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Empathy and Mental Health
An Integral Model for Developing Therapeutic Skills in Counseling and Psychotherapy
Arthur J. Clark
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eBook - ePub
Empathy and Mental Health
An Integral Model for Developing Therapeutic Skills in Counseling and Psychotherapy
Arthur J. Clark
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About This Book
Empathy and Mental Health shows mental health professionals how to employ a deeper understanding of subjective, objective, and interpersonal modalities of empathy in their practice.
Chapters are full of case studies and examples that demonstrate empathy's role in challenging and complex encounters, and as each concept and process is introduced, Dr. Clark discusses strategies for responding empathically. The book has a sound theoretical grounding that is informed by extensive material on empathy and empathic understanding from the counseling and psychotherapy literature and related fields of inquiry.
Drawing from psychodynamic, existential-humanistic, cognitive behavioral, and other contemporary orientations, this text makes empathy immediately useful and understandable to students and practitioners.
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Chapter 1 The Promise, Challenges, and Potential of Empathy in Counseling and Psychotherapy
DOI: 10.4324/9781003168355-1
If empathy is to remain relevant and influential in counseling and psychotherapy, its therapeutic scope and unrealized potential must be illuminated and capitalized upon. Across the mental health literature, narrow and ambiguous conceptions of empathy restrict avenues for facilitating client change and development. In particular, the internal functioning and deliberative reasoning of counselors and therapists are often overlooked or neglected as significant capacities for empathically understanding clients in relational contexts. While widely recognized among a range of therapeutic traditions as a core condition in successful treatment practice, empathy is too often taken for granted or marginalized due to contemporary demands for efficiency and client symptom relief. Carl Rogers’s urgent call to the field to view empathy as an attitude or as a way of being of a practitioner has largely gone unheeded outside of his person-centered approach. Instead, empathically understanding a client is often reduced to being equated with the technique of reflection of feelings. In many skill acquisition publications accessible to students and professionals, empathy is represented in terms of reflecting feelings or is superficially addressed with a cursory discussion of the process. Despite the availability of extensive literature on empathy representing a broad range of theoretical orientations, most counseling and psychotherapy texts restrict extended consideration of the topic to the person-centered tradition of Rogers. As a result of inadequacies in defining and conceptualizing empathy, in treatment contexts the conception may be inaccurately expressed through such statements as, “I know exactly how you feel,” “I feel so sorry for you,” and “I agree. Given the way they treat you, don’t put up with your job for even one more day.”
Strivings of a counselor or a therapist to foster a therapeutic relationship and empathically understand a client receive wide-acclaim as essential pursuits in counseling and psychotherapy. Research findings consistently suggest that more fully knowing an individual within a sound working alliance contributes to positive treatment outcomes. With a sense of feeling empathically understood, a client’s response to threat and defensive posture tends to lessen and compliance with therapy goals increases. At the same time, the development of a therapeutic relationship and seeking insight into the deeper nature of an individual must be cultivated and nurtured over the course of the treatment process. However, contemporary calls for an escalating pace of therapy and cost-containment potentially compromise the pursuit of empathic understanding. While empathy is portrayed as being highly valued across almost all therapeutic persuasions, the empathic process is subject to efficiency questions due to perceptions of its time-consuming and diversionary influences. Spending time getting to know a client on a personal basis engenders a more caring way to treat a person, but valuable treatment periods are possibly lost at the expense of more purposeful endeavors. With defined limits on the number of therapy sessions, goal-oriented and directive strategies and interventions may seem more efficient and timely to a practitioner. Moreover, advances towards deeper ways of empathically understanding a client assume a secondary level of importance to a counselor or a therapist who focuses on immediate client change in seeking problem resolutions.
Although the promise of empathy emphasizes the value of empathically knowing a client in a relational context, various challenges hinder progress and a full engagement of the process in the direction of therapeutic gain. Introduced over 100 years ago in an era of meandering and depth-focused therapy, empathy today exists in a climate of accountability and evidence-based practice and outcomes. Yet, since the 1960s, systematic efforts to evaluate and develop empathy in research and training venues have achieved only limited and mixed results. One significant difficulty relates to the multitude of meanings of empathy in the treatment literature. Presently, there is a lack of consensus in counseling and psychotherapy of a conceptual and operational definition of empathy in which researchers and practitioners can find some degree of common ground. A particular research problem is that a counselor’s or a therapist’s expression of empathy is typically measured through observations of behavior in training and practice settings. More subtle and nuanced conceptions of empathy largely remain unexplored and unexamined. Much to the dismay of Carl Rogers and others adhering to the person-centered approach, another concern is that reflection of feelings tends to be equated with empathy in research and instructional arenas. Further, a number of related terms, such as sympathy and compassion, are semantically confused with empathy, leading to misapplications in treatment encounters.
