alfred Adler, an ordinary man who had an interest in ordinary people like you and me.

Theory Review: Dr. John’s Study Tips on Adlerian Theory

Adlerian theory is a little like an iceberg. It’s seems simple and manageable on the surface, but gets more complex as you dive down and try to explore it more completely. As a consequence, I recommend that you stay with the basics; if you decide to go the Adlerian path, there are many ways to explore the theory in greater depth. The following statements about people will help you get in touch with your inner Adlerian—at least for now.

  1. People are unique (idiographic) whole beings (holistic) who act with a sense of purpose (purposeful behavior). This sense of purpose is there whether the person realizes it or not.
  2. Part of an Adlerian therapist’s goals is to help clients have insight or become aware of their purposeful behavior. This insight generates motivation. In some cases clients may not be able to become aware of their deeper behavioral purpose. If so, just becoming aware of the behavior and its negative price can be enough to ignite motivation for change.
  3. Not only is the concept of social interest unique to Adlerian therapy, but the idea that developing social interest, a community feeling or spirit, and having compassion and empathy for others as a therapeutic goal is radical.
  4. Social interest flows from or is related to Adler’s inferiority concept. Think about it this way: We all feel inferior in some ways. But if we focus too much on our own inferiority, it will almost always lead down the dead end of excessive self-interest in compensating for inferiority (e.g., acting superior) or buckling under to our inferiority feelings and complexes (e.g., chronic low self-esteem or depression). This is why focusing on others—and even on their natural inferiority feelings—can help move clients away from the narcissistic or depressive extremes associated with excessive self-interest.
  5. Everyone’s overall way of being is highly subjective. Our style of life (or cognitive schema about self, others, and the world) is created or constructed from our subjective experiences. If you have siblings or caretakers and you sit down and talk about shared memories, you may discover you hold differing perceptions of what happened—even though you were all there together!! This is an example of the subjectivity filter that affects our individual experiences (phenomenology) and that then contributes or feeds back into our style of life.
  6. Therapy is all about fixing our internal, cognitive map (style of life) so it works as perfectly as possible. This requires feedback, awareness, and motivation to fix the distortions in our subjective internal map. The therapist’s role is to guide or assist clients in looking at these distortions (basic mistakes) and making appropriate changes. Therapists explicitly encourage (or give courage to) clients so that clients can feel encouraged (and have courage).
  7. When clients are encouraged and motivated (because they see the maladaptive nature of parts of their lifestyle), they naturally move forward toward a more complete or perfect self that is able to better face and manage the six Adlerian tasks of life.

This is probably enough Adler for now. But if you’re interested in more, you can find it on a new and exciting website called AdlerPedia: https://www.adlerpedia.org/

 

 

 

 

Counseling and Psychotherapy Theory and Practice, Personal Reflections, Politics

Congressional Baseball . . . and the Psychology of Doing Good, Part II

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The evening after the shooting at the republican congressional baseball team’s practice, Mike Doyle, D-PA was standing beside Joe Barton, R-TX. In a PBS News Hour interview, Barton was describing the support he and his fellow republicans had received from Doyle and the democrats.

Barton said, “We have an R or a D by our name, but our title—our title is United States representative.”

Silence.

Barton had choked up with emotion.

Doyle’s response was, in a word, Gemeinschaftsgefühl. Another word to describe Doyle’s response might be, “Fantastic.”

Doyle noticed the silence. He looked over and up to Barton. He saw Barton’s tears. Then he reached out in compassion, squeezing and patting his friend’s arm.

I know there are cynics who’ll frame this as a corny or staged bipartisan exhibition. I don’t blame you. We’ve been fed so much polarizing rhetoric from the media and the internet that it’s hard to believe genuine human connection is possible.

So I’ll speak for myself. I’ve been hating the news media. But not this. The Doyle-Barton interaction is my favorite media moment of the year. It was a demonstration of how politicians can put aside differences and engage each other as compassionate humans.

