Effective Psychotherapists Ch3 & 4 PDF

CH A P T ER 3 Accurate Empathy “Empathy” is a word that has many meanings. We begin with a brief consideration of empathy as a trait that is part of normal human development. We then describe the therapeutic skill of accurate empathy, and explore its underlying attitude and interpersonal expressio...

CH A P T ER 3 Accurate Empathy “Empathy” is a word that has many meanings. We begin with a brief consideration of empathy as a trait that is part of normal human development. We then describe the therapeutic skill of accurate empathy, and explore its underlying attitude and interpersonal expression. Finally, we summarize a long history of research linking therapist empathy to better client outcomes across various forms of counseling and psychotherapy. Trait Empathy The experience of empathy is highly evolved in humans (Hojat, 2007) and includes at least two separate but related components with distinct neuroanatomical foundations. The first of these is cognitive perspective-taking: reading the apparent inner experience and intention of others amid complex and sometimes conflicting cues (Fonagy, Gergely, & Jurist, 2002; Lamm, Batson, & Decety, 2007). It is easy to imagine how this ability could convey an advantage within small bands of evolving humans who needed to cooperate and understand each other in order to survive. This ability to anticipate others’ intentions can bestow a competitive advantage in sports, debate, games, or conflict. A second component of trait empathy is shared affective responding: to recognize and experience, at least in part, another person’s 19 20 THERAPEUTIC SKILLS emotion. Particular types of neurons “mirror” the actions and emotions of others (Gallese, Gernsbacher, Heyes, Hickok, & Iacoboni, 2011), observable in changes in heart rate and electrical skin conductance (Critchley, 2009). An example is feeling sadness or fear during a movie. Particularly relevant for present purposes, these changes can be concordant between speaker and listener. The physiological responses of a therapeutic dyad can become empathically entrained during treatment sessions (Levenson & Ruef, 1992; Messina et al., 2013). Co-feeling can occur in counseling and psychotherapy, with the therapist not only recognizing, but partially experiencing a feeling such as sadness or joy that a client is expressing. Shared affective responding may inspire compassionate action, but can also evoke responses that are not in the best interest of the individuals involved or of society. Paul Bloom (2016) cautioned against impulsive responding to affective empathy and instead advocated “rational compassion”—objective humane decision-making— to avoid biases generated by sympathy. A classic example is whether to move a particular child up the waiting list for organ donation, based on emotional empathy (Batson, Klein, Highberger, & Shaw, 1995). Trait empathy is partially heritable (Hojat, 2007) and probably normally distributed in a population (Gillberg, 1996). Individuals may be unusually high or low in empathy, with most being somewhere in between. Some people seem to have a keen natural talent for understanding what other people are thinking, feeling, and meaning. Others may enhance their skill by various means. As with other talents like musical ability or athletic prowess, empathy can be increased by life experience (Fox, 2017; Miller & C’de Baca, 2001) or intentional practice (Miller, 2018; Thwaites et al., 2017). The practice of therapy itself may increase clinicians’ capacity for empathy. The Skill of Accurate Empathy Within the context of helping relationships, “empathy” has a particular meaning. It is a skill more than just a trait or inner experience. It is not the same as sympathy, feeling sorry for someone. The skill of accurate empathy does not require feeling the same thing another person is feeling at the same time she or he is experiencing it. Co-feeling Accurate Empathy 21 may happen, but even if it does, that in itself is not particularly helpful to the other person. In fact, therapists often moderate their own expressed affect to counterbalance clients’ emotional arousal (Soma et al., 2020). Nor is it necessary for you to have had similar experience yourself in the past. In fact, if your own experience causes you to identify with the person, it can actually interfere with accurate empathy. Having similar experience now or in the past is neither necessary nor sufficient for you to provide accurate empathy. Finally, it is not just perspective-taking (the capacity to put yourself in another’s position and imagine what she or he may be experiencing), although that is a prerequisite for accurate empathy. A central aspect of this skill is seeking to understand the client’s own perspective and experience. Therapists low in this skill appear to pay little or no attention to the client’s perspective. Those with high skill in accurate empathy show a deep understanding of a client’s meaning, typically talking less than the client does and reflecting their understanding back to the client (Perez-Rosas, Wu, Resnicow, & Mihalcea, 2019). Accurate empathy is both an observable skill (as described below) and an internal experience or attitude. The Attitude of Accurate Empathy A starting point is knowing