Capitalizing on the promise of empathy in therapeutic contexts, while addressing its challenges and limitations, constitutes a purposeful direction in research and practice. Yet, in order to pursue the full potential of empathy, a new paradigm is needed that transcends narrow and divergent conceptions in counseling and psychotherapy. In this quest, an integral model significantly extends the scope and impact of empathy through a practitioner’s sustained engagement of multiple empathy modalities over the course of the therapeutic process (Clark, 2004, 2007, 2010a; Clark & Butler, 2020). Conceptualized in this way, empathy is a higher-order frame of reference in which different modes can be nested in a tripartite framework (Elliot, Bohart, Watson, & Murphy, 2018). Subjective empathy evokes a counselor’s or a therapist’s internal resonating capacities which are often overlooked or neglected as experiential resources for understanding and making empathic connections with a client. Objective empathy draws upon a practitioner’s scholarly and theoretical knowledge and accrued therapy experience in the service of empathically knowing a client. Interpersonal empathy involves a therapist’s grasp of a client’s phenomenological experiencing and facilitates a broad range of empathy-related skills that are subject to training and development.
A more expansive and inclusive conception of empathy facilitates a comprehensive understanding of an individual through three ways of knowing that continue to evolve over the course of the therapeutic process. In this pursuit, a practitioner experientially participates with a client and periodically oscillates to an observer and data-informed stance. From this objective perspective, the counselor is able to step back and draw from reputable sources of knowledge and professional experience in order to reflect on treatment interactions. Over time, a holistic model of an individual begins to emerge through differentiations of an ever-deepening integration of a client’s way of being (Wilkinson & Dewell, 2019). In turn, a more depthful empathic understanding of a client’s pattern of functioning contributes to informing the treatment process and the judicious operation of therapeutic skills.
The Promise of Empathy in Counseling and Psychotherapy
Developing trust and rapport with a client forms the basis of a sound psychotherapeutic relationship. An individual’s feelings of threat tend to decrease in an emotional climate of support and reciprocity. Understanding a client in inclusive relational contexts also represents the promise of empathy that is in keeping with the view of many counselors and therapists as an essential therapeutic aim. For these practitioners, a sensitive and accurate awareness of a client’s experiencing seems indispensable for engendering treatment progress. For decades, scholars and researchers have explored the effect of the therapy relationship and client understanding on treatment outcomes. Today, however, with an emphasis on targeted symptom relief, defined protocols, and session time limitations, the urgency of fostering human connections and seeking a deeper way of knowing a client are subject to speculation relating to professional efficiency. In this regard, the promise of empathy has become debatable—even in the most fundamental therapeutic arenas of relating to and understanding a client.
Empathy and the Therapeutic Relationship
The reciprocal and interactive quality of the therapeutic relationship encompasses multiple components that have a potential to foster the development of a positive milieu in which to effect client change (Bachelor & Horvath, 1999; Sexton & Whiston, 1994). In an effort to distinguish critical aspects of the therapeutic relationship, Bordin (1979) made reference to the personal bonds between a client and a therapist, a striving towards mutual goals, and a viable means to achieve them. Since Bordin initially defined the alliance or working alliance, the formulation has been a focus of extensive empirical research and training endeavors in counseling and psychotherapy (Sexton & Whiston, 1994). Understandably, engendering emotional connections and collaboratively working towards shared aims are sound treatment pursuits. Implications relating to empathy in the alliance involve the relational bonds in which a client feels understood through an emotional climate of mutuality and respect. At the same time, Horvath (2018) cautioned that important distinctions between the alliance component and the broader conception of the therapy relationship can be obscured by adapting and extending the definition of the alliance beyond its initial iteration by Bordin in 1979. In recent years, the more narrowly conceived working alliance has nearly become synonymous with the ther-apeutic relationship, potentially creating significant misunderstandings in research, training, and practice (Gelso, 2019; Myers & White, 2010).
Beyond the alliance, the real or personal relationship is also situated within the broader context of the therapeutic relationship (Gelso, 2011, 2019). Frequently, there is confusion between the alliance and the real relationship due to a similarity of the relational concepts. Both processes facilitate the development of emotional bonds, but ultimately serve different functions in therapy practice. The working alliance emphasizes the sharing of mutual goals and tasks, while the real relationship is a product of the personal connections in the treatment encounter. Greenson (1960, 1967) conceptualized the working alliance as emerging from the real relationship. More recently, Gelso (2019) found that both modes mutually influence one another in the direction of therapeutic gain and seem to emerge simultaneously. Greenson’s framework also includes transference/countertransference configurations with the potential to hinder or enhance the relationship between a client and a practitioner. Although the three processes, the alliance, the real relationship, and transference reactions, overlap, it is conceptually possible to distinguish each formulation in order to clarify sound research and treatment practices.
