Tag Archives: empathy

Differentiation of self through the lens of mindfulness

By Kevin Foose and Maria Cicio February 7, 2018

A few years ago, while teaching a course in family therapy, a particularly bright and insightful student named Maria lingered after class one day and asked, “Isn’t differentiation of self similar to mindfulness?” I hadn’t quite thought of it like that before, but it certainly seemed plausible. “Let’s set aside some time to talk,” I suggested. With that single question began many months of conversations.

In 2015, a continuation of those hours of exploration transformed into an “anti-presentation” that was awarded “Best of Show” at the Louisiana Counseling Association Annual Conference. The examination continued the following spring at the American Counseling Association Conference & Expo in Montréal. In the end, it was inquiry rather than answers that animated our informal lyceum. Quest and question are born of a common root. And teaching is thin soup if only the student grows. The current work is an attempt to extend the spirit and tone of those many fruitful hours of meeting.

Attempting to define differentiation

Differentiation of self (DoS), since first being introduced by Murray Bowen in the early years of the family therapy movement, has remained a lofty, elusive and often misunderstood concept. As Bowen’s colleague, Michael Kerr, pointed out, differentiation contains so many unique conceptual facets that it defies simple definition.

Bowen himself, persistently mystified by the consistent misinterpretation of differentiation, noted late in his life in one of his more cantankerous moments that he wished he’d never “discovered” it in the first place. Anthropologist Gregory Bateson once said of Charles Darwin that he didn’t discover evolution, he made it up. The same may be said of DoS. Viewed through this lens, DoS becomes a story (the point of which is to communicate its creator’s intent) steeped in a deep faith in science and the relatively recent emergence of the Western nuclear family.

If we are to accept the premise that differentiation does indeed defy simple definition, or at the very least is so subtle and nuanced that it is open to numerous interpretations, the initial question that emerges is: What in the world are we actually talking about when we talk about differentiation?

Michael Cowen, one of my colleagues at Loyola University New Orleans, provides a useful foundation from which to launch this conceptual ship with his interpretation of differentiation as “the capacity to be aware of one’s own unique pattern of feeling, valuing and thinking, and to decide and act in ways that remain faithful to that awareness.” Cowen’s definition shifts the focus of differentiation away from some thing that one is or has or even does, toward a description of understanding and action. It is a process that, at its core, allows individuals to make distinctions between thoughts and feelings and to remain calm in highly emotional situations. It is the ability to be both a part of and apart from significant relationships, and it places a high premium on the ability to behave rationally. It is not, however, a call for a Spock-like hyper-rationality nor a ringing endorsement of the ruggedly individualistic American mythology.

For the sake of moving forward with consensus, nebulous as it may be, I (Kevin) am inclined to give Bowen the final say in the construction of a working definition of differentiation as “a way of thinking that translates into a way of being.” So the story goes.

If that description of differentiation is to be accepted, the question then becomes, how is one to cultivate such “a way of thinking?” And who might act as a reliable translator? This is the point at which the teaching of the Buddha, in general, and mindfulness, specifically, can offer a helpful perspective from which to view perceptions and human experience.

At first glance, Bowen and Buddha may seem to be a strange pairing. After all, Bowen’s search for understanding led him back to the tumult of his family of origin, whereas Buddha left home seeking transcendence and never returned. Logistically, Buddha’s eightfold path provides a different road map toward liberation and understanding than does Bowen’s eight interlocking theoretical concepts. But the wisdom gained beneath the Bodhi tree may not be as divergent from the family tree as one might think. When differentiation is examined through the prism of mindfulness, significant conceptual convergences begin to emerge. The potential implications for personal growth, insight and clinical practice merit a pause, perhaps a deep breath, and further contemplation.

Mindfulness

Mindfulness is essentially the act of being present. Anchored in continuous awareness of each emerging moment, it is the cultivation of a calm, dispassionate state in which experience can be examined with acceptance and nonjudgment. Mindfulness, not unlike DoS, is a process that provides the possibility of escaping the trappings of emotional reactivity.

In an excellent article examining mindfulness (“Mindfulness: A Proposed Operational Definition” in the September 2004 issue of Clinical Psychology: Science and Practice), a group of Canadian academics, led by Scott R. Bishop, pointed out that the insight that emerges through disciplined contemplative practice creates an open “space between one’s perception and response, ultimately making it possible to respond and interact more reflectively (as opposed to reflexively).” Rather than becoming tangled up in “ruminative, elaborative thought streams about one’s experience and its origins, implications and associations, mindfulness involves a direct experience of events in the mind and body,” wrote Bishop and his colleagues

In other words, we are able to stay tethered in the present, experiencing our life with courage and composure as it actually unfolds in our midst. In this awakened state, our mind is freed from anger, attachment to desire and misperception. Providing an alternative to being swept away in a flood of emotionality and elaborate misinterpretation, we are able to resist the urge to flee into ideations of the imagined future clouded by the residue of the past, or compulsively bend reality to meet idiosyncratic needs.

Mindfulness is the antidote to fear, confusion and anxiety. It is a practice and process that tethers us to the immediacy of our lives with the insight to see “relationships between thoughts, feelings and actions and to discern the meaning and causes of experience and behavior” (as described in “Mindfulness: A Proposed Operational Definition”). Essentially, mindfulness cultivates the ability to interact rather than react.

The greatest hurdle in defining a self or sustaining mindful attention is emotional reactivity. When emotions escalate beyond a critical threshold, a state of mind emerges in which rational thinking evaporates and agitation hijacks the cognitive process. It is impossible to differentiate in such an agitated state. We become prisoners to automatic emotional responses saturated in fear.

Buddha referred to this reactive state as “monkey mind,” in which fear becomes much like a loud, drunken monkey frantically screeching the alarm bells of danger in our brains. The ability to quickly regain composure and quiet the monkey mind is the cornerstone of both differentiation and mindfulness.

The quiet mind is fertile ground for exploring what Buddha called “store consciousness.” Long before Sigmund Freud proposed his theory of the unconscious (again, see Bateson above) or Bowen began his examination of psychobiological cognitive-emotional processes, Buddha was wandering about preaching the Dharma, teaching practices aimed at liberating people from misperception and attachment to mental formations that seemed to be just beyond the reach of everyday awareness.

Vietnamese Buddhist monk Thich Nhat Hanh writes in the introduction of Cultivating the Mind of Love: “In our store consciousness are buried all the seeds, representing everything we have ever done, experienced or perceived. When a seed is watered, it manifests in our mind consciousness. … The work of meditation is to cultivate the garden of our store consciousness.”

Getting back into harmony with our lives

Whatever we “attend” to will grow. And what we don’t attend to will tend to grow out of control without insight into content and coping strategies buried deep in our store consciousness. For multigenerational family systems theory, the seeds in the soil are the early experiences in the family of origin. Differentiation allows for a bit of psychic “weeding” to occur so that intimacy and integrity may grow.

Buddha, too, was attuned to the influence that family members have on one another. Perhaps more poetic, but no less prophetic, a Buddhist teaching examines the importance of the emotional climate of filial bonds, invoking the image of the garden again: “A family is a place where minds come in contact with one another. If these minds love one another, the home will be as beautiful as a flower garden. But if these minds get out of harmony with one another, it is like a storm that plays havoc with the garden.”

It is precisely in those moments when one finds oneself in the “I” of the storm where mindful intention allows the well-differentiated self to stay calm and sift through frenetic cognition that often causes impairment in our lives. The ability to sit in the midst of the tempest and remain present, self-aware and in close emotional contact with others is the essence of what Soto Zen monk Shunryu Suzuki calls “imperturbable composure.”

The well-differentiated self exhibits radical acceptance to what Jon Kabat-Zinn calls the “full catastrophe of living.” In this way, we remain open and curious to the actual events of our lives as they unfold, freeing ourselves from endless cycles of suffering and automatic reactivity. Whether we call this mindfulness or differentiation becomes an exercise in semantics.

Through work and practice, we become available to the full reality of our lives, with the insight and courage to quietly slip through the cracks of our conditioning and allow our ego-cramped consciousness to release its grip on our battered psyche. Quite simply, DoS and mindfulness bring us back into harmony with our lives.

For Buddha, the ultimate act of enlightenment is to wake up. The Dharma teaches that it is possible for any of us to awaken at any moment in our lives. Much like achieving a fully mindful present state, people often find embarking on the path of defining a self to be a daunting task.

Bowen was clear and consistent in his insistence that the fully differentiated self is a theoretical concept that is practically unattainable. It is a guiding light rather than prescription. However, with much work and practice, it is possible to increase one’s level of differentiation. Bowen pointed out that if we can “control the anxiety and the reactiveness to anxiety, the functional level will improve.” The task at hand becomes “getting beyond anger and blaming to a level of objectivity that is far more than an intellectual activity. … The overall goal is to be constantly in contact” with emotional issues involving ourselves and others.