that each person has experience that is, in some ways, like all other people’s, like some other people’s, and like no other person’s (Kluckhohn & Murray, 1953). You have enough in common with your clients to be able to grasp some of their meaning and experience, and yet it is wise to have a beginner’s mind and not assume that you understand fully. A fundamental attitude in empathic understanding is curiosity, an openness to and interest in another’s experience. Often curiosity about human experience is what attracts people to helping professions. A wonderful aspect of being human is that you are not limited to your own experience and perspectives. With flexible openness, you know that you do not start with an accurate understanding of another person’s life, and you want to understand (Lazarus, Atzil-Slonim, Bar-Kalifa, HassonOhayon, & Rafaeli, 2019). You’re willing to take the time to enter into the client’s frame of reference, to look through the lens with which he or she perceives the world. 22 THERAPEUTIC SKILLS In ordinary conversation, people tend to listen just long enough to reply. With accurate empathy, you listen with the intent to understand. You set aside, at least for the time being, the expression of Each person has experience your own perspectives and wisthat is like all other people’s, dom. Your whole attention is like some other people’s, and focused on understanding what like no other person’s. this person is experiencing. The intensity of concentration and absorption is akin to the discipline of mindfulness meditation (S. C. Hayes, Lafollette, & Linehan, 2011; Kabat-Zinn, 2016; Thich Nhat Hanh, 2015). There is an unfolding quality to empathic listening. Starting with a beginner’s mind, you gain gradually deeper levels of understanding of the person’s meaning and experience. Listening in this way involves a continuing openness that resists the premature closure of telling yourself (or your client), “OK, now I’ve got it.” Your internal experience of empathy is of little use to your client unless you communicate it. As will become apparent below, this ongoing process of reflecting back your understanding also makes your understanding deeper and more accurate. By offering your empathic reflections and listening carefully to your client, you come successively closer to accurate understanding. The How of Communicating Accurate Empathy A helping relationship involves understanding and appreciating another’s experience, being able to perceive reality from his or her perspective as if you were that person. Yet, something is still missing if you only have these internal experiences of empathy. Accurate empathy is a therapeutic skill, a particular kind of outward expression of understanding (Gelso & Perez-Rojas, 2017). It involves conveying your internal understanding to your client. It is easy to misunderstand someone’s meaning and experience. What you imagine or assume that someone is thinking or feeling can be inaccurate. How, then, can you Accurate empathy involves develop the skill of accurate empaconveying your internal thy? That is the focus of the rest of understanding to your client. this chapter. Accurate Empathy 23 Three Ways Communication Goes Wrong Behind what someone says to you is an unspoken meaning to be conveyed, and there are at least three ways in which you may misunderstand that meaning. First, people don’t always say exactly what they mean. The words a client speaks convey only part of what she or he means. What is said, and how it is said, might be colored by the speaker’s motivation to please, to create a good impression, or to deceive. Furthermore, the same words can have widely varied meanings to different people or in particular contexts. Meaning is also conveyed by the “music” of speech: tone of voice, pace, volume, and pauses that give more information beyond the words that would appear on a transcript. A second place where communication can falter (besides people not saying what they mean) is through mishearing. Did you correctly hear the words that were spoken? Mishearing might happen due to inattention, background noise, accents, hearing impairment, or listening in a language that is not your native tongue. Even if you do get the words completely right, there is a third potential source of misunderstanding, which is your own interpretation of what they mean. When you hear a word, you essentially look it up in your mental dictionary and consider the possible meanings, perhaps choosing the one that seems most likely to be correct. This all happens instantaneously, automatically, and often unconsciously. The danger is in assuming that your interpretation of the words you think you heard is what the person actually meant. Silence One way of listening is to keep silent, to say nothing in response to what you hear. Indeed, there is value in allowing people time to process what they are saying. Counselors do well to develop a tolerance for silence, resisting the urge to say something after a few seconds’ pause in conversation. Yet, too much silence can leave a speaker wondering what the listener is thinking, and it invites people to project their imaginings onto the listener. This was an intentional strategy in classic psychoanalysis, using therapist silence to elicit and study clients’ projections. Unless you want to invite projections, however, it is better not to be unresponsive for long spans of time. In ordinary conversation, speakers take turns inserting their personal 24 THERAPEUTIC SKILLS perspectives and reactions. In helping relationships, though, the focus is on the client’s well-being, and it is usually unhelpful for counselors to be regularly inserting their own perspectives, opinions, advice, and agreement or disagreement as might occur in ordinary conversation. In accurate empathy, the therapist’s responses convey emerging understanding of what the client means and is experiencing. Roadblocks to Listening Well Accurate empathy is, in part, defined by what you are not doing while listening. Thomas Gordon (1970) described 12 kinds of responses that people often offer instead of good listening. He characterized these as roadblocks in that speakers are easily diverted by them and must, in essence, go around them in order to keep on exploring their original train of thought and experience. These responses can literally get in the way of empathic listening. Here in paraphrase are Gordon’s 12 roadblocks to listening, beginning with those that counselors may be more likely to offer: 1. Probing is asking questions to gather facts or obtain more information. 2. Advising includes making suggestions and providing solutions. 3. Reassuring includes comforting, sympathizing, or consoling. 4. Agreeing is telling people they are right, perhaps approving or praising them. 5. Directing is telling a client what to do, as if giving an order or a command. 6. Persuading can be lecturing, arguing, disagreeing, giving reasons, or trying to convince logically. 7. Analyzing offers a reinterpretation or explanation of what someone is saying or doing. 8. Warning involves pointing out the risks or dangers of what a person is doing. 9. Distracting tries to draw people’s attention away from what they are experiencing, as by humoring or changing the subject. 10. Moralizing is telling people what they should do and why they should do it. Accurate Empathy 25 11. Judging can take the form of blaming, criticizing, or simply disagreeing. 12. Shaming can have a demeaning or ridiculing tone, or apply a disapproving label. We hasten to add that there are times when some of these responses are appropriate in helping relationships. It’s just that they are all different from empathic listening and tend to divert the person away from what he or she is saying or experiencing. Agreeing, for example, can communicate that the listener has heard enough and no more needs to be said. This may be helpful if you want to move forward, but much less so when the goal is to deepen your understanding of a client’s experience. Asking a question requests information about some particular aspect of what the person was saying, potentially derailing the original direction of self-exploration. It’s not wrong to agree or to ask a question. It’s just different from (and often easier than) accurate empathy. Empathic Listening What is accurate empathy? It is a way of listening that helps you avoid roadblocks and step inside another person’s world. It is not passive, but active listening (Gordon, 1970; Gordon & Edwards, 1997; Miller, 2018), a kind of mirroring. You give your full attention to what the person is saying, and you also reflect back your understanding. James Finley (2020) described a psychotherapist as “someone who keeps inviting you to slow down and listen at the feeling level to what you just said.” It’s not an echo chamber in which you merely repeat what you heard. Rather, you make a guess about what it means, what has not (yet) been said. Instead of merely reiterating a client’s words, you speak what might be the next sentence in the paragraph. At first, you may stay closer to the person’s words, but as you gain understanding, you make gradual guesses (Miller, 2018; Nichols, 2009). SPEAKER: It’s been a pretty rough week. LISTENER: You’ve been having a hard time. SPEAKER: I’ll say! Nothing seems to be going right. 26 THERAPEUTIC SKILLS LISTENER: Not the way you hoped. SPEAKER: I guess I’m not surprised, really, but our daughter’s been spending time again with friends we told her she shouldn’t see anymore. She just doesn’t listen. LISTENER: You’re pretty worried about her. SPEAKER: Worried? She wound up in the emergency room the night before last. LISTENER: You’re more than worried! SPEAKER: We just don’t know what to do. I feel like we’ve tried everything to get her on the right track, but she’s not thinking about her future. It’s like she doesn’t care. LISTENER: You do care, though, and aren’t willing to give up on her. SPEAKER: I just feel so helpless sometimes. Notice how, with small changes, this might be one continuous paragraph: “It’s been a pretty tough week. I’ve been having a hard time. Nothing seems to be going right, not the way I hoped. I guess I’m not surprised, really, but our daughter’s been spending time again with friends we told her she shouldn’t see anymore. She just doesn’t listen, and I’m pretty worried about her. More than worried. She wound up in the emergency room the night before last. We just don’t know what to do. I feel like we’ve tried everything to get her on the right track, but she’s not thinking about her