Preparatory Empathy

Empathy is such a central part of what makes therapy therapeutic that it's almost a cliche. You know what empathy is - understanding someone else's experience from within their experience, rather than superimposing your own experience, assumptions, etc. However, in all of our discussions of empathy, we often forget about a important but very difficult kind of empathy: preparatory empathy.

As you might infer from the phrase, preparatory empathy is empathy we experience in preparation for a clinical encounter - before it happens. Garden-variety empathy happens during a clinical encounter, with direct access to the person with whom we are trying to empathize. That makes it easier to know that we're connecting with that person's experience rather than superimposing our own. In contrast, trying to empathize with someone we haven't met - or even someone we have met but are not currently with - leaves more to the imagination, and is therefore more susceptible to the influence of our own "stuff."

So, given the potential for errors, why both with preparatory empathy? Why not just wait until the encounter occurs to call up empathy?

Here is my opinion: In the absence of preparatory empathy, we (being human) run the risk of making judgments that are not particularly empathic. Think about it: when we meet with a client for the first time, we have usually received some sort of information about that person already. We have a referral, or paperwork from another provider, or their own responses on an intake screening or questionnaire. Based on this information (particularly if it contains a diagnosis), we automatically form snap-judgments. Some might be accurate, and others are not. However, regardless of accuracy, they influence our initial interaction with the client - how we approach him or her, our tone and expression, the questions we ask and how we ask them.

When our judgments are accurate, we might chalk that up to "practice wisdom" - because, yes, some incoming information is accurate and does have clinical implications that we have learned about over the years. When they are inaccurate, it might be the result of cultural or clinical bias, or our own history. However, by the time we recognize our error, we may have already damaged our initial rapport with the client.

Preparatory empathy, while still leaving room for inaccurate judgments, seeks to minimize the risk of harm by extending the benefit of the doubt. Imagining what the client may be thinking and feeling, their distress, creates openness and compassion, and shifts our approach slightly. While both judgmental and empathic assumptions can both be erroneous...they can also both create self-fulfilling prophecies. People who receive a gentle and supportive welcome soften, and people who receive a brusque welcome become defensive. Therefore, it serves everyone's best interest for us to work - ahead of time - to foster empathy for clients and clients-to-be.

How do you sort out clinical wisdom from bias? How do you think about preparatory empathy?

You Catch More Flies With Honey

A few weeks ago, I wrote about accepting feedback, and part of what makes that difficult. However, it's also worth reflecting on what makes giving feedback also a challenge.

The most obvious answer, of course, is that many people are uncomfortable with conflict and fear that even well-meant negative feedback will be received with some degree of defensiveness, hurt, or anger. It's not really an irrational fear - any of those responses are definitely possible, while it is not possible to control what response you receive.

It's also true that most of us do not have the luxury to avoid giving feedback. We give feedback to our supervisees, sometimes our supervisors, and yes, even clients. In the case of clients, feedback may take the form of confrontation (e.g., highlighting discrepancies between a client's words and behavior), or redirection of inappropriate or detrimental behavior.

We provide feedback in order to be helpful: to facilitate growth and/or prevent harm. We may undertake it in the most nonjudgmental and kindhearted of mindsets...but the other person does not know what our mindset is, and many of our clients (and more than a few of us) may have insecurities that make them (us) vulnerable to criticism. Any sort of feedback can affect self-esteem, depending on how the receiver internalizes it. So, while one person may think, "Oops, she's right, I should have done that differently," another person may think "I should have known better than to make that mistake. She must think I'm an idiot."

Now, as I said above, it isn't possible to control the other person's reaction - to make sure, for example, that they think like person #1 rather than person #2. However, there are some strategies that we can use to make our feedback easier to hear. These strategies all seem to fall into the category: "You catch more flies with honey than with vinegar."

1) The feedback sandwich
Perhaps the most straightforward strategy is to "sandwich" a piece of negative feedback between two pieces of positive feedback: praise, criticize, praise. The positive feedback makes the negative feedback easier to hear, perhaps because it protects against a precipitous drop in self-esteem that might accompany negative feedback alone.

2) Empathic feedback
Any negative feedback is easier to hear when it is said in the kindest possible way, in an empathic and understanding tone, with explicit recognition of the person's best intentions, and assurance of ongoing positive regard (i.e., that you still respect the person and that their good qualities are not negated by the feedback).