We need to see more of this Gemeinschaftsgefühl.

You may not recognize (or be able to pronounce) the word Gemeinschaftsgefühl. But in your gut, you know what it means. You’ve experienced it many times.

Gemeinschaftsgefühl is a multidimensional German word. It includes social interest, community feeling, caring for others as equals, empathy, and the pull toward kindness, compassion, and companionship.

You also may not know about Alfred Adler. Adler was a popular psychiatrist in the early 1900s. He was Freud’s contemporary. He wrote about Gemeinschaftsgefühl. But like lots of Adlerian things, Gemeinschaftsgefühl has been overlooked. Adler believed humans were naturally predisposed to work together, cooperatively, in community, with empathy, and positive social feelings. Lydia Sicher, an Adlerian follower, captured his ideas with one of the best professional journal article titles of all time: A Declaration of Interdependence.

Interdependence and Gemeinschaftsgefühl are so natural that, unless we’re broken in some way, we cannot stop ourselves from experiencing empathy; we cannot stop ourselves from helping others in need.

We see this every day in our personal lives, but not so much in politics. If your neighbor (or a stranger) has fallen on the sidewalk, do you refuse to stop and help, based on political affiliation? Not likely. You help . . . because you’re wired to help.

You may have noticed that, now more than ever in the history of the planet, it’s easy to rise to the bait and insult other people. Aggression is natural too, but the media inflates it; the internet contributes to it; we’re fed a visual and auditory diet of political extremism. To be blunt: We need to turn that shit off.

What are other solutions? Gemeinschaftsgefühl is like a muscle. Without regular exercise, it can weaken. Without getting connected to real people in real time, we can become judgmental, insensitive, and mean.

About 10 years ago I had the good luck to watch a congressional baseball game on the West Point campus. The democrats were playing the West Point faculty. I longed to join in. This is another Adlerian principle. I longed to belong.

Almost always, the Adlerian solution is to increase belongingness and usefulness. The more you feel “in” the group and the more you feel useful to that group, the more you naturally experience Gemeinschaftsgefühl.

The opposite is also true. The less you feel part of a group and the less useful you feel, the more likely you are to seek power, control, attention, revenge, and despair. Who hasn’t felt that? No doubt, most shooters feel desperate, disconnected, and useless. That’s no excuse. It’s just one way to understand senseless, violent, and tragic actions.

Adler would say that we have a national problem of disconnection and uselessness. To address this, we need policies to promote inclusion and connection. A good place to start: integrated congressional baseball teams. We need Rs and Ds playing baseball with each other, not against each other. Cooperation, like most things, is contagious.

To further address national disconnection, members of both political parties should become Adlerians and help their constituents to feel included and useful. How to do that? Instead of meeting (or avoiding) town halls where disenfranchised constituents yell at their political representatives, we need new and improved town halls that focus less on venting and more on problem-solving. Problem-solving can help constituents feel useful and connected. But here’s an even more radical idea. The town halls shouldn’t be segregated. They should be held jointly, republicans and democrats, together.

Alfred Adler lived through World War I. The Nazis forced him to leave Austria and then quickly closed down his child guidance clinics. Despite all that, Adler still believed in Gemeinschaftsgefühl. If he could, we can too.

Various writers, and Adler himself, have noted that Gemeinschaftsgefühl essentially boils down to the edict “love thy neighbor.” Jon Carlson and Matt Englar-Carlson described Gemeinschaftsgefühl as being the “same as the goal of all true religions.” It’s not a bad goal for atheists and agnostics either.

Eighty years after his death, we still have much to learn from Alfred Adler. We need to do what he did every day. Get up. Put on our Gemeinschaftsgefühl pants, our love thy neighbor t-shirts, engage in community problem-solving, and, in honor of Joe Barton and Mike Doyle, reach across the aisle and start caring for each other.