future. It’s like she doesn’t care. I do care, though, and I’m not willing to give up on her. I just feel so helpless sometimes. Such mirroring allows people to stay focused on, and take a closer look at, their own experience. It also allows you to confirm (or correct) your understanding of what the client is trying to say, and conveys that you care about what he or she is saying. Notice that the reflections above are statements, not questions. Aware that you are making a guess, there can be a tendency to inflect your voice upward at the end, which turns it into a question. That has an unintended effect of questioning (rather than understanding) what the client has said. The result can be that the client backs away Accurate Empathy 27 from what was said rather than continuing to explore it. For example, can you see how these pairs of reflections might yield different responses? “You’re feeling anxious?” or “You’re feeling anxious.” “You’re angry with her?” or “You’re angry with her.” “You don’t see anything wrong with what you did?” or “You don’t see anything wrong with what you did.” The difference can be subtle, but reflections as statements tend to flow like a normal conversation, whereas the same words posed as questions may foster defensiveness. What to Reflect? How do you decide which aspects of clients’ statements are important to reflect? The act of reflection focuses on particular facets of what someone says, selectively emphasizing or strengthening them. No one reflects randomly; to do so would be bizarre. In listening to clients, therapists make implicit and often unconscious decisions about what is important to highlight. Of all the things clients say, a counselor “must be able to separate the wheat from the chaff” (Truax & Carkhuff, 1967, p. 160), but what is the wheat, the most important content to reflect? These are moment-to-moment decisions in any conversation, and there have been various proposals: • A common belief is that a person’s underlying feeling or emotion is particularly important to reflect (Gordon, 1970). • Charles Truax and Robert Carkhuff (1967) suggested that the “most reliable” clue of what is therapeutically meaningful is “outward signs of upsetness, anxiety, defensiveness, or resistance” (p. 291), and recommended selectively reinforcing three themes: (1) human relationship, (2) self-exploration, and (3) positive self-concept. • Leslie Greenberg and Robert Elliott (1997) proposed that therapists should reflect the client’s experiences, particularly those of intense vulnerability, so that they can be brought more fully into the moment (p. 183). 28 THERAPEUTIC SKILLS Some authors have suggested that what is reflected, and indeed how much empathy is expressed, should be aligned with the needs of the client. Certain clients may be less able to tolerate expressions of empathy and prefer a more “businesslike” therapist (Elliott, Bohart, Watson, & Greenberg, 2011b). For such clients, a skilled therapist might, because of empathic understanding, actually reduce expressions of empathy. In any event, it matters what you choose to reflect. An empathic listening response places particular emphasis on something a client has said, and tends to encourage more of the same. Chapter 9 will offer some examples of how difIt matters what you choose to ferential reflection can affect client reflect. outcomes. Overshooting and Undershooting A subtle but important aspect of empathic listening has to do with the intensity of a reflection. Some authors have emphasized exact matching of the client’s own intensity (Truax & Carkhuff, 1967), but there can be strategic reasons to modestly “overshoot” or “undershoot” expressed emotion or opinion (Miller & Rollnick, 2013). Understating often allows people to reaffirm and continue exploring what they have said, whereas overstating may prompt them to back away from what they expressed. Consider three possible therapist responses (undershooting, matching, or overshooting) to this client statement: “I’m just upset with my mother. She makes me so angry sometimes.” 1. “You’re a bit annoyed with your mother.” 2. “You’re angry with your mother.” 3. “You’re furious with your mother.” A client might respond quite differently to these three reflections; perhaps: 1. “Annoyed? No, I’m more than annoyed. I’m really cross with her!” 2. “Well, I don’t know. She just frustrates me sometimes.” 3. “Oh, it’s not that bad. I know she’s under a lot of stress, too.” Accurate Empathy 29 Or, suppose a client says, “My son just keeps making the wrong choices!” 1. “You’re a little discouraged.” 2. “He hasn’t been making good choices.” 