3) Focus on concrete behaviors rather than personal qualities
We've all heard this advice when it comes to child-rearing: discipline should emphasize that a behavior is wrong, not that the child is "bad." The same principle can be applied to adults. Feedback is most effective when it focuses on a concrete behavior that the person can identify and change, rather than either vague feedback that does not suggest a specific change, or feedback focused on something that the person cannot easily changed (e.g., shyness).

4) The VCR technique
From the book Teens Who Hurt, this strategy suggests that feedback may be more effective when structured as follows: V - begin by validating, i.e. expressing understanding of the other person's perspective, and acknowledging a strength or positive quality (kind of like the feedback sandwich). C - next comes challenge, i.e. provide the corrective feedback, ideally building upon the information contained in the validation. R - finally, request, i.e. identify a specific behavioral corrective action.

How do you think about giving feedback? What strategies do you find make it easier for someone to hear and respond positively to feedback?

Psychosis from the Inside Out

It used to make me very uncomfortable to work with clients who were psychotic. In the act of empathy, I would find myself trying to follow their thought processes. My mind, however, pulled back from the experience of insanity with a sort of primal anxiety - as if my brain feared that, by understanding or empthazing with the experience of psychosis, it could lose its own equilibrium.

At the beginning of Surviving Schizophrenia: A Manual for Families, Patients, and Providers(which I consider an absolute must-read), Dr. Torrey talks about how schizophrenia is a tragedy that elicits little sympathy because people can't imagine (or can't tolerate imagining) it happening to them. The first, best thing we can do to help clients with psychosis is to understand, and help their families understand, what they're experiencing internally.

To that end, Dr. Torrey offers us a glimpse into the inner experience of people with schizophrenia, in their own words, highlighting the changes that occur as a result of the illness:

• Alterations of the senses
• The most common change, especially early in the course of illness, is heightening of the senses, which become overacute
• "noises all seem louder to me than they were before....it makes it difficult to keep your mind on something when there's so much going on that you can't help listening to."
• "Colors seem to be brighter now, almost as if they are luminous painting. I'm not sure if things are solid until I touch them."
• As a result of heightened senses, the person may experience their senses as being flooded with stimuli
• "Sometimes when people speak to me my head is overloaded. It's too much to hold at once."
• Stimuli may become distorted
• "suddenly the room became enormous, illuminated by a dreadful electric light that cast false shadows....voices were metallic, without warmth or color. From time to time, a word detached itself from the rest. It repeated itself over and over in my head, absurd, as though cut off by a knife."
• The person may also be flooded by internal stimuli - thoughts and memories. At times these thoughts are experienced as if they have been inserted into the person's head by someone else.
• "a local pharmacist was tormenting me by inserting his thoughts into my head and inducing me to buy things I had no use for."
• While heightened senses are often an early symptom of schizophrenia, the opposite often happens later in its course, and people find their senses blunted (this can include the ability to perceive physical pain - a definite health risk!)
• "However hard I looked it was as if I was looking through a daydream and the mass of detail, such as teh pattern on a carpet, became lost."
• Inability to sort and interpret sensations, and consequently, to respond appropriately
• Normally, the brain sorts through incoming information, interprets it using logic and past experiences, and provides an appropriate (often learned) response. In schizophrenia, this process breaks down
• "If I look at my watch, I see the watchstrap, watch, face, hands, and so on, then I have got to put them together to get it into one piece."
• It can be particularly hard to integrate two different types of stimuli
• "I can't concentrate on television because I can't watch the screen and listen to what is being said at the same time."
• Incoming information is often connected with inappropriate responses - such as laughing when told a loved one has died. Such responses interfere with the ability to relate to other people.
• Thoughts become disorganized or disjointed
• "My thoughts get all jumbled up, I start thinking or talking about something but I never get there."
• The person may also experience periods of thought blocking
• "Sometimes I commit brief disappearances - my mind pauses and closes down for a short while, like falling asleep suddenly"
• Altered sense of self - specifically the sense of where one's body stops and the outside world begins
• The person may experience somatic perceptual distortions
• "Hands, arms, adn legs soemtimes feel an inch to the side of where they really are at. Fingers at times feel and look longer or shorter than usual. My face can feel twice as long as it is."
• They may have difficulty distinguishing themselves from another person, or their reflection
• "several of the patients having breakfast were me. I recognized them by the way they held their knives and forks."
• Different body parts may seem to take on lives of their own
• "The arms and legs are apart and away from me and they go on their own. That's when I feel I am the other person and copy their movements, or else stop and stand like a statue."
• Changes in emotions
• Early in the illness, depression, guilt, fear, exaggerated and rapidly fluxtuating emotions are common
• "I sat in my basement with a fear that I could not control. I was totally afraid - just from watching my cat look out the window."
• Later in the illness, emotions flatten (further hampering relationships by impeding empathy on both sides) - the person may feel "nothing," or they may have emotions but be unable to show them.
• Changes in movement
• Movement may speed up, slow down, and/or become clumsy
• Spontaneity decreases, and repetitive movements may occur
• Some may become catatonic, with the person not moving for an extended period of time
• Changes in behavior
• Other symptoms may cause the person to withdraw and become immobile at times, often to moderate the incoming flood of stimuli.
• Movements are slower due to difficulties with integration
• "If I do something like going for a drink of water, I've got to go over each detail - find cup, walk over, turn tap, fill cup, turn tap off, drink it. I keep building up a picture."
• The person may also engage in ritualistic behaviors - which have a meaning and purpose to the person but seem bizarre to others
• The person may repeat whatever is said to them (echolalia) or mimic behavior (echopraxia)
• Decreased awareness of illness (what we professionals euphemistically call "insight")
• In the early stages of schizophrenia, the person is usually aware that something is going wrong with their brain (which is the most tragic element of the experience, from my perspective). When the disease is fully manifest, however, most lose this awareness as a result of damage to specific parts of the brain.
• Decreased insight results in decreased depression and suicide, but increased involuntary hospitalization and medication refusal.