A common thread

Although Bowen and Buddha’s conceptualization of the “self” superficially seems to be the point at which the Venn in the Zen between DoS and mindfulness begins to diverge, it is through interdependence that the deepest synthesis actually occurs. Whether one adopts a scientific or a spiritual perspective, the influence that each of us has upon the other is the thread that ties mindfulness and differentiation together.

Bowen was certain that the self exists. Buddha sent his disciples out into the world in search of the self and sat patiently waiting for the report back. Ralph Waldo Emerson, with his ever-present, transcendental wisdom, offered this: “All that is said of the wise man by Stoic or Oriental or modern essayist … describes his unattained but attainable self.”

Both Buddha’s and Bowen’s philosophical views were undergirded by a belief in the profound effect that each of us has upon one another. Bowen believed that successfully differentiating oneself within the system could have significant influence on all others in that system. He noted that if one is able to successfully define a solid sense of self and defend against requests from others to change back to old ways of being, then the entire system can catapult forward into higher levels of functioning.

The Dharma teaches that when one is awakened with compassion and wisdom, all are touched by the light. In Cultivating the Mind of Love, Hanh examines Buddha’s teachings, exploring the ways in which the Dharma opens each of us to the possibility of deeper understanding and more intimate connection. In his introduction, Hanh invites us to become fully present, and “the rain of the Dharma will water the deepest seeds of your store consciousness. If the seed of understanding is watered … the fruits of love and understanding will grow.”

Examining the teaching of interbeing and the delusion of separateness falsely constructed in the mind, Hanh concludes: “We must vow to practice for everyone, not just for ourselves. … Because of our ignorance and habit energies, we usually perceive things incorrectly. We are caught in our mental categories, especially our notions of self, person, living being and life span. We discriminate between self and nonself. … When we see things this way, our behavior will be based on wrong perceptions. Our mind is like a sword cutting reality into pieces, and then we act as though each piece of reality is independent from other pieces. If we look deeply, we will remove these barriers between our mental categories and see the one in the many and the many in the one, which is the true nature of interbeing. … Everything is touching everything else. … To bring relief to one person is to bring relief to everyone, including ourselves. This insight brings about the kinds of actions that are truly helpful.”

These are hopeful thoughts for troubled times. What is called for in this moment, if one is to view differentiation through the lens of mindfulness, is a “way of thinking that translates into a way of being in the world” that accurately perceives the deep connection that we have with the world surrounding us and the profound effect that each of us has upon one another. So the story goes.

Compassionate listening

Counseling is a reciprocal process of story and interpretation. As a conversational intervention, much attention has been given to the narrative telling of the tale — the “talk” in talk therapy. Often lost in the reciprocity is the transformative power of listening. As Hanh points out, when we listen to another deeply and compassionately, we help that person to suffer less. “One hour like that can bring transformation and healing,” he teaches.

If listening in this way does indeed, as we believe, lead to the alleviation of suffering, the question becomes, how does one engage in the process of compassionate listening?

The calm that accompanies the differentiated self, and a mindful stance tethered in the present, provide a helpful perspective from which to enter into another’s story. It allows one to avoid judgment without abandoning discernment and concern. This way of being allows the counselor to bear witness to the tumultuous content of clients’ troubled narratives without becoming overwhelmed. We can tolerate intense emotion without needing to flee for safety and care without getting carried away.

Deep listening contains the seeds of empathy. The calm that accompanies a well-differentiated presence opens up the space to create the distance necessary to examine problem-saturated narratives. The practice of active listening artfully folds the story continuously back upon itself, returning the client to present-moment awareness. The acceptance that accompanies awareness invites the client to slow down, resist the impulse to avoid the suffering and instead examine the story with compassion. The wisdom to accept that which is beyond our control paradoxically generates the flexibility necessary for transformation to occur.

Pragmatically speaking, compassionate listening is rooted in language. To listen in this manner, it is essential to remain firmly planted in the present, gathering content without getting lost in the labyrinth of past suffering or anxious projections of the future. When listening to stories of suffering, it can be easy to lose sight of the fact that the actual experience is the retelling of the tale here and now, not what occurred there and then. It is imperative to honor our clients’ suffering while also uncovering their strength.

The task is to attend to the content of the client’s story while staying deeply connected to the person. Listening in this way allows us to wonder what the client is trying to communicate about his or her struggle through the story. What meaning is seeking to be understood? What are the relational and emotional elements recurring in the client’s words? Compassionate listening is the conduit into the deepest sense of clients’ experiences. It asks, how can we be present to the struggle and help our clients confront the frustrating and most frightening moments of their lives?

At its core, compassionate listening holds the therapeutic space. It widens the client’s interpretation just a bit. It uses the client’s language, symbols and metaphors. It sees as well as hears, deconstructing the story, searching the margins for what has been edited out, pulling the thread of seemingly disjointed pieces and reflecting it back in recognizable form. This way of listening is ultimately a path toward healing that allows for safe passage through suffering. As American Buddhist nun Pema Chödrön points out, mindfulness allows us to choose an alternative course for our lives. A process such as DoS requires us to first notice the true nature of our experience, then disrupt our habitual patterns and do things differently and, finally, practice again and again, one moment at a time.

A client suffers and a change is necessary. The struggle often comes with not knowing how to manifest a healthy change. The client has likely been avoiding, wrestling with and running away from anxiety for years, creating deeply ingrained habits. In the space created by deep listening, the client can experience something different. Clients may be able to look at their anxiety for the first time with compassion and understanding. The paradox is that once they are able to sit with their struggle instead of avoiding it, anxiety loosens its grip on their lives.

DoS, viewed through the lens of mindfulness, creates the clarity and compassion for transformation to occur. Mindfulness aids in the process by creating awareness of our mind-body interaction so that we can become more skillful in our interpersonal, and intrapersonal, relationship(s).

Just as the counseling process makes space for emotions, thoughts, ideas and stories in session, mindfulness creates a similar space for our internal experience to occur. This is the “deep listening” to our own process. Mindful awareness allows for attunement, not only with our clients but with ourselves. It creates systemic and intrapsychic awareness to the ways that we get hooked into metanarratives and mental confines. Emotions no longer run amok, and we are available to be in relationship with others. As clinicians, we must first listen deeply to the mystery and history of our own stories before making contact with someone else’s.

The Beat Zen of Richard Brautigan leads us to a quiet place to begin in his poem “Karma Repair Kit: Items 1-4”:

1. Get enough food to eat,/ and eat it.

2. Find a place to sleep where it is quiet,/ and sleep there.

3. Reduce intellectual and emotional noise/ until you arrive at the silence of yourself,/ and listen to it.

4. ???

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Kevin Foose is an assistant professor in the Department of Counseling at Loyola University New Orleans. He maintains a private practice that focuses on couples and adult individuals. Contact him at kjfoose@loyno.edu.

Maria Cicio is a graduate of the Loyola University New Orleans master’s in counseling program, class of 2015. A licensed professional counselor, she is currently working in community mental health in rural Oklahoma.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Building better counselors

By John Sommers-Flanagan and Kindle Lewis November 6, 2017

In the opening chapter of the sixth edition of Counseling and Psychotherapy: Theories and Interventions (published by the American Counseling Association), David Capuzzi, Mark Stauffer and Douglas Gross make the case that the helping relationship is central to all effective counseling. Not many counselors would argue with this idea. Nevertheless, many counseling practitioners still feel pressure to implement empirically supported or evidence-based mental health treatments. Consider this case:

Darrell is a 50-year-old Native American. He identifies as a male heterosexual. In his first counseling session, he talks about feeling “bad and sad” for the past six months and meets diagnostic criteria for a depressive disorder. Darrell’s counselor, Sharice, is trained in a manualized, empirically supported cognitive-behavioral model for treating depression. However, as a professional counselor, she values collaborative counseling relationships over manualized approaches. She especially emphasizes relational connections during initial sessions with clients who are culturally different from her.

The question is, how can Sharice be relationally oriented and still practice evidence-based counseling? The answer: She can use evidence-based relationship factors early and throughout the counseling process.

Evidence-based relationship factors

Back in 1957, Carl Rogers wrote that “a certain type of relationship between psychotherapist and client” was “necessary and sufficient” to produce positive change. In contrast, if you immerse yourself in contemporary research on counseling and psychotherapy, you might conclude that relationship factors in counseling are passé and that, instead, cutting-edge (and ethical) practitioners must use empirically supported treatments. But you would be wrong.

Most reasonable people recognize that both relationship factors and techniques contribute to positive outcomes. However, it is also true that relationship factors in and of themselves have strong empirical support. More than 60 years of scientific evidence supports Rogerian core conditions of congruence, unconditional positive regard and empathic understanding. In fact, counseling relationship factors are just as scientifically potent (and maybe more so) as so-called empirically supported treatments.