3. “He never makes good decisions.” What you choose to reflect makes a difference. If you want people to continue self-exploration of their experience, it’s generally better to reflect at or a bit below their intensity level. On the other hand, an amplified reflection (like the #3 responses above) may help a client to reconsider an extreme position or overgeneralization, but only if spoken with no hint of sarcasm or criticism in the tone of your voice (Miller & Rollnick, 2013). Research on Accurate Empathy Of all the therapeutic factors that have been studied, accurate empathy has the most consistent relationship to positive client outcomes. In a meta-analysis of 82 independent samples representing more than 6,000 clients, empathy showed a moderately strong relationship with client outcomes (d = 0.58, p < 0.001) across a wide range of theoretical orientations and presenting problems (Elliott, Bohart, Watson, & Greenberg, 2011a; Elliott, Bohart, Watson, & Murphy, 2018). Higher therapist levels of accurate empathy have predicted better outcomes in client-centered counseling (Truax & Carkhuff, 1976), psychotherapy (Elliott et al., 2011a, 2011b), cognitive-behavior therapy (Burns & Nolen-Hoeksma, 1992; Miller & Baca, 1983; Miller et al., 1980; Moyers, Houck, et al., 2016), emotion-focused therapy (Watson, McMullen, Rodrigues & Prosser, 2020), health promotion (R. G. Campbell & Babrow, 2004), motivational interviewing (Fischer & Moyers, 2014), and even computer-delivered brief intervention (J. D. Ellis et al., 2017). Empathic therapists are more likely to establish the kind of strong working alliance that predicts better outcomes (McClintock, Anderson, Patterson, & Wing, 2018). Outside the psychotherapeutic realm, empathy is strongly associated with medical patients’ satisfaction with their physician, independent of factors such as waiting time or visit duration (Kortlever, Ottenhoff, 30 THERAPEUTIC SKILLS Vagner, Ring, & Reichel, 2019). Even small increases in the level of empathy of emergency room physicians can lower patients’ thoughts of litigation (D. D. Smith et al., 2016). Therapists with low levels of empathy in practice may be of particular concern (Mohr, 1995; Moyers & Miller, 2013). Analyses of therapist effects sometimes reveal a few therapists with outstandingly poor client outcomes (McLellan, Woody, Luborsky, & Goehl, 1988; Project MATCH Research Group, 1998). Poor outcomes, in turn, have been linked to therapists with low levels of accurate empathy and of Rogers’s core therapeutic skills more generally (Lafferty, Beutler, & Crago, 1989; Miller et al., 1980; Valle, 1981). Truax and Carkhuff (1967) found no outcome differences between clients whose therapists had moderate or high levels of core skills, but both groups had much better outcomes than did clients whose therapists had low levels of interpersonal skills. Do Clients Cause Therapist Empathy? One rival explanation is that better-prognosis clients (e.g., those who are more “motivated”) inspire counselors to be more empathic, and that’s why therapist empathy predicts better outcomes. Empathic responding does vary within as well as between therapists. In some ways, this makes intuitive sense: Clients who are able and willing to express more of what they are experiencing offer therapists many more opportunities for expression of empathy (Barrett-Lennard, 1981). Therapists, on average, tend to show higher levels of empathy with clients who are more intelligent and show less pathology (Elliott et al., 2018; Kiesler, Klein, Mathieu, & Schoeninger, 1967). A negative therapist attitude toward a client has been linked to judgments of greater disturbance and poorer prognosis, with a potentially deleterious impact on the course of therapy (Strupp, 1960). There is also evidence that empathy levels are higher depending on the similarity between client and therapist (Duan & Hill, 1996). In contrast, Truax and Carkhuff (1967) found that therapists’ core therapeutic skills (including empathy) were relatively independent of clients. Furthermore, they demonstrated experimentally that when therapists switched between high and low levels of therapeutic skill within sessions, clients’ levels of self-exploration tracked the therapists’ responses as predicted (Truax & Carkhuff, 1965). Accurate Empathy 31 The truth is likely both: that therapists do differ in their accurate empathy skills, and clients also influence the process. In sum, therapeutic empathy is co-created, with therapists having greater responsibility for their own contribution. KEY POINTS • Accurate empathy is a reliably measurable and learnable therapist skill that is associated with better client outcomes across a range of interventions and problem areas. • Empathic (reflective, active) listening is a particular way of responding that mirrors a client’s experience while avoiding “roadblocks.” • A skillful reflection does not merely repeat what a client says but makes a gentle guess about what may be unsaid. • Meta-analyses indicate that empathic listening is associated with greater client self-exploration and better treatment outcomes. • Client self-exploration can be affected by the intensity of offered reflections (undershooting, matching, overshooting). CH A P T ER 4 Acceptance Nonjudgmental acceptance has long been recognized as an impor- tant therapeutic skill in counseling and psychotherapy, and is even regarded by some to be the most important (Wilkins, 2000). Here is an early description: It involves as much feeling of acceptance for the client’s expression of negative, “bad,” painful, fearful, defensive, abnormal feelings as for his expression of “good,” positive, mature, confident, social feelings, as much acceptance of ways in which he is inconsistent as of ways in which he is consistent. (Rogers, 1957, p. 98) In this sense, the counselor’s manner is “unconditional.” Clients are not required to meet certain criteria in order to be accepted or respected by the