Empathy
One of the most important elements to establishing an effective therapeutic relationship is empathy. In order to create an environment of trust the therapist must listen to the client’s concerns. Something more however must happen, which occurs when the therapist actually cares about the client and what the client is saying, and the client becomes convinced this is so. What operational steps can the therapist take to facilitate this outcome?
Here are some examples.
1. Freud’s practice was to sit behind his client so the client could not see him as the client (presumably) free-associated. He would not say anything during this process. He may never have said anything to the client at all. In fact a perfect situation for Freud might have been if he and his client never even saw each other or had any contact whatsoever. He would remain “unknown” to the client.
2. Is it appropriate for the therapist to greet the client upon the commencement of the session, or should the protocol be that the client simply shows up and starts talking (or not)? Would it be socially awkward not to do so?
3. The therapist is facing the client. The client is disclosing a sensitive problem to the therapist. The therapist listens to the client impassively. Perhaps the therapist looks away from time to time, bored by the pace of the proceedings.
4. Same as #3 but the therapist nods sympathetically from time to time, perhaps establishing eye contact with the client.
5. Same as #3 but the therapist says, “I can’t imagine what that must have been like.”
6. Same as #3 but the therapist says, “I understand what you’re saying.” Perhaps the therapist self-discloses an incident from her own life that presents an analogous experience.
In our post-modern era it is fair to say we all are Rogerians, if only tacitly. Rogers famously held empathetic listening was one of the fundamental ingredients of effective therapeutic intervention. Hypotheticals #1 – #3 are not particularly conducive to developing empathy. They create a hostile environment, seemingly impervious to the client’s concerns. The client hears the therapist saying, “I don’t need to know (by interacting with you) who you are, or how not to be who you are.” This hardly is unconditional positive regard. The therapist has erected a wall around the client and therapy most likely will fail.
Hypotheticals #4 – #6 are more conducive. The therapist facilitates the process of client growth by creating a value-free environment where the client feels she won’t be judged. It is open, safe and trusting. The therapist is alert, alive and stays on point. She doesn’t become distracted by peripheral concerns. To the fullest extent possible she is fully in the patient’s present. To some extent this may involve a suspension of values or even disbelief by the therapist. The therapist however does not necessarily have to be in agreement, and probably isn’t, with the substantive propositional content of what the client says. By expressing empathy the therapist does not commit to any such agreement.
Hypothetical #4 shows weak empathy.
Hypothetical #5 shows mild empathy. The client might believe “my experience is unique. It derogates from its uniqueness (and my “special-ness”) for anybody to presume to know what it’s like.” Even so #5 negates the very premise on which empathy is based.
Hypothetical #6, for Rogers, is the only scenario that shows strong empathy. Empathy, says Rogers, is:
To perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as if one were the person, but without ever losing the “as if” condition. Thus, it means to sense the hurt or the pleasure of another as he senses it and to perceive the causes thereof as he perceives them, but without ever losing the recognition that it is as if I were hurt or pleased and so forth. (1)
Empathy thus is a condition of mutual intelligibility. When they are in empathy the therapist and the client resonate with and are attuned to each other. Mutual intelligibility implies not only that the therapist and the client understand each other, but also that they know that they do. The dialog Rogers ideally envisions goes something like this:
Client: “I have the following problem {x, y, z}.”
Therapist: “I understand what you are saying. You are telling me you have the problem {x, y, z}.” The therapist does not simply repeat what the client says. Rather she reparses it by highlighting the key points, or summarizing the gist of the client’s remarks. Perhaps she asks questions about what the client has said, or requests further detail on certain key points.
Client: “How do I know you understand what I am saying?” The client is dissatisfied with mere assurances. The client wants empirical evidence of genuine congruity. Without losing focus the therapist-client dialog might even dwell on why the client needs further understanding or confirmation of the therapist’s intentions.
Therapist: “I understand because I have had the following experiences that are analogous to {x, y, z}.” The therapist need not go into exhaustive detail or disclose personal facts. After all therapy is about the client’s problems, not the therapist’s problems. The therapist should however say enough to break through the client’s skeptical defenses that she is not being understood, or that she is being misunderstood. The therapist must demonstrate empirically to the client that the therapist is aligned with the client in ascertaining and evaluating the nature, scope and extent of the client’s complaint. The best way to do this is modulated self-disclosure. It is not enough for the therapist to offer up a purely imaginal construct. To do so would violate the integrity of the therapist-client relationship. The client also would see through it right away as being feigned and insincere, negating the very premise on which it is based. It lacks the nuances and cues of genuine experience. It is ineffective because it is insufficiently granular, lacks compelling detail, and ultimately isn’t persuasive.
This is what Rogers means by the “as if” condition. Rogers says the therapist doesn’t need to have had the client’s actual experience. By the same token it’s insufficient for the therapist simply to contemplate what that would be like. The therapist can’t simply “imagine.” Rather, empathy must be mirrored experientially. By affirming to the client she has been heard and understood, the therapist validates the client’s perception her problem is significant and worthy of consideration. What the client needs is evidence the therapist is empathetic. To reach this level of insight and awareness the therapist must draw on her own background and experiences, those presenting the best retrievable analogy to the present experience. If successfully done so, it becomes “as if” the therapist were experiencing the same thing. This is the only way for the therapist to develop an empathetic relation with the client.
Self-disclosure by the therapist presents an interesting subset of issues. For example, most forms of 12-step addiction therapy actually require the group leader to be in recovery from the specific addiction, which the group addresses. This same principle also applies in other situations. Who wants a marriage therapist, who isn’t married? Who wants a therapist to talk about eating disorders, if she hasn’t struggled with one herself? Who wants a family therapist, who doesn’t have a family? It could credibly be argued that thorough knowledge of systems therapy might be more important for a marriage counselor than actually having been married. On balance though I think the odds weigh in favor of actually being a participant in the process. With marriage counseling, for example, actually having been married gives the counselor emotional reactivity and empathetic resonance, facilitating transference. This is far more important than application of theory.
Still however there can be no doubt but that it is a slippery slope. For example one would not want the leader of a group on borderline personality disorder, herself to have borderline personality disorder. The same pertains to any number of other DSM-IV pathologies. What are the criteria to differentiate those situations where the therapist should have personal experience from those where it isn’t necessary? Further research is necessary to develop and expand these issues.
Endnotes
(1) Rogers, C. R. (1959). “A theory of therapy, personality and interpersonal relationships, as developed in the client-centered framework.” In S. Koch (ed.), Psychology: A study of science, 3, 210 – 211; 184 – 256. New York, NY: McGraw Hill. Adler also was concerned with empathy, which he characterized as “love.” The patient must feel the therapist cares; empathetic listening furnishes the patient with evidence this is so. Adler, A. (1964). Problems of Neurosis. New York, NY: Harper & Row.