Newer terminology for acknowledging the research base for therapeutic relationships has been coming for about 15 years. In 2001, a task force from Division 29 (Society for the Advancement of Psychotherapy) of the American Psychological Association coined the phrase “empirically supported therapy relationships.” The task force’s purpose was to place therapeutic relationships on equal footing with empirically supported treatments. Despite those efforts, many (and perhaps most) psychologists value technical procedures (for example, cognitive behavior therapy) over relational factors. In contrast, because of counseling’s emphasis on therapeutic relationships, in some ways, empirically supported therapy relationships are much more relevant to professional counselors.

In this article, we use the broader phrasing of “evidence-based relationship factors” (EBRFs) to represent ways in which professional counselors can integrate research-based relationship knowledge into counseling practice. But what is an EBRF, and how can counseling practitioners implement them in ways that are more specific than simply saying, “I value the therapeutic relationship?”

EBRFs include the three Rogerian core conditions and other purposefully formed and implemented relational dimensions. Below, we provide concrete examples of 12 EBRFs that are empirically linked to positive counseling and psychotherapy outcomes. For each EBRF, we use the case of Sharice and Darrell to illustrate how Sharice can work relationally with Darrell and still engage in evidence-based practice.

Evidence-based attitudes and behaviors

Rogerian core conditions of congruence, unconditional positive regard and empathic understanding are foundational EBRFs. Although Rogers described them as attitudes, they also have behavioral dimensions. Additionally, counselors bring other relational factors into the room, such as role induction, cultural humility and scientific mindedness. Together, these EBRFs create a welcoming, safe and transparent environment that fosters therapeutic relationship development. Simultaneously, counselors are responsible for managing their countertransference throughout the relationship development process.

Congruence

Congruence implies counselor self-awareness and involves holding an attitude that values authenticity. Clients typically experience counselor congruence as the unfolding of a genuine relationship with their counselor. Genuineness involves counselors striving to be mindfully open and honest in their interactions with clients. This usually, but not always, involves self-disclosure, immediacy and offering feedback.

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Sharice displays congruence in several ways. First, she presents Darrell with an informed consent document that is written in her unique voice and that includes information on how she works with clients in counseling. She also greets Darrell with clear interest in learning more about who he is and what he wants. To focus on him, she might sit and emotionally center herself before going to meet him in the waiting room.

During the session, when Darrell talks about details of his professional work, Sharice openly expresses curiosity, “Oh, you know, I’m not sure what you mean by that. Could you tell me more so I can better understand what you’re experiencing in the workplace?” After Darrell shares details, she says, “Thank you. That helped me understand what you’re up against
at work.”

Role induction

Role induction is the process through which counselors educate clients about their role in counseling. Role induction is necessary because clients do not naturally know what they should talk about and because they may have inaccurate expectations about what counseling involves. When it goes well, role induction is interactive, and counselors simultaneously exhibit Rogerian core conditions (“I hope you’ll always feel free to ask me anything you want about counseling and how we’re working together”). Role induction begins with the written informed consent form.

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Sharice includes in her informed consent document what her clients can expect in counseling. She also explores these topics with Darrell in their first session.

Sharice: I’d like to share a bit with you about what we’ll be doing in this first session. To start, I want to hear about what’s been happening in your life that brings you to counseling now. As you talk, I’ll ask a few questions and try to get to know you and your situation better. We’ll talk about what’s happening now in your life and, if it’s relevant, we’ll talk some about your past. Then, toward the end of our session, I’ll share with you some ideas on how we can work together, and we’ll start to make a counseling plan together. Please ask me questions whenever you like.

Unconditional positive regard

Unconditional positive regard involves the warm acceptance of clients. Rogers himself noted that unconditional positive regard was an “unfortunate” term because no counselor can constantly experience unconditional positive regard for clients. However, to the extent that it can be accomplished, unconditional positive regard involves acceptance of the client’s self-reported experiences, attitudes, beliefs and emotions. Unconditional positive regard allows clients to feel the safety and trust needed to explore their self-doubts, insecurities and weaknesses.

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Throughout their time together, Sharice shows Darrell unconditional positive regard by listening to his experiences, attitudes, beliefs and emotions without showing judgment. She’s open to whatever he brings into the session and encourages him when they encounter subjects he finds difficult to explore. She not only listens nondirectively but also asks questions such as, “What’s your best explanation for why you’re feeling down now?” and “What are you thinking right now?” These questions show acceptance by supporting and exploring Darrell’s self-evaluation rather than focusing on Sharice’s judgments.

Empathic understanding

Empathy is one of the strongest predictors of positive counseling outcomes. However, there is one interesting caveat. It doesn’t matter if counselors view themselves as empathic; what matters is for clients to view their counselors as empathic.

Although measuring empathic responding is challenging, there is consensus that using reflections of feeling and engaging in limited self-disclosure are effective strategies. Also, there is evidence from neuroscience research that resonating with or feeling some of what clients are feeling is part of an empathic response.

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When responding to Darrell, Sharice uses her facial expressions, posture, voice tone and verbal reflections in an effort to comprehend Darrell’s unique thoughts, feelings and impulses. She expresses empathy as he talks about work stress.

Darrell: I feel pressure coming at me from everywhere. Deadlines that need to be met, clients to make happy, bills that need to be paid, and I need to maintain this image in the community, you know?

Sharice: That sounds stressful. You have people counting on you, and it feels overwhelming.

Following an initial reflection of feeling, Sharice uses what Rogers referred to as “walking within” to emotionally connect on a deeper level.

Darrell: It’s starting to get to me in ways stress hasn’t before. Like, I can’t sleep, it’s harder to focus, and I feel like I’m going to burn out soon.

Sharice: It’s like you’re saying, “I don’t know how much more of this I can take, and I don’t know what to do.” Do I have that right?

Later, Sharice uses a reflective self-disclosure (which combines congruence with empathic understanding) in an effort to deepen her empathic resonance.

Sharice: As I listen to you, Darrell, and as I try to put myself in your shoes, I feel physically anxious. It’s almost like this pressure and pace make me feel out of breath. Is that some of what it feels like for you?

Just like Carl Rogers would do, Sharice intermittently checks in with Darrell on the accuracy of her reflections (“Do I have that right?”). Additionally, if Darrell indicates that Sharice is not hearing him accurately, she uses paraphrasing to refine her reflection and sometimes apologizes while correcting herself.

Cultural humility

Cultural humility is an overarching multicultural orientation or perspective that includes three dimensions:

1) An other-orientation instead of a self-orientation

2) Respect for client values and ways of being

3) An attitude of equality, not superiority

Like the Rogerian core conditions, cultural humility is an attitude that counselors adopt before entering the counseling office, but there are also behavioral manifestations of cultural humility.

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In their first session, Sharice creates a space for Darrell to speak about what his culture means to him. She notes that even though they come from different cultures, understanding his culture is important to her.

Sharice: Thank you for filling out the intake form, Darrell. I know it can be daunting with all the personal information we ask for. I see that you are Native American. I’m a mix of German and Swiss and grew up outside of Denver. What this means to me is that I’ll be trying my best to understand your life experiences. If at any point you think I’m not getting your perspective, I hope you’ll tell me. Sound OK? (Darrell nods.) Thanks. Also, whenever you’d like, I’d be interested in hearing more about your culture and how it informs your way of being in the world.

Scientific mindedness

Scientific mindedness is a concept and skill originally described by Stanley Sue. It refers to the process of counselors forming and testing hypotheses about clients rather than coming to premature, and potentially faulty, conclusions.

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As Sharice gets to know Darrell and the issues that brought him to her office, she uses scientific mindedness to hypothesize how culture may (or may not) be a salient factor in his experience of stress in the workplace. When he talks about “immense pressures” that he puts on himself, she’s reminded of how some individuals from minority groups can feel added stress because they view themselves as representing their entire minority community. Sharice keeps this hypothesis in the back of her mind and, eventually, when the time seems right, uses a reflective listening response to test her hypothesis.

Sharice: When you talk about the pressure you put on yourself to perform, it sounds like you’re performing not only for yourself but also for others.

Darrell: Absolutely. I can’t help but worry because my family depends on me to generate income. (Somewhat to Sharice’s surprise, Darrell doesn’t identify his tribe or the reservation community as an additional source of pressure to perform, so she explores the issue more directly.)

Sharice: I’ve read and heard from some of my other Native American clients and students that it’s possible to feel added stress because they might view themselves as representing their tribe or other Native American people. Is that true for you?