counselor. Acceptance is “the ability to listen without preconception, prejudgment, or condemnation” (Strupp, 1960, p. 99). This can be quite a departure from everyday social discourse in which people may argue, disapprove, warn, judge, analyze, moralize, criticize, blame, or express sarcasm—virtually all of the roadblocks described in Chapter 3. This very contrast with ordinary communications may be what renders acceptance so therapeutic. In this chapter, we focus in particular on this interpersonal quality of nonjudgmental acceptance. We recognize that the term “acceptance” has also been applied to other therapeutic conditions including 32 Acceptance 33 warmth, positive regard, and affirmation (Farber & Doolin, 2011b; Orlinsky & Howard, 1986; Rogers, 1951). In Chapter 5, we will turn our attention to these related therapeutic attributes. The Attitude of Acceptance Nonjudgmental acceptance is a key element in the practice of mindfulness, which gained prominence in psychotherapy research early in the 21st century, particularly in third-generation cognitive-behavior therapies (S. C. Hayes, 2004; S. C. Hayes et al., 2011), stress management (Kabat-Zinn, 2013; S. L. Shapiro, Astin, Bishop, & Cordova, 2005), and addiction treatment (Witkiewitz, Bowen, Douglas, & Hsu, 2013; Witkiewitz, Lustyk, & Bowen, 2013; Witkiewitz & Marlatt, 2004). Based on ancient contemplative practices (Anonymous, 1957; Salzberg, 1995; The Dalai Lama & Hopkins, 2017), mindfulness involves attentive observation of one’s immediate experience without needing to judge or evaluate, approve or disapprove. It is an accepting appreciation of what is, without critique or demand for what ought to be. Implicit in this therapeutic attitude is a belief that human beings have inherent worth and deserve respect without needing to earn it. This belief is not just a broad reverence for humankind, but a respect for and acceptance of this particular, unique individual, the client in front of you. Therapists seek to communicate acceptance of clients as they are, affirming their sense of inherent worth (Farber & Doolin, 2011a). How is the expression of acceptance therapeutic? Carl Rogers’s (1951) perspective was that when people experience themselves as unacceptable, they are immobilized and unable to change. Like punishment, a sense of unacceptability may suppress behavior, but it does not foster a new way of being. Paradoxically, it is when people experience unconditional acceptance of themselves as they are—be it from parents, a loved one, a therapist, or from God—that they are enabled to change. This runs contrary to a belief that people will change if they can just feel bad enough about themselves. In Rogers’s view it is the very experience of unacceptability, of conditional worth, that causes people to reject experience that does not conform to their conditions of worth. Conversely it is the experience of nonjudgmental 34 THERAPEUTIC SKILLS acceptance that is healing, even when provided briefly as by a therapist (Miller, 2000; Rogers, 1961). (An added benefit of developing this skill is that through practicing unconditional acceptance of others, you may come to more fully accept and integrate your own experience as well.) The counselor seeks to understand clearly the client’s experience and reflect back that understanding, responding without judgment, accepting what the client offers. Through this modeling, clients may come to accept and respect their own experience. Do you find yourself objecting, “Doesn’t this just give people permission to do whatever they please?” In truth, people already have this freedom of choice, and further rejection or disapproval is Acceptance offers the unlikely to be remedial. Implicit possibility of change. in nonjudgmental acceptance is a recognition “of their right as a self-determining individual not to change, to be ‘cured’ or to grow” (Wilkins, 2000, p. 27). Acceptance offers the possibility of change. Underlying Beliefs about Human Nature Beyond a general reverence for the value of each individual, there are broader beliefs about human nature. Consider these three contrasting views about people’s inherent nature (Miller, 2017; Rogers, 1962): Theory A: People are fundamentally self-serving; without social controls, they would revert to an instinctual nature that is self-centered, hostile, antisocial, and destructive. Theory B: People have no basic nature, but are a happenstance product of their genes and experience; they are essentially a blank slate written upon by nature and nurture. Theory C: People’s natural predisposition is collaborative, constructive, and trustworthy; at least when given the supportive conditions for change, people will typically move in a positive and pro-social direction. One cannot conclusively prove the truth of any of these three views of human nature, but there is evidence regarding the consequences of embracing one or another of these views. In management theory, Douglas McGregor (2006) differentiated what he called Acceptance 35 “Theories X and Y.” Theory X is that workers are inherently lazy and unmotivated, dislike working, and will get away with doing as little as possible. Managers who accept Theory X therefore tend to be vigilant, skeptical, and mistrustful of their employees and rely heavily