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If you need a dose of Gemeinschaftsgefühl, check out Judy Woodruff’s interview of Barton and Doyle on the PBS News Hour (June 14, 2017): http://www.pbs.org/newshour/bb/rivals-baseball-field-congressmen-share-solidarity-shooting/

 

 

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Why Therapists Should Never Say, “I know how you feel”

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The following excerpt is adapted from the fifth edition of the text, Clinical Interviewing (John Wiley & Sons, 6th edition forthcoming in October).

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Many writers have tried operationalizing Carl Rogers’s core conditions. However, efforts to transform person-centered therapy core conditions into specific behavioral skills always seem to fall short. As Natalie Rogers (J. Sommers-Flanagan, 2007) emphasized, trying to translate the core conditions into concrete behaviors is usually a sign that the writer or therapist simply doesn’t understand person-centered principles.

This lack of understanding occurs principally because core Rogerian attitudes are attitudes, not behaviors. This is a basic conceptual principle that has proven difficult to understand—perhaps especially for behaviorists. The point Rogers was making then (in the 1950s), and that still holds today, is that therapists should enter the consulting room with (a) deep belief in the potential of the client; (b) sincere desire to be open, honest, and authentic; (c) palpable respect for the individual self of the client; and (d) a gentle focus on the client’s inner thoughts, feelings, and perceptions. Further complicating this process is the fact that the therapist must rely primarily on indirectly communicating these attitudes because efforts to directly communicate trust, congruence, unconditional positive regard, and empathic understanding is nearly always contradictory to each of the attitudes.

A counselor educator friend of ours, Kurt Kraus, articulated why trying to directly communicate understanding is problematic. He wrote:

When a supervisee errantly says, “I know how you feel” in response to a client’s disclosure, I twitch and contort. I believe that one of the great gifts of multicultural awareness is for me accepting the limitations to the felt-experience of empathy. I can only imagine how another feels, and sometimes the reach of my experience is so short as to only approximate what another feels. This is a good thing to learn. I’ll upright myself in my chair and say, “I used to think that I knew how others felt too. May I teach you a lesson that has served me well?” (J. Sommers-Flanagan & Sommers-Flanagan, 2012) (p. 146)

Kraus’s lesson is an excellent one for all of us. The phrases, “I know how you feel” and “I understand” should be stricken from the vocabulary of counselors and psychotherapists.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Exploring Empathy III

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This is a practice-based situation that makes for good discussion about how empathic and how leading it’s appropriate to be in a counseling or psychotherapy session.

Putting It in Practice 5.1

What and How to Validate? Empathic Responding to Trauma and Abuse

Empathy often includes validation of client emotional experiences. But sometimes clients have ambivalent feelings about their own experiences which makes empathic validation complicated. This is especially possible in cases of trauma and abuse where victims can and do experience victim guilt—feeling as though they caused their own abusive experiences. For example, take the following Therapist-client interaction:

Therapist: “Can you think of a time when you felt unfairly treated? Perhaps punished when you didn’t deserve it?”

Client: “No, not really. (15-second pause) Well, I guess there was this one time. I was supposed to clean the house for my mother while she was gone. It wasn’t done when she got back, and she broke a broom over my back.”

Therapist: “She broke a broom over your back?” (stated with a slight inflection, indicating possible disapproval or surprise with the mother’s behavior)

Client: “Yeah. I probably deserved it, though. The house wasn’t cleaned like she had asked.”

In this situation, the client seems to have mixed feelings about her mother. On the one hand, the mother treated her unfairly; on the other hand, the client felt guilty because she saw herself as a bad girl who didn’t follow her mother’s directions. The therapist was trying to convey empathy through voice tone and inflection. This technique was chosen due to concerns that focusing too strongly on the client’s guilt or indignation and anger might prematurely shut down exploration of the client’s ambivalent feelings. Despite the therapist’s minimal expression of empathy, the client defended her mother’s punitive actions. This suggests that the client had already accepted (by age 11, and still accepted at age 42) her mother’s negative evaluation of her. From a person-centered or psychoanalytic perspective, a stronger supportive statement such as “That’s just abuse, mothers should never break brooms over their daughters’ backs” may have closed off any exploration of the client’s victim guilt about the incident.