Darrell: I always tell myself that that’s not an issue for me. But if I’m totally honest with myself and with you, I’d have to say that being an Indian man in an intense business environment makes for more stress. In some ways, I think it has less to do with representing my people and more to do with how I think my colleagues — and even my friends at work — somehow expect me to be less competent. I don’t know exactly what they think of me, but I feel I need to work twice as hard to earn and keep their respect. (After listening to Darrell’s disclosure, Sharice updates her hypothesis about how race and culture might be adding to his stress at work.)

Sharice: So, it’s not so much that you feel like a representative for your people. It’s more that you’re thinking and feeling that you should do double the work to prove yourself to your colleagues. I can imagine how feeling discounted compounds the everyday workplace stress you feel.

Managing countertransference

Countertransference is unavoidable. Countertransference includes the counselor’s emotional reactions to any or all clinically relevant client material (transference, client personality, content presented by the client, client appearance and so on). These reactions may be related to the counselor’s unresolved personal conflicts or the client’s interpersonal behaviors. Countertransference can be a hindrance or a potential benefit to the therapeutic process; it can distort your perceptions of your client, but it can also inform your relationship with the client.

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During their work, Sharice notices that she gets impatient with Darrell’s pace of speech and finds herself feeling annoyed with him. She brings this to her consultation group to understand why this is happening and how it is affecting her work with Darrell. Talking about it with her supportive group helps her deal with her emotional reactions more effectively and build understanding for why she is experiencing frustration and how to adjust so she can provide the best service possible to Darrell.

The evidence-based therapeutic alliance

The therapeutic alliance was a psychoanalytic construct until Edward Bordin described it in pantheoretical terms. Alliance factors include three dimensions:

1) The emotional bond

2) Mutual goals

3) Collaborative tasks in counseling

Additionally, progress monitoring and rupture and repair can be viewed as EBRFs related to the alliance.

The emotional bond

Although it can be difficult to measure an emotional bond, in the counseling context it is usually defined as clients showing a positive affective response toward their counselors. In many ways, the counselor-client emotional bond is a natural byproduct of the Rogerian core conditions and of the work that counselors and clients do together. However, counselors lead in this process by greeting clients with a positive affect and consistently showing interest in what clients talk about.

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When Darrell arrives at Sharice’s office, she is visibly happy to see him. In addition, she expresses her interest in working with him and her belief that he possesses the ability to overcome the issues with which he is struggling.

After a few sessions, Darrell begins to show trust in Sharice. He no longer looks anxious to be in her office, his speech is less guarded and he smiles more during their interactions. He mentions that although counseling is difficult at times, he appreciates having time every week with Sharice to talk about his life and sort out what is troubling him. He has become emotionally bonded to Sharice and looks forward to counseling sessions.

Mutual goals

In the first few sessions, counselors and clients explicitly discuss clients’ personal problems and corresponding counseling goals. Eventually, and sometimes even in the first session, clients and counselors agree on which goal or goals to focus on in counseling.

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Sharice (after discussing Darrell’s presenting problems and possible solutions): Darrell, we’ve identified several goals that we can work on together: stress management, managing the negative or critical thoughts you have about your work performance and getting better sleep. Which of these would you like to focus on first?

Collaboration on tasks linked to goals

After working with clients to decide on counseling goals, counselors introduce tasks or activities in session (or as homework) that are meaningfully related to the agreed-upon goals. These collaborative tasks often constitute the “technical” part of counseling.

When applying techniques, relationally oriented counselors:

  • Are careful to listen closely to what clients have already tried
  • Use reflective listening to gain a mutual understanding of what has worked worse or better
  • Jointly brainstorm new options with clients
  • Ask permission to try out technical procedures
  • Jointly monitor client reactions to new strategies

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Sharice: We’ve been talking about everything you’ve tried to help yourself sleep better. It sounds like you’ve been working on this for years. How about we rank which strategies have worked better for you and which have worked worse?

Darrell: Sure. (Sharice and Darrell work on Darrell’s rankings.)

Sharice: One of the things I’ve noticed that seems to work better for you is
when you’re able to distract yourself from your thoughts about work. Does that sound right?

Darrell: Absolutely. It’s so hard for me to get my brain to stop problem-solving.

Sharice: One thing I’d add to your list of possible strategies is mindfulness meditation. It can be a powerful technique to deal with racing thoughts. What’s your reaction to that idea?

Progress monitoring

After counseling goals are established and collaborative tasks identified, counselors and clients work together to evaluate counseling progress. There’s a robust body of research attesting to the positive effects of progress monitoring.

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Sharice consistently checks in with Darrell in two ways. First, she uses the Session Rating Scale after each session to gauge her therapy alliance with Darrell. Second, she directly asks Darrell about his reactions to the counseling strategies they are working on together.

As a part of her progress monitoring efforts, Sharice asks Darrell to keep a log of his mindfulness meditation activities, along with his sleep quality and quantity. Each week, they discuss what went well and what was challenging. She offers empathy and makes adjustments to his homework as needed.

Rupture and repair

Rupture is defined as tension or a breakdown in the counselor-client collaborative relationship. Repair involves counselors making statements and taking actions to restore the therapeutic relationship. Rupture can happen at any time during counseling. Usually it involves clients withdrawing or showing irritation.

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After a few weeks of logging his mindfulness meditation, Darrell appears agitated. When Sharice asks about the log, Darrell says, “This is a waste of time, and I don’t know why you thought it was going to help. I’m done with this stupid meditation.”

Sharice responds empathically and then explores with Darrell the source of his frustration. She discusses how embracing a passive attitude during meditation can be extremely difficult, especially because of the pressured and problem-solving orientation he has at work. She apologizes for pushing the idea of mindfulness meditation.

Darrell’s response is paradoxical. He spontaneously shares how important it is for him to find time to get out of his hard-driving mentality. Sharice then tweaks the mindfulness approach they have been using. The new emphasis moves away from formal logging and embraces small moments of progress.

The relationally focused, scientifically based counselor

Beginning with Rogers and moving forward into the 21st century, counseling practitioners have embraced the therapeutic relationship as central to positive counseling outcomes. However, at times, allegiance to and emphasis on the counseling relationship has been viewed as anti-science. The good news is that, now, more than ever, we have growing empirical evidence to support the efficacy and effectiveness of a relational emphasis in counseling. In this article, we reviewed and illustrated specific ways in which you can emphasize the therapeutic relationship and be evidence-based. This is welcome progress for the counseling profession in general and counseling practitioners in particular.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

John Sommers-Flanagan is a professor in the Department of Counselor Education at the University of Montana. He has co-authored many books, including Tough Kids, Cool Counseling (published by the American Counseling Association) and Counseling and Psychotherapy Theories in Context and Practice (published by Wiley). Contact him at john.sf@mso.umt.edu or through his blog at johnsommersflanagan.com.

Kindle Lewis is a doctoral student in counselor education and supervision at the University of Montana. She is a national certified counselor, holds a license in school counseling and has 10 years of experience working with youth in education and counseling settings both locally and internationally. Her areas of focus are youth and school counseling, community building and holistic wellness. Contact her at kindle1.lewis@umconnect.umt.edu.

Letters to the editor: ct@counseling.org

 

 

 

 

 

 

 

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Creative and novel approaches to empathy

By Ed Neukrug February 2, 2017

Near the end of Carl Rogers’ life, he wrote a scathing article noting that his conceptualization of empathy had little to do with the popularized notion of empathy that had become known as “reflection of feelings.” He may have been particularly angry because there were some apocryphal stories circulating about Rogers’ work with clients. One of them goes something like this:

Rogers is seeing a client in his office on the 10th floor of a building. The client tells Rogers that he is really depressed, and Rogers says, “Sounds like you’re really depressed.” The client goes on to say that he is thinking of killing himself, and Rogers responds, “You’re so depressed that you’re even thinking you might take your life.” This “reflection” goes on and on for quite a while until the client eventually declares, “I’m so depressed I’m thinking I might jump out of that window.” Rogers again reflects back, almost verbatim, what the client just said, at which point the client goes over to the window, opens it and says, “I’m so depressed, I’m going to jump out of this window.” Rogers says, “You’re so depressed you might jump out of that window.” Exasperated, the client stands on the ledge, and the last thing out of his mouth as he jumps is, “Ahhhhhh!” Rogers, left in the office alone, repeats, “Ahhhhhh.”

You can understand why Carl Rogers, the person who popularized empathy in the 20th century, was pretty upset by this distorted image of his work. In fact, his actual definition of empathy was much more nuanced than “reflection of feelings.” Rogers suggested that empathy is the ability to understand another person’s experience in the world, as if you were that person, without ever losing the “as if” sense. He also noted that empathy entails letting the person know that you understand his or her experience. However, he never suggested that one should rely solely on reflection of feelings to show this understanding. In fact, he implied there were many ways to show your clients that you have understood them.