on threat, coercion, restrictive supervision, rewards, and punishment to make workers do what they would otherwise avoid doing. Theory Y, in contrast, is the view that workers have untapped talents and creativity, often enjoy their work, and are capable of self-control and self-direction. It is the Theory Y manager’s job, then, to provide such workers with the proper atmosphere to bring out their responsibility, motivation, and creative engagement in the workplace. Both views, it turns out, tend to be self-fulfilling prophecies (Jones, 1981), and successful businesses discovered long ago the advantages of a Theory Y organization to inspire collaborative productivity, creativity, and commitment (Deming, 2000). After all, which manager would you rather have? There are obvious parallels in counseling and psychotherapy. The finding of significant differences among therapists is far from new. In one of the earliest studies of psychotherapists, Hans Strupp (1960) distinguished two kinds of therapists. Group I therapists were warmer, more accepting, humane, permissive, and democratic, whereas those in Group II were more directive, disciplinarian, moralistic, cold, and harsh. Therapists in Group I viewed client prognosis more optimistically; those in Group II were more pessimistic. As we will discuss in Chapter 8, perceived prognosis matters and tends to produce outcomes consistent with expectations. In another early study, John Whitehorn and Barbara Betz (1954) found that the improvement rates of clients with schizophrenia varied from 0 to 100% depending on the therapist who treated them, in a population where the average improvement rate was 50.6%. Working backward from treatment outcomes, they compared the characteristics of seven psychiatrists who had the highest rates of symptomatic improvement (averaging 75%) with those of another seven who had the lowest success rates (averaging 26.9%), even though their clients’ characteristics differed only slightly. A key difference between these two groups of therapists was that the former were rated as more accepting—“respectful, sympathetic, and active”—whereas the latter were characterized as “superficial, impersonal, and passive.” More recent evidence on the specific impact of therapist acceptance is reviewed below. 36 THERAPEUTIC SKILLS Resistance The phenomenon of “resistance” is another way in which one’s attitude about human nature can become self-confirming. There was once a widespread belief among clinicians working in addiction treatment that people with substance use disorders (then called “alcoholics” and “addicts”) are pathological liars, extremely resistant to treatment, and characterologically dependent on immature defense mechanisms like denial. Indeed, addictions were classified as personality disorders prior to DSM-III (American Psychiatric Association, 1980). This description puzzled us because it did not match how we experienced the people we were treating. There never was scientific evidence that people with substance use disorders have a defining personality structure or overuse particular defense mechanisms. Addiction is not confined to particular demographics or personality types. How, then, did this view of clients’ characteristic similarities become so widespread among treatment professionals? It was, in essence, a self-fulfilling prophecy. The directive, non-accepting, and confrontational style of communication that was prevalent in addiction treatment at the time naturally evokes defensiveness rather than honesty, and is thereby counter-therapeutic, fostering a pessimistic view of clients’ prognosis (White & Miller, 2007). The very concept of “resistance” attributes to client pathology what is inherently an interpersonal phenomenon that is highly responsive to therapist behavior (Miller & Rollnick, 2013; Patterson & Chamberlain, 1994; Patterson & Forgatch, 1985). In contrast, an accepting style of communication normally diminishes defensiveness. Client “resistance” can be turned up and down like the volume control of a radio by changes in therapists’ response style (Glynn & Moyers, 2010; Patterson & Forgatch, 1985), and defensive or resistant client responses, in turn, predict poorer treatment outcome. Counseling in a manner that evokes resistance is unlikely to yield benefit; counseling in a way that reduces defensiveness is more likely to yield positive change. This phenomenon may have long evolutionary roots in interpersonal communication dynamics. “Psychological reactance” refers to a well-documented tendency for people to act contrary to uninvited persuasion and advice, even if they agree with it (Brehm & Brehm, 1981; Rains, 2013; Steindl, Jonas, Sittenthaler, Traut-Mattausch, & Greenberg, 2015). Dominance hierarchies are clearly observable in Acceptance 37 higher mammals, and are governed by complex social behavior that allows the loser in a conflict to escape by signaling acquiescence (de Almeida Neto, 2017). For humans, dominance dynamics are encoded in language (often judgmental) and may operate unconsciously. Within this perspective, to comply with persuasion or advice is to accept a “one-down” position. Behavioral advice is an ideal context for triggering reactance and noncompliance, because people ultimately have discretion over their own