Alternatively, this is a situation where gentle, open and empathic questioning might help deepen the therapist’s understanding of the client’s unique personal experience and help her explore other feelings, like anger, that she might have in response to her mother’s abuse. For example, the therapist could have asked:

I hear you saying that maybe you feel you deserved to be hit by your mother in that situation, but I also can’t help but wonder . . . what other feelings you might have?

Or, the therapist might use a third-person or relationship question to help the client engage in empathic perspective-taking herself:

What if you had a friend who experienced something like what you experienced? What would you say to your friend?

From a nondirective perspective, sensitive nondirective responses that communicate empathy through voice tone, facial expression, and feeling reflection are usually more advantageous than open support and sympathy. There’s always time for open support later, after the client has explored both sides of the issue.

In first version of this interaction, the therapist used a nondirective model, expressing only nonverbal empathy for the client’s abuse experience. He didn’t openly criticize or judge the mother’s violence. Do you think the therapist might have been too nondirective—in some ways aligning with the part of the client that felt her mother was justified in abusing her? Is it possible that the client actually might have been more able to explore her anger toward her mother if the therapist had led her in that direction using immediacy (i.e., empathic self-disclosure):

“When I imagine myself in your situation, I can feel the guilt you feel, but also, a part of me feels angry that my mother would care so much about housecleaning and so little about me.”

This self-disclosure is both empathic and leading. Do you think it’s too leading? Or do you think it’s a better response than the neutrality often emphasized in psychoanalytic therapies? These are important issues to discuss as you intentionally develop your own therapy style. . . and so be sure to discuss the variety of ways you might respond empathically and therapeutically to this client scenario.

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Exploring Empathy: Part II

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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:)

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Exploring Empathy — Part I

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Happy Saturday. This post is the first of a three-part preview of our discussion on Empathy from Clinical Interviewing, 5th Edition.

See: http://www.amazon.com/Clinical-Interviewing-2012-2013-John-Sommers-Flanagan/dp/1118390113/ref=ntt_at_ep_dpt_1

Empathic Understanding

Empathic understanding is a central concept in counseling and psychotherapy. Rogers (1980) defined empathy as:

. . . the therapist’s sensitive ability and willingness to understand the client’s thoughts, feelings, and struggles from the client’s point of view. [It is] this ability to see completely through the client’s eyes, to adopt his frame of reference, (p. 85) . . .  It means entering the private perceptual world of the other . . . being sensitive, moment by moment, to the changing felt meanings which flow in this other person. . . . It means sensing meanings of which he or she is scarcely aware. (p. 142)

Rogers’s definition of empathy is complex. It includes several components.

  • Therapist ability or skill
  • Therapist attitude or willingness
  • A focus on client thoughts, feelings, and struggles
  • Adopting the client’s frame of reference or perspective-taking
  • Entering the client’s private perceptual world
  • Moment-to-moment sensitivity to felt meanings
  • Sensing meanings of which the client is barely aware

A Deeper Look at Empathy

As with congruence and unconditional positive regard, the complexity of Rogers’s definition has made research on empathy challenging. Many different definitions of empathy have been articulated (Batson, 2009; Clark, 2010; Duan & Hill, 1996). According to Elliott, Bohart, Watson, & Greenberg (2011), recent advances in neuroscience have helped consolidate empathy definitions into three core subprocesses:

  1. Emotional simulation: This is a process that allows one person to experientially mirror another’s emotions. Emotional simulation likely involves mirror neurons and various brain structures within the limbic system (e.g., insula).
  2. Perspective-taking: This is a more intellectual or conceptual process that appears to involve the pre-frontal and temporal cortices.
  3. Emotion regulation: This involves a process of re-appraising or soothing of one’s own emotional reactions. It appears to be a springboard for a helping response. Emotional regulation may involve the orbitofrontal cortex and prefrontal and right inferior parietal cortices.