The five levels of responding

During the 1960s and 1970s, microcounseling skills were popularized. Although these preprogrammed methods of teaching basic counseling skills were pretty effective, they reinforced the notion that counselors should mostly reflect back feelings and content to be empathic. Models developed by such well-known authors as Gerard Egan, Allen Ivey and Robert Carkhuff flourished at this time, and their work, and similar work by others, continues to dominate the ways that counselor trainees learn basic counseling skills.

The downside of these models was that many counselors grew to believe, and continue to believe, that empathy and reflection of feelings are pretty much synonymous. The upside was that counselors could learn this one form of empathic responding pretty quickly. Because empathy has been shown to be related to positive client outcomes, and because students can learn how to be empathic (or at least good at demonstrating this one type of empathy) in a relatively short amount of time, counselor educators have been generally satisfied to continue using these approaches.

All of the microcounseling skills models were pretty similar, but I was always partial to Carkhuff’s model because he suggested there were five levels of responding. Level 1 is when the counselor is simply horrible, reflects little if any of the feelings and content, and may even be critical of the client. Level 2 is when the counselor misses the mark by using a feeling that is not quite on target (e.g., saying “You feel upset” when “You feel depressed” would be more accurate) or uses content that does not quite capture the meaning of what the client said. Level 3 is when the counselor is on target, reflecting back feelings and content that capture exactly what the client was saying.

Level 4 is when the counselor “subceives” feelings just below what the client was outwardly expressing and accurately reflects those feelings back to the client. For example, “So, I’m sensing that in addition to your anger, you feel pretty hurt …”

Level 4 responses can also demonstrate complex and critical thinking that helps the client gain awareness about his or her life: “It seems like every time you get close to someone, you get scared — similar to how you felt when you were rejected by your parents.” These responses reflect understanding, not a “guess” or an interpretation.

Another Level 4 response is when the counselor reflects back a dilemma that the client may be experiencing but is not seeing directly. For instance, “So on one hand, I hear your deep attraction to this person in your office, but on the other hand, I also hear your ongoing love for your spouse.”

Level 4 responses are like icing on the cake — bringing more depth and clarity to the client’s experience — but they are not essential. In fact, I usually tell beginning counselors to shoot for Level 3 responses, and if a Level 4 response happens to pop into their consciousness, then go for it.

Level 5 responses occur when the counselor is “with” the client in his or her deepest moments of pain and demonstrates this in some way with the client. These are relatively rare responses, usually made in long-term counseling relationships, so I won’t go into depth about them in this article.

Because microcounseling skills models train students effectively and quickly at making basic empathic responses, they have become the gold standard in the field. However, they lack the nuance and complexity that can be offered by creative and novel empathic responses. Rogers alluded to this complexity and creativity when he said, “Gradually my understanding of empathy extended to an intuitive capacity for empathy, where I would find something rising in myself that wanted to be said. It might be bizarre. It might be out of context. But I found that if I voiced it, it often rang a real bell with the person and opened up all kinds of areas that had been dimly sensed by the client but not really experienced.”

Ten creative and novel empathic responses

Enamored of this definition of empathy from Rogers, and personally being a little burned out by the reflection of feelings formula, I began to look at other ways to operationalize empathy. I eventually came up with 10 empathic responses that I call creative and novel empathy.

1) Reflecting nonverbal behaviors: The most basic of the advanced responses, most counselors likely have already made such empathic rejoinders simply by acknowledging a client’s nonverbal behaviors. The following is a brief example of such a response:

Client: I’m not even sure where to begin today. So much has been going on.

Counselor: Well, just looking at your nonverbal behaviors, I can see that you have probably gone through a lot this past week. Your slouching body just looks depressed, and I can see you’re on the verge of tears.

Such basic but important responses acknowledge, through reflection of body language, what the client is saying and cuts through the verbal jargon about the client’s feeling state.

2) Reflecting deeper feelings: This type of advanced empathic response is similar to Carkhuff’s understanding of a Level 4 response, when the counselor is subceiving feelings beyond what the client is outwardly saying. It is important to note that these are not interpretive responses in which the counselor is hypothesizing about what the client is feeling. These responses are when the counselor actually experiences a feeling of which the client is unaware that resides just below the surface. For example:

Client: I’m at my wits’ end. I’m so frustrated with my spouse. No matter what I do, nothing seems to work. I keep offering new ways to try and work things out, but he doesn’t seem to care. I feel like throwing something at him.

Counselor: Your frustration really shows. You’ve tried so many different things, yet nothing seems to work. But most of all, I think I hear the sadness in your voice — sadness about the lack of connection that you feel with your husband.

In the example, look at how the counselor first reflects the frustration the client is clearly feeling, but then moves on to reflect sadness. Not outwardly stated by the client, this sadness was subceived by the counselor. If the counselor is on target, the client will respond accordingly.

3) Pointing out conflictual feelings and thoughts: Also an outgrowth from the Carkhuff model, this response enlightens the client’s understanding of self by pointing out different and conflicting parts of self with which the client is struggling. These contradictory parts of self are often responsible for a client feeling stuck in life. It is only through awareness of these conflicting parts of self that one can make smart choices about how to move forward in life. For instance:

Client: You know, I love my wife so much that the thought of being without her is incredibly painful. She is my rock and makes my life so much easier.

Ten minutes later

Client: I went out to lunch with my co-worker the other day, and I know she was flirting with me. When I’m around her, I feel lifted out of my depression. I so wish that I had someone like her in my life, and I’m even thinking I could have an affair with her.

Counselor: I’m hearing two parts of you. One that feels as if your spouse is your bedrock — a person who keeps you grounded — and another that wishes there were more excitement and vibrancy in your life.

All of us have feelings and thoughts that conflict with one another, and counselors can highlight these conflicts. Once these dilemmas are faced squarely, they can be understood more fully. Otherwise, individuals go through life bouncing from one conflicting thought or feeling to another, and they have a difficult time making sense of it all. Imagine what the conversation might be like if the client in the example talked about his or her conflicting feelings.

4) Using visual imagery: Using visual imagery reaches a client through different neural pathways than does traditional talk therapy. For instance, imagine working with a client who has been so bullied by friends and family that the client has considered suicide. As you sit with your client, an image floats into your consciousness that you share with your client.

Counselor: You know, as you’re telling me about your situation, I imagine you lying on the ground, surrounded by friends and family as they hover over you and barrage you with negative statements. You feel like you can’t move. You’re looking for an escape route, but none comes to mind.

Powerful images such as this show the client that you understand the gravity of his or her situation. They also help the client understand the intensity of the situation in a new and dramatic manner, potentially leading to the client generating ways of freeing himself or herself from the situation.

Another visual image was used with me. I was depressed and kept trying different change strategies, but nothing seemed to work. My therapist looked at me and said, “Sounds like you’re rearranging chairs on the Titanic.” On the surface this may seem like a pretty dismal state of affairs, but at least in my situation, it gave me hope. I knew that I had to get off this ship. And, indeed, it led me to make significant changes in my life.

5) Using analogies: Like visual images, analogies reach clients through different neural pathways than those used with basic reflections. Analogies use a logical analysis to compare a person’s situation to another situation that has a similar theme but different content. This allows the client to see the situation from a slightly removed and alternative position — a perspective that is sometimes more palatable for the client. For instance:

Client: I work in this huge office, and every day I go in and sit in my cubicle. There are literally dozens of people around me, and yet I feel like I’m alone. It’s almost more depressing than actually being by myself — all of these people around me and no one acknowledging, talking with or interacting with me. Sometimes I get so low, I just want to kill myself right there in my cubicle, but no one would probably even notice.

Counselor: It’s kind of like you’re an ant in an ant colony. All the ants are busy, busy, busy, and they don’t see you, hear you or touch you. You could just disappear, right there, and none of the rest of the colony would know you’re gone.

In the example, the counselor builds an image that can be related to the client’s situation but is clearly different visually. This allows the counselor to use different words than the client has used and also allows different channels of understanding.

6) Using metaphors: As with the use of visual images and analogies, metaphors also allow clients to receive information in a different form than the typical reflections used in traditional talk therapy. In this case, however, the counselor uses a figure of speech that is symbolic or representative of the client’s situation.

Client: Things have been going so well for me. Since I’ve been coming here, I just feel like everything has changed. I’m happier, I’m more in touch with myself and, best of all, I have met all these new people and have had all these new experiences. I am just flying.

Counselor: You certainly found the light and now seem to have an infinite spectrum of possibilities.

Here we see the counselor using a figure of speech (rather than a logical comparison as in analogies) to make a comparison between the client’s situation and the counselor’s response. This allows the counselor to reflect back a meaningful understanding of the client’s situation without having to use the client’s same words. It also reaches the client at a deeper level.