Dr. Torrey recommends trying to understand schizophrenia by going to an art museum and imagining what it might be like to live inside the paintings. Others have invented a virtual reality machine that mimics hallucinations. However you go about it, I recommend doing what you can to develop your understand of and empathy for this debilitating illness.

For more information, check out the rest of Dr. Torrey's book:                     

  

Do "Shrinks" Read Minds?

A hesitation some people have about beginning therapy seems to be a fear of having all their deepest, darkest secrets suddenly exposed. They know people talk about that kind of thing in therapy, but they can't imagine doing so with a stranger (with good reason!). However, they may wonder (based on media portrayals, perhaps) whether therapists are somehow trained to be able to "tell" what their secrets are - some kind of mind-reading trick that's a trade secret.

I confess that I have at times feared others in the field would be able to look at me and know things I'd rather keep secret - not because I believed they could read my mind, but because I feared they'd be more attuned to barely-noticeable but tell-tale cues. 

However, as everyone (client and clinician alike) who's learned about cognitive distortions hopefully knows, believing you know what someone else is thinking is risky business - we're almost always wrong! I often tell clients that humans as a species are notoriously bad at mind reading. 

Why are we so bad at "mind reading?" We tend to have trouble setting aside our own perspective completely enough to fully grasp someone else's. As a result, what we assume other people are thinking usually says more about ourselves than the other person. (Psychodynamic theories would say we project our own "stuff" - often what we can't acknowledge about ourselves, in fact - onto other people, acting as if it's theirs instead).

Training as a therapist (usually, hopefully) involves learning enough about our own "stuff" to keep it from distorting our understand of clients. Working as a therapist involves intentionally setting aside our own priorities, motives, feelings, and needs in order to focus solely on the client's. Indeed, a necessary ingredient in any therapy is empathy - the ability to accurately perceive what the client is experiencing. 

And if you're doing that well - accurately tapping into the client's inner experience from within their own worldview, and keeping your own white noise to a minimum - it might seem at times like you are reading their mind. 

How so? Well, accurately reflecting what they're communicating just seems like you're listening and understanding (powerful in itself, of course). However, accurately reflecting to them what they're not yet even fully aware of themselves...that's really powerful. To the point it makes you seem like you might have powers. (I've heard this technique called empathic conjecture, because you're making an educated guess about the client's inner experience based on your empathic understanding). 

Since there are a host of reasons clients may not be fully aware of, or may be unable to communicate important aspects of their experience, this skill is not only powerful, but can also break through impasses in treatment. In fact, I'm writing about it right now because after muddling through for months with an angry client who was only coming to see me because therapy is required if you want medication, just empathizing with a feeling she was barely aware of having finally allowed her to open up to me and the work.

I'm curious what experience others have had with empathy and/or "mind reading" - when it works, when it may have backfired...and any advice folks have for those trying to learn to subtle art.