Empathy is an interpersonal process that requires experiencing, inference, and action. In chapter 1 we noted that playing a note on one violin will cause a string on another violin to vibrate as well, albeit at a lower level. In therapy, this has been referred to as resonance. Most people have had the experience of feeling tears well up at a movie or while someone talks about pain or trauma. This is the experiential component of empathy that Elliot et al., (2011) referred to as emotional simulation).

Beyond this physical/experiential resonance, one person cannot objectively know another person’s emotions and thoughts. Consequently, at some level, empathy always involves subjective inference. This process has been referred to as perspective-taking in the scientific literature and is considered a cognitive or intellectual requirement of empathy (Stocks, Lishner, Waits, & Downum, 2011).

Empathy—at least within the context of a clinical interview—also requires action. Therapists must cope with and process the emotions that are triggered and then provide an empathic response. Most commonly this involves reflection of feeling or feeling validation, but nearly every potential interviewing response or behavior can include verbal and nonverbal components that include empathy. The action component of empathy is likely what Elliot et al., are referring to with the term emotional regulation.

Simple guides to experiencing and expressing empathy can help you develop your empathic abilities. At the same time, we don’t believe any single strategy will help you develop the complete empathy package. For example, Carkhuff (1987) referred to the intellectual or perspective-taking part of empathy as “asking the empathy question” (p. 100). He wrote:

By answering the empathy question we try to understand the feelings expressed by our helpee. We summarize the clues to the helpee’s feelings and then answer the question, How would I feel if I were Tom and saying these things? (p. 101).

Carkhuff’s empathy question is a useful tool for tuning into client feelings, but it also oversimplifies the empathic process in at least two ways. First, it assumes therapists have a perfectly calibrated internal affective barometer. Unfortunately this is not the case as clients and therapists can have such different personal experiences that the empathy question produces completely inaccurate results; just because you would feel a particular way if you were in the client’s shoes doesn’t mean the client feels the same way. Sometimes empathic responses are a projection of the therapist’s feelings onto the client. If you rely solely on Carkhuff’s empathy question, you risk projecting your own feelings onto clients.

Consider what might happen if a therapist tends towards pessimism, while her client usually puts on a happy face. The following exchange might occur:

Client: “I don’t know why my dad wants us to come to therapy now and talk to each other. We’ve never been able to communicate. It doesn’t even bother me any more. I’ve accepted it. I wish he would accept it too.”

Therapist: “It must make you angry to have a father who can’t communicate effectively with you.”

Client: “Not at all. I’m letting go of my relationships with my parents. Really, I don’t let it bother me.”

In this case, asking the empathy question: “How would I feel if I could never communicate well with my father?” may produce angry feelings in the therapist. This process consequently results in the therapist projecting her own feelings onto the client—which turns out to be a poor fit for the client. Accurate empathic responding stays close to client word content and nonverbal messages. If this client had previously expressed anger or was looking upset or angry (e.g., angry facial expression, raised voice), the therapist might resonate with and choose to reflect anger. However, instead the therapist’s comment is inaccurate and is rejected by the client. The therapist could have stayed more closely with what her client expressed by focusing on key words. For example:

Coming into therapy now doesn’t make much sense to you. Maybe you used to have feelings about your lack of communication with your dad, but it sounds like at this point you feel pretty numb about the whole situation and just want to move on.

This second response is more accurate. It touches on how the client felt before, what she presently thinks, as well as the numbed affective response. The client may well have unresolved sadness, anger, or disappointment, but for the therapist to connect with these buried feelings requires a more interpretive intervention. Recall from Chapter 3 that interpretations and interpretive feeling reflections must be supported by adequate evidence.