Here is another use of metaphor:

Client: I have been so busy lately that I can hardly keep track of what I’m doing. It’s a great relief in some ways because I don’t think about my problems and I kind of feel refreshed — like nothing is sticking to me. I mean, the usual problems I deal with don’t seem to take hold. I kind of like it.

Counselor: That makes me think about that old saying, “A rolling stone gathers no moss.”

Again we see a figure of speech being used to make a comparison between the client’s situation and the counselor’s response. This particular response is short and to the point and allows the client simply to think about what is going on in his or her life.

7) Using targeted self-disclosure: Revealing an aspect of self that parallels what the client is experiencing can be an important way to demonstrate understanding. In addition, clients will sometimes assume that if their counselor was able to overcome a struggle similar to theirs, then they can also be successful. One type of self-disclosure includes the counselor revealing feelings in the moment. Often called immediacy, this response demonstrates understanding of the client’s feelings and also models how the client can share his or her innermost thoughts and feelings with someone close.

Client: I’m at my wits’ end. I’m as depressed as ever. I keep trying to change my life, but nothing works. I try communicating better, I change my job, I change my looks … I even take antidepressants, but nothing helps.

Counselor: As you talk, I feel sad and anxious. Sad, because I can tell how hard this is for you, and anxious, because I feel the frustration of nothing working.

Content self-disclosure, on the other hand, reveals an event about a counselor’s life that mimics the client’s experience. This type of response shows the client that you understand him or her and that such struggles can be overcome.

Client: I’m at my wits’ end. I’m as depressed as ever. I keep trying to change my life, but nothing works. I try communicating better, I change my job, I change my looks … I even take antidepressants, but nothing helps.

Counselor: You know, there was a time in my life when I really struggled. I remember how difficult it was for me to get through that time.

Here, the revelation about the counselor’s life demonstrates that the counselor understands the client’s struggles. Notice the nonspecifics of this response. The counselor clearly does not want to reveal too much about his or her life. Targeted self-disclosure should be done carefully and used only to show a client that he or she is being heard, not because the counselor gets something out of self-disclosing. I often say that if it feels good to self-disclose, then you are probably doing so for your own benefit.

8) Reflecting media: Sometimes a client’s situation might remind the counselor of a particular movie, book or popular story. To show the client that the counselor recognizes his or her situation, the counselor references the media. For example:

Client: I had everything. I just bought a new home, was about to go into business for myself and simply had a wonderful life. Then the tornado took it all away.

Counselor: What you have gone through reminds me of the book The Old Man and the Sea. After catching the fish of his life that will lift the man out of poverty, he ties it to his boat, but sharks attack it, and the man’s treasure is lost.

Here’s another example:

Client: I’m going to avenge my brother’s attackers. I will do whatever I can to make sure they are caught and brought to justice.

Counselor: You remind me of Luke Skywalker, ready to take on injustice.

These responses can sometimes lead to more involved discussions about the characters, and analogies can then be made to the client’s life. For instance, The Old Man and the Sea ends with the defeated and worn-out fisherman saying that he promises to fish again with a young boy who has taken him on as a father figure. This story can provide hope to the client who has lost everything in the tornado.

9) Reflecting tactile responses: Using the counselor’s own physical reactions to the client’s disclosures can also demonstrate empathy. Here, the counselor closely monitors his or her bodily sensations and reflects those to the client in an attempt to mirror the client’s own experience.

Client: Anytime I’m around my partner, he harasses me with negative statements. I try my best to be what he wants me to be but just can’t live up to his expectations. Even when I think I’m doing what he wants me to do, it’s not good enough. I’m lost.

Counselor: When you just told me what you’re going through, I felt a gripping bite in my jaw and my stomach twist and turn. I imagine this is how you must be feeling.

Acknowledging a client’s physical state can assure the client that you understand the gravity of the situation. However, such responses are not limited to sad or negative emotions.

Client: I went into work today and, out of the blue, my boss came up to me, told me what a great job I was doing and said she was recommending me for a raise. I was elated!

Counselor: I just felt this chill go through my body when you told me about your experience with your boss. I know how difficult your work situation has been, and your boss’s feedback must have been an incredible high.

10) Using discursive responses: Based in narrative therapy, discursive empathy assumes that part of the client’s experience is based on older, historical and, possibly, cultural narratives. Clearly, one has to possess knowledge of the client’s old narratives, historical roots and cultural experiences.

For example, when conducting a workshop on empathy, I role-played a real situation in my life about having had cancer. I noted that I wished I had been “stronger” when facing my potential death. Asking for workshop participants to respond empathically to me, one said something akin to this: “The pain you felt in facing death seems like it may be related to a broader, more historical event in your life.”

Being Jewish, I immediately thought of the Holocaust and the kinds of messages I received growing up. I realized that “death” was something that was pervasive in my life as a child, and it continued to have an impact on me as an adult. I began to sob, realizing that my death was more than the death of my “self” — it also included the death of a people. It turns out that the person who made the response was the child of Holocaust survivors and saw in me some themes she had experienced. It was quite a powerful response.

Here is another example of discursive empathy:

Client: You know, I feel like wherever I go, I’m treated as a second-class citizen and I don’t get the same opportunities that Whites get.

Counselor: I wonder if I’m hearing how pervasive racism has been in your life as you were growing up — and even today — and how it has impacted your view of the world in such an important way.

Of all the responses I have introduced in this article, discursive empathy has the most potential for abuse because it makes assumptions about a client’s past. Thus, it should be used only if the counselor has a good feel for and understanding of the client’s historical themes.

Final thoughts

Creative and novel empathic responses can bring new energy to sessions as they help clients understand their situations through new modalities and in different ways. However, I always caution that these responses should be made spontaneously, as opposed to trying to manufacture them in the moment. My experience has been that when one becomes expert at basic empathy (e.g., Level 3 empathy on the Carkhuff scale) and has some understanding of creative and novel approaches, then these advanced responses will become a natural part of the counselor’s repertoire.

For those readers who regularly use such responses, you know how fulfilling they can be, both to the client and the counselor. For those who are new to such responses, it is akin to having an “aha” experience. When you offer these empathic responses, you know that you have given your clients a new way to look at their experiences and have likely broadened their depth of knowledge about self.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Ed Neukrug is professor of counseling at Old Dominion University. A well-known author of 10 books in counseling and human services, he has worked in a variety of settings, including agencies, schools and private practice, and has been active in numerous professional associations over the years. He maintains a variety of open access websites, including one in which visitors can assess their theoretical orientations, another that features oral stories about famous therapists and a third that features animations of famous therapists discussing their theories (see odu.edu/~eneukrug). Contact him at eneukrug@odu.edu.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Why you should incorporate volunteering into your training: A student’s perspective

By Eleanor Rector October 17, 2016

You’re about to start a graduate counseling program. You’ve likely traveled to a new place, so you’re trying to adjust and find a new go-to burger joint. You have your priorities straight.

The last thing you want to do is research places to start volunteering. Besides, you’re already training for a career in which the focal point is helping people. Do you really need to go out of your way to do more? Sure, volunteering sounds good, and you would like to do it, but you’ve worked so hard to get here, and you don’t really have the drive to begin something that won’t further your career.

I have been there. You’re talking to a professional promise-maker here. I’ve organized groups to bring food and hygiene products to homeless individuals, but I’ve also made a thousand promises to myself or to other groups with good missions to volunteer, and when the time came, there was always a great excuse not to follow through. Maybe my cat was being extra cute, or my murder mystery suddenly took an interesting turn.

Whatever the excuse is, it seems important at the time. Besides, I tell myself, if I’m not there to help, someone else will take my place. And sometimes the amount of hurt in the world feels like photo-1469398718052-b9d13df0d7c9too much for me to bear. And I wonder, even if I am there to help, will it really make any difference?

Fortunately, I attend a university that removes the hard part from the equation. At Adler University, volunteering in your first year is a mandatory part of every program. Students fill out a form about their experiences, strengths and interests. Then, in a process I have been promised is not random, they are assigned volunteer positions in underserved communities.

Some individuals are placed in nonprofit organizations they find interesting; others remain confused about their placement throughout the experience. I have watched one particular thing happen across the board, however. Those individuals who complete their volunteer hours with as little effort as possible don’t really gain much from the experience. On the other hand, those who complete their placements by really getting involved and being passionate about serving the underserved ultimately grow immensely.

This experience is so pedestrian that a saying developed around it: “You get out of it what you put into it.” However, clinicians, and especially those of us studying to become clinicians, may not understand how vital this volunteer experience is to our clinical practice. If we are to be guided by the ethical principle of beneficence, then we must do more than simply our jobs to help our communities and the individuals within them.

We must find ways to integrate our pledge to help the community into our everyday lives. Otherwise, we are following only the principle of nonmalfeasance. That is an essential principle, but simply doing no harm is not enough. Doing actual good reaches much further.