In the therapeutic relationship, Greenson (1967) asserted that the real relationship is often overlooked and misunderstood as a significant variable. Through a pursuit to identify elements of the real relationship, he made reference to the genuine and realistic relations between a therapist and a client (Greenson, 1967). Genuineness reflects the ability to be one’s authentic self in the relationship, and realism pertains to accurately understanding another’s reality in undistorted and unbiased ways (Gelso, 2011). In therapy contexts, genuineness manifests in being who one truly is, in contrast with assuming a phony or inauthentic facade. Genuine expressions of feelings and thoughts involve experiences of loss, failure, rejection, hope, success, joy, and other matters in the province of human existence (Gelso, 2011).
In response to such intimate disclosures, a counselor or a therapist attempts to empathically connect with client narratives through affirming and respectful interactions emphasizing a two-way relationship. With respect to realism, being perceived in realistic terms involves a process of empathic understanding, and a failure to accurately capture the reality of a client frequently evokes negative emotional reactions. For example, a client exclaims with irritation: “I don’t think that you know me at all.” “You keep pushing your ideas on me.” “Are you listening to what I am saying?” In a more therapeutic direction, a practitioner has a subjective capacity to fleetingly identify with the life experiences of a client, and this empathic attunement bolsters and strengthens the real relationship.
As evolving concepts originally formulated by Sigmund Freud, configurations of transference and countertransference are influential variables in the therapeutic relationship that are recognized in most contemporary approaches in counseling and psychotherapy (Sommers-Flanagan & Sommers-Flanagan, 2017). In treatment practice, transference and countertransference dynamics have a potential to compromise or enhance an empathic relationship between a client and a practitioner. Traditionally, transference reactions encompass a client’s largely unconscious projection of feelings and attitudes rooted in past ways of relating that are directed at a practitioner in the present (Corey, 2017). Transference involving parents, siblings, and other significant persons in the early life of a client produce distorted perceptions of a positive or negative valence that do not fit the counselor or therapist (Cormier, Nurius, & Osborn, 2017). Empathically understanding transference dynamics facilitates the exploration of a client’s less accessible past relations that deter therapeutic change and progress towards forging the real relationship (Greenson, 1967).
In contrast with transference centering on misperceptions of the client, countertransference relates to unresolved personal issues of a counselor or therapist that restrict empathic understanding and hinder the development of genuine and realistic therapeutic connections (Gelso, 2011, 2019). As an example, a therapist repeatedly demonstrates an excessive pattern of nurturance and a crossing of professional boundaries with a client that disrupts the development of a mutual and reciprocal relationship. As the practitioner gains an awareness of countertransference reactions and begins to manage the conflictual issue, an empathic understanding of a client emerges that had previously been masked and there is an accompanying growth in the real relationship (Cormier, Nurius, & Osborn, 2017).
Within the context of a therapeutic relationship, a counselor or a therapist has an empathic capacity to emotionally engage a client while being able to shift to a broader and more reasoned position in order to reflect in more depth about the individual’s condition. In this regard, as a psychoanalytic conception, a practitioner may assume a participant observer stance with a client by oscillating between personal connections and data-informed ways of knowing (Greenson, 1967; Sullivan, 1953). A participant involvement enables a therapist to form a close relationship that is essential for grasping intimate details in the lived experience of a client (Greenson, 1967). At the same time, embracing a more detached stance facilitates a dispassionate understanding of conceptual and theoret-ical material relating to the functioning of a client. Further, a participant posture fosters an optimum capacity for empathy when therapeutically moving back and forth between experiencing with the client and then thinking about the person (Jaffe, 1986).
In treatment practice, a counselor or a therapist is in a position to shift from functions of subjective experiencing to a more analytic and objective position in order to empathically enhance a therapeutic understanding of a client from multiple perspectives (Gelso, 2019). As an example, from a participant mode a counselor becomes aware of her tendency to be excessively controlling in interactions with clients in counseling. By stepping back and assuming an observer role, she is able to empathically grasp the reality of a client more accurately and recognize the possible operation of countertransference involving personal control issues. In this instance, the counselor engages in critical thinking by reflecting on how she experiences her controlling tendencies through different, but related perspectives (Deal, 2003).
Empathy and Client Understanding
An empathic understanding of a client evolves and deepens in the interpersonal contact of a sound therapeutic relationship over the course of the treatment experience. The personal and working relations between a client and a practitioner, fostered by an empathic connection, give rise to an emotional climate of mutuality and inclusion. An individual’s experience of being deeply understood frequently evokes feelings of relief and a sense of being cared about and taken seriously (Myers, 2000; van Kaam, 1959). This mode of empathic experiencing, particularly when sustained and repeated over time, engenders a sense of trust and credibility in the therapist or counselor, while holding promise for enduring client growth and development (Myers & White, 2010). For a practitioner, efforts to empathically understand a client transpire on a moment-to-moment basis in situational contexts or as a way of knowing from a broader and ...