To help with the intellectual process of perspective-taking, instead of focusing exclusively on what you’d feel if you were in your client’s shoes, you can expand your repertoire in at least three ways:

  1. Reflect on how other clients have felt or might feel
  2. Reflect on how your friends or family might feel and think in response to this particular experience
  3. Read and study about experiences similar to your clients’.

Based on Rogers’s writings, Clark (2010) referred to intellectual approaches to expanding your empathic understanding as objective empathy. Objective empathy involves using “theoretically informed observational data and reputable sources in the service of understanding a client” (Clark, 2010, p. 349). Objective empathy is based on the application of external knowledge to the empathic process—this can expand your empathic responding beyond your own personal experiences.

Rogers (1961) also emphasized that feeling reflections should be stated tentatively so clients can freely accept or dismiss them. Elliot et al., (2011) articulated the tentative quality of empathy very well: “Empathy should always be offered with humility and held lightly, ready to be corrected” (p. 147)

From a psychoanalytic perspective, it’s possible to show empathy not only for what clients are saying, but also for their defensive style (e.g., if they’re using defense mechanisms such as rationalization or denial, show empathy for those):

Client: “I don’t know why my dad wants us to come to therapy now. We’ve never been able to communicate. It doesn’t even bother me any more. I’ve accepted it. I wish he would.”

Therapist: “Coming into therapy now doesn’t make much sense to you. Maybe you had feelings about your lack of communication with your dad before, but it sounds like you feel pretty numb about the whole situation now.”

Client: “Yeah, I guess so. I think I’m letting go of my relationships with my parents. Really, I don’t let it bother me.”

Therapist: “Maybe one of the ways you protect yourself from feeling anything is to distance yourself from your parents. Otherwise, it could still bother you, I suppose.”

Client: “Yeah. I guess if I let myself get close to my parents again, my dad’s pathetic inability to communicate would bug me again.”

This client still has feelings about her father’s poor communication. One of the functions of accurate empathy is to facilitate the exploration of feelings or emotions (Greenberg, Watson, Elliot, & Bohart, 2001). By staying with the client’s feelings instead of projecting her own feelings onto the client, the therapist is more likely to facilitate emotional exploration.

A second way in which Carkhuff’s (1987) empathy question is simplistic is that it treats empathy as if it had to do only with accurately reflecting client feelings. Although accurate feeling reflection is an important part of empathy, as Rogers (1961) and others have discussed, empathy also involves thinking and experiencing with clients (Akhtar, 2007). Additionally, Rogers’s use of empathy with clients frequently focused less on emotions and more on meaning. Recall that in his original definition, Rogers wrote that empathy involved: “. . . being sensitive, moment by moment, to the changing felt meanings which flow in this other person. . .” (p. 142). And so empathic understanding is not simple, it involves feeling with, thinking with, sensing felt meanings, and reflecting all this and more back to the client with a humility that acknowledges deep respect for the validity of the client’s own experiences.

More to come on this tomorrow in “Exploring Empathy” Part II.

References

Akhtar, S. (Ed.). (2007). Listening to others: Developmental and clinical aspects of empathy and attunement Lanham, MD, US: Jason Aronson.

Carkhuff, R. R. (1987). The art of helping (6th ed.). Amherst, MA: Human Resource Development Press.

Clark, A. J. (2010). Empathy: An integral model in the counseling process. Journal of Counseling & Development, 88, 348-356.

Greenberg, L. S., Watson, J. C., Elliot, R., & Bohart, A. C. (2001). Empathy. Psychotherapy: Theory, Research, Practice, Training, 38(4), 380-384.

Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin.

Rogers, C. R. (1980). A way of being. Boston: Houghton Mifflin.

Stocks, E. L., Lishner, D. A., Waits, B. L., & Downum, E. M. (2011). I’m embarrassed for you: The effect of valuing and perspective taking on empathic embarrassment and empathic concern. Journal of Applied Social Psychology, 41(1), 1-26. doi: http://dx.doi.org/10.1111/j.1559-1816.2010.00699.x