Yes, we are “doing good” when we are effective and ethical practitioners. But at the same time, we are simply doing our job well. To fulfill the principle of beneficence, we must go beyond the minimum of being effective clinicians and do good that effects change outside of our own personal spheres. Involving ourselves in our communities, in whatever way one chooses, will also benefit our practices immensely and allow us to be much more effective clinicians.

 

Acknowledging privilege

This, of course, requires a brief discussion on privilege. Luckily, the program at my university that organizes this volunteer placement to underserved populations also provides training sessions that help students understand the oppressive systems at work in the world, specifically inside the United States, and confront the privilege that we all possess.

This is incredibly helpful because acknowledging our own privilege is uncomfortable for many of us. All of us have faced struggles in one form or another throughout our lives. Some of us may not feel that we possess privilege in many respects. And this may be true, because privilege comes in multitudinous forms. But no matter the lack of Master Statuses we may possess, being able to afford (or even have the good standing to take out loans) to go to graduate school and become a counselor is a privilege in its own right.

Many people are afraid of acknowledging their privilege because they think that having privilege is a shameful thing. That’s a logical, although untrue, line of thought. There is often unnecessary guilt inherent in being born with privilege because we live in a world that works to keep the privileged on top while oppressing the underserved.

I am a Caucasian woman. So, even though I am a woman, I still carry the Master Status of “whiteness.” No matter what I’ve experienced or how difficult life may have been, I still carry that one Master Status. I can do my best to understand the experiences of other individuals and empathize with them. But there has to be a point at which each of us acknowledges that some individuals have had experiences we simply cannot understand.

This isn’t something to be ashamed of because no one can control the circumstances into which she or he was born. However, it is our responsibility to confront these circumstances and subsequent biases head-on if we are going to be socially conscious clinicians who are dedicated to following ethical principles. Furthermore, those of us with privilege have a responsibility to help those without privilege and without a voice.

I think the writer Toni Morrison expressed this sentiment particularly effectively: “I tell my students, when you get these jobs that you have been so brilliantly trained for, just remember that your real job is that if you are free, you need to free somebody else. If you have some power, then your job is to empower somebody else. This is not just a grab-bag candy game.”

 

Giving empathy another dimension

Acknowledging our privilege is important for many aspects of our work and a vital component of volunteerism. For starters, it helps us form empathy.

Although most (hopefully all) clinicians and clinicians-in-training possess some amount of empathy, acknowledging privilege gives our empathy another dimension. For instance, when working with homeless individuals as a teenager, I clearly had empathy for the population. Especially during the Great Recession, I understood that circumstances beyond these individuals’ control had led them to this place of desperation.

But this empathy needs to be multidimensional. Acknowledging one’s own privilege, and therefore the societal systems of oppression at play, allows one’s empathy to extend not only to the individual directly before you, but also to a whole group of individuals who have been affected by these systems. Now instead of feeling empathy only because of a particular individual’s immediate circumstances, I’m able to understand that clients’ lives have often been controlled by societal systems that existed long before these people came to be. These systems were created to oppress classes of individuals, leaving upward mobility out of the question for many and, too often, making simple survival an enormous feat.

 

Understanding community

In addition to growing our empathy, acknowledging our privilege is an essential part of understanding our own communities. Because we all experience privilege, we simply remain unaware of certain parts of our communities. These sections of our communities don’t concern us, so we often don’t bother to get involved in them.

This isn’t a lack of empathy. Rather, it is simply a lack of knowledge. Acknowledging our privilege means opening ourselves up to learning about the underserved of our communities and the problems that plague those with less privilege than us. Because we are clinicians, learning often sparks passion in us, and when we become passionate about changing an issue and providing voice to the voiceless, we can be unstoppable.

This deeper understanding of my community took place for me at my volunteer site, where I took notes at a monthly meeting for the Harm Reduction Coalition, which aims to provide prophylactic availability in prisons to stop HIV transmissions both inside and outside of prison. By being in a meeting of this kind, I ended up learning far more about the correctional system than prophylactic availability. Simply by being involved, I was able to meet so many individuals whose lives had been touched by the general lack of health care within prisons. In the process, I was forced to let go of my preconceptions.

I logically had assumed that when individuals in prison became sick, they were provided with the health care to which they have a right. That is until I met a woman whose husband had been diagnosed with cancer in prison but was refused knowledge of his diagnosis and treatment. His family only learned that he had cancer when he died behind bars in the arms of his friends and an autopsy revealed the truth. I met another man who had been so deprived of sensory stimulation that he had to relearn how to talk, read, write and interact with individuals upon being released from prison. I heard horror stories of treatment being denied again and again and again so that the cost wouldn’t cut into the profits of privatized correctional healthPeople Hands Holding Colorful Word Volunteer care corporations. When you are in prison, you are still supposed to have certain rights. But when those rights are violated, you are voiceless and powerless.

When I started volunteering, I thought I understood the population I was working with and the system by which they are controlled. But when you have the privilege to not automatically be aware of these systems, you find that they are far more intricate than you ever could have imagined. Often, simply learning about the populations who live within these systems and cannot escape makes it impossible to not want to be involved.

As clinicians, we need to understand that we have preconceived beliefs that are inaccurate about many parts of our society. And the reality is, we are going to have clients who are part of these populations or have been touched by these systems. To be truly responsible clinicians, we need to confront these preconceptions head-on by involving ourselves with populations with which we would not generally come into contact.

I still struggle with the idea that what I do doesn’t really make a difference — that the oppressive systems at work are so big and so concrete that anything I do can only make a dent. That’s true in a way. After all, I’m only one person. There’s only so much I can do. But I can help educate others so that they too can begin to make chinks in the armor around this system. And they can educate the people around them about the reality of the world in which we live. At the end of the day, no matter how small the things I’ve accomplished are, they’re still there. And they still make a difference.

Don’t be afraid to admit that your preconceptions are wrong. Instead be afraid of keeping those preconceptions rather than confronting them. Identify an area of society that sparks your interest and passion, and find ways to get involved. Only through accepting your privilege and confronting your biases and beliefs can you deepen your understanding of society and strengthen your abilities as a clinician.

So force yourself to get off the couch. Find a nonprofit that works in an area that interests you. Schedule a time to volunteer, and then follow through. You won’t regret it.

 

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Eleanor Rector is a second year master’s counseling student specializing in forensic psychology at Adler University in Chicago. Originally from South Florida, she studied poetry and psychology at the University of Miami. She hopes to continue her education by pursuing a Ph.D. in applied neuropsychology. Contact her at erector@my.adler.edu.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

 

 

Counseling ‘unlikeable’ clients

By Laurie Meyers August 25, 2016

It’s not a politically correct statement, but, sometimes, clients are tough to like. Yes, counselors are supposed to remain professional at all times and practice unconditional positive regard. But they are also human, and fending off creeping feelings of “dislike” can be a challenge, especially when clients espouse racist, misogynistic or homophobic beliefs; have abrasive personalities; or simply remind counselors of someone in their own lives whom they find difficult to be around. So the question becomes, how do counselors handle that reality?

Tamara Suttle is a licensed professional counselor (LPC) in Castle Rock, Colorado, with more than 30 years of experience in mental health. She also runs a business in which she provides supervision, consultation, private practice coaching and counseling for other therapists. In her Branding-Images_Difficultopinion, most counselor education programs and the counseling profession itself don’t do enough to prepare future clinicians for those instances when they will experience negative feelings toward a client. In truth, she says, it’s a bit of a taboo topic.

“If your professors don’t talk about these things and our clinical supervisors don’t talk about these things and our colleagues and our friends and our bosses and our professional associations don’t talk about these things, then we learn pretty quickly that we aren’t supposed to talk about these things or even experience these things,” says Suttle, a member of the American Counseling Association.

But in reality, all counselors experience discomfort with and dislike of a client at some point in their careers, says Keith Myers, an LPC and ACA member in the Atlanta metro area. “If someone tells you that it does not [happen], they’re not being honest with themselves,” he says. “We are counselors who also happen to be human beings.”

Digging deeper

The key is being able to set aside and even learn from those negative feelings when they pop up, Suttle says. To do that, counselors need to discern what is truly at the root of those feelings.

Lauren Ostrowski, an LPC at a group private practice who also works at a community mental health agency in Pottstown, Pennsylvania, agrees. “To me, what is far more common [than fully disliking a client] is working with clients who do things or have traits that I don’t like,” says Ostrowski, a member of ACA. “Even if I feel like I have a client I don’t like at all, I make it a point to figure out what it is they are doing or saying that I don’t like. Then I figure out whether the problem is really me — [making] a value judgment perhaps — or whether they are doing something in session that also affects their everyday life that they are motivated to change.”

Suttle acknowledges that after reflecting on her negative feelings toward a client, she sometimes discovers that the problem actually resides with her. She is reacting with dislike because the client triggers personal issues she has struggled with herself, such as having been raised to be a people pleaser.

“I’m sure many therapists can relate to having a certain type of client that they simply prefer not to work with,” Suttle says. “For me, that has historically been a client who is so focused on people pleasing and [is so] passive or passive-aggressive that she is often unable or unwilling to own her truth and … tell the truth.”

“After years of struggling with this type of client and [having] lots of opportunities to reflect on my struggles, I now recognize my discomfort as being much more about me and my own people-pleasing tendencies than those of my clients,” she continues. “It’s one of those issues that I must continually be cognizant of and work on in order to work with clients.”

Likewise, Myers says that his feelings of dislike or discomfort with a client are often about him. “Most times … it’s [dislike] about an interpersonal issue or a client reminding me of someone I know or knew,” he says. “I think, for me, it comes down to countertransference and how a client may stir up my own unconscious — or, at times, conscious — parts of me.”

Myers and Suttle both stress the importance of counselors practicing self-reflection to identify personal issues that can creep into counseling.

When Suttle works with other counselors who are struggling to like one of their clients, she looks for what she calls “signature issues” in the counselors’ backgrounds. She does this by helping them to construct genograms. The purpose is to identify how a counselor’s family members interacted in relationships going back several generations, such as Suttle’s long line of people pleasers.

Together, Suttle and the counselor search for behavior patterns related to family relationships. For instance, passivity might be a pattern in the counselor’s family. Suttle also asks about how conflict was handled in the counselor’s home growing up. As an example, a counselor whose father punched walls when he was angry might not be comfortable with conflict. This could engender a negative reaction to clients who push back, are stubborn or struggle to control their anger, Suttle notes.

Identifying the personal issues and biases that contribute to a counselor’s dislike of a client is an important step, but that alone will not solve the problem, say Myers and Suttle. Both stress the importance of counselors receiving supervision and even engaging in individual therapy when their personal issues trigger feelings of dislike toward a client.

“Supervision and consultation play a huge role in processing the material and my own internal responses that occur within my counseling relationship with clients,” Myers says. “Having someone who comes alongside me in my process of helping others and is willing to see me through a different lens … who is often challenging me and exploring my conscious and my unconscious feelings. … [That] is so important to me keeping those ‘dislikes’ [about a client] in check.”

“Another thing I do is participate in individual therapy,” Myers says. “Sometimes if a client is rubbing me the wrong way or I feel irritated or agitated with a client, my therapist provides me with a safe space to be able to process those things.”

In addition, Ostrowski urges counselors to seek more informal supervision when struggling with negative feelings toward a client. “This doesn’t have to be the official [type of] supervision with a contract and consultation agreement, etc.,” she says. “While I think that kind of supervision is important, here I’m talking more about a trusted co-worker or another clinician where you can just have a discussion about exactly what you are reacting to, how you reacted in session and what you are going to do moving forward.”

Suttle has a consulting group that she meets with regularly, and she urges other practitioners to participate in similar groups to help them deal with problematic feelings toward clients.

Setting aside personal beliefs

In accordance with the ACA Code of Ethics, counselors know that they must not force their own beliefs on clients, but what happens when a client espouses beliefs that are hateful, personally hurtful or just uncomfortable to the counselor?

“Sometimes working with clients who have different values can be challenging,” Ostrowski says. “In that case, I really try to learn more about the client’s worldview and, in some cases, ask about how looking at a situation in a certain way may affect them or their family. Often, they are already aware of these things and will say that they understand that it causes certain trouble with extended family dynamics or may be part of why they don’t have a relationship with someone important to them. There can be some very fruitful discussions about how important their beliefs are to them compared to what it is that they want in life and whether there is some sort of balance that they see.”

When Myers, a past co-chair of the ACA Ethics Committee, is working with a client who has strong prejudices or biases against certain groups and is making judgmental or harsh comments in session, he tries to tie it back into the therapeutic process.

“I normally use this time to explore these comments so that I can gain further insight into the client’s background, values, beliefs [and] family-of-origin issues,” he explains. “This is usually an opportunity to hold the tension while exploring deeper with the client. And if we believe it’s important to be fully accepting and nonjudgmental with all clients, then it’s important for us to accept those who are different from us and who hold very different values and opinions, even when they are being judgmental.”

Although Ostrowski often manages to make therapeutic use of a client’s biases or prejudices, she acknowledges that it isn’t always easy, recounting the story of one of her recent cases as an example. “A few days after the tragic shootings in the Orlando nightclub [at Pulse in Florida on June 12], I had a client discussing his beliefs on the whole idea with me. Let’s just say that [the client’s beliefs and Ostrowski’s beliefs] were about as far opposite as one can get, and on top of that, he had a lot of the facts incorrect. I did mention that I had heard different facts on the news, but he disagreed,” she says. “I stopped trying to point out things that were different from what I had heard, and I allowed him to discuss how all of this had affected him, restating what he was saying and asking for more information.”

Ostrowski says the situation served as a good reminder for her to closely monitor her reactions when faced with a client’s prejudicial statements and biases. “I will say that for the rest of the session after the topic was brought up, I was checking every statement or question I used before I said it to see whether it was to benefit me or my client,” she notes.

It is important for counselors to know themselves well so they can better guard against their personal beliefs and biases slipping into the counseling session, Ostrowski says. However, that doesn’t mean that counselors have to give up their personal beliefs.

“We can keep our worldview [as counselors] and simultaneously learn more about the world as our clients see it,” she explains. “For that matter, it’s not even about hiding our beliefs, but more about disclosing only those that would further the conversation we are having with our clients about what they believe and leading them in the direction of their therapeutic goals.”

Regardless, hearing a client spout hateful or misinformed comments in session can still take a toll on counselors, Myers and Ostrowski say, and that is one reason why they think counselor self-care is crucial in these situations. Myers take breaks to walk in nature after client sessions that may have been upsetting because the activity helps him clear his head. Ostrowski, meanwhile, has found that staying grounded helps her and can be particularly useful while in session.

“[Staying grounded] may decrease the feeling of being emotionally flooded or overwhelmed,” she explains. “[It] can be as simple as taking the time to notice your feet on the floor or your hips in the chair. The possibilities are endless. Each and every one of us can find some way that we can move or notice the location of our body in the room or the chair in a way that is not distracting to a client. It takes only a matter of seconds and can change the trajectory of the session because of having an increased ability to stay present with the client in that moment.”

‘Liking’ versus ‘accepting’

Other clients can be difficult to like not so much because of their beliefs but because they possess abrasive personalities.

Christine Moll, an LPC who practices in the Buffalo, New York, area, points out that no one ever said that counselors have to like every client they come in contact with. She cites the writings of Carl Rogers — one of the founders of the client-centered approach — to support her statement.

“He called for empathy,” Moll explains. “Nowhere did he say like, but [rather] embracing the person with concern or care, wanting the best for that person.”

Moll, an ACA member who is also a past president of the Association for Adult Development and Aging, says she has definitely encountered clients whom she didn’t like, but she always tries to put her personal feelings in perspective. “I have worked with clients that I have found difficult, arrogant, elitist or biased,” she says. “But I am not in their lives. I don’t need to share a fence with them. I think to myself that if I [have to put my reactions] aside, it’s just for 50 minutes, and I tell myself, ‘It’s not about you.’”

Regardless of how a counselor feels about a client, the goal should always be to help that client find and attain a good quality of life, says Moll, who is also a counselor educator at Canisius College. “I try to use what I’ve not liked about a person and figure out how to reframe it,” she notes.

For instance, clients might come to counseling complaining that no one likes them and they don’t know why. Moll explains, “I might point out a [client’s] passion for life that other people might see as a chip on the shoulder and say, ‘I see your energy and your passion for life, and if you feel threatened and put up against a wall, you are going to fight back. That’s great. That’s a gift. But can you see how that can lead people to see you negatively?’”

Ostrowski suggests exploring whether a client’s difficult personality is connected to the reason that person is seeking counseling. “For example,” she says, “if clients come across very gruff and unpleasant, it could be that they have emotions that they don’t understand or they struggle to have effective conversations, thereby leading them to react in ways that are perceived as unpleasant because of self-protection strategies.”

Moll also tries to identify positive aspects in even the most unpleasant client. “I was raised with the idea that everyone’s got something [good] about them,” she says. “If I find a glimmer or find a good quality, I praise it.”

Myers comes back to the importance of always putting the client first in the counseling relationship. “I will say, yes, it is harder to work with a client that I don’t like, at least at first. But then I remind myself that I must accept each client where they are in their lives and that I don’t have to like them necessarily to fully accept them, support them and offer them respect.”

 

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To contact the counselors interviewed for this article, email:

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.