behavior (de Almeida Neto, 2017). Consider this dialogue around behavioral activation with a client who is depressed: THERAPIST: I think what you need to do is to get out of the house and do some things that you enjoy around other people. CLIENT: I just don’t have the energy. THERAPIST: Your lack of energy is just part of your depression, and it’s not going to get any better if you stay at home with the blinds closed. You should be doing things that you enjoy. CLIENT: But I don’t even enjoy things I used to like. THERAPIST: That’s part of depression, too. It’s called anhedonia, lack of pleasure. If you just get out and try things you used to like doing, you might find there is still some enjoyment in them. CLIENT: I doubt it. THERAPIST: Well, that’s what I’m going to assign you to do this week as homework. On at least three days this week, plan to get out of the house and do something you might enjoy. You’re not required to enjoy it—just do it! CLIENT: I guess I can try. The therapist’s intention is good. The advice is sound and evidencebased. In the process of this dialogue, however, the therapist takes an expert stance by persuading, advising, educating, and directing, which can feel perfectly natural to a helping professional. However, the teach/direct dynamic of this conversation is one that normally evokes defensive responses, which, in turn, predict nonadherence and lack of change (Miller & Rollnick, 2013; Patterson & Forgatch, 1985). The therapist is not listening well (Chapter 3) and not communicating acceptance. 38 THERAPEUTIC SKILLS The How of Communicating Acceptance So, how does one manifest a therapeutic condition of acceptance? To an important extent, acceptance is communicated by what you do not do. It involves refraining from judgmental responses such as disapproving, criticizing, disagreeing, labeling, warning, or shaming. Many of the communication roadblocks that we described in Chapter 3 have the effect of placing clients in a one-down position. Even approval can be judgmental, in that it implies an appraisal (in this case, positive) of a client’s experience. “Confronting” is a therapist response with particular potential for communicating judgment and triggering reactance or resistance. The essence of confrontation can be to direct, persuade, disagree with, correct, disapprove, judge, or shame—all communication roadblocks. One observational system for therapist behavior describes a confront response as “directly and unambiguously disagreeing, arguing, correcting, shaming, blaming, criticizing, labeling, warning, moralizing, ridiculing, or questioning the client’s honesty” (Moyers, Rowell, Manuel, Ernst, & Houck, 2016). A relatively small number of confront responses can undermine an otherwise productive counseling session. How might the above dialogue be different if the therapist began with listening and acceptance? THERAPIST: I have an idea that has worked for some other people I’ve seen. I don’t know whether it will make sense to you, but I wonder if it’s OK to tell you about it. The therapist immediately communicates acceptance by giving the client permission to disagree (“I don’t know whether it will make sense to you”) and asking permission first, rather than charging into advice. CLIENT: Sure. THERAPIST: Part of the trap of depres- Respectfully checking in to sion is in becoming isolated from see if the client is following. people, places, and things that you care about. Do you know what I mean? Acceptance 39 CLIENT: Yeah, I mostly stay at home, Change talk (see Chapter 9) rather than resistance. and I know that’s not good. THERAPIST: And one way out of the Acknowledging potential trap is to get out and do some reluctance. things that you used to enjoy, even and especially when you don’t feel like it. Now, that may sound impossible to you. CLIENT: No, I can see what you mean, but I just feel so tired most of the time. THERAPIST: Of course you do; I understand. When you’re feeling that tired, it’s hard to imagine getting out to do anything that might be fun. It really is like a trap. There is a compassionate, accepting tone here. Reflective listening in itself communicates acceptance. CLIENT: That’s right. I feel like I’m stuck and need to get unstuck. THERAPIST: I don’t know what you’re willing to do, and it’s up to you. I wonder, though, if you might be willing to try something new this week. Acknowledging and honoring the client’s autonomy. Asking in a way that emphasizes the client’s choice. Notice that there is still some psychoeducation happening, but in a more collaborative rather than directive way, acknowledging the truth: that clients get to decide what they will accept and do. The etymology of confront is “to come face to face,” and in this sense, it could be thought of not as therapist behavior (“getting in someone’s face”) but rather as a goal of counseling: to help clients take a close look at themselves in a safe and supportive environment. Some gentle confronting may promote self-exploration and change, but only in the context of a trusting, empathic, accepting therapeutic relationship (S. C. Anderson, 1968; Moyers, Miller, & Hendrickson, 2005). Communicating acceptance diminishes defensiveness and makes it safer to consider what is potentially threatening or difficult. 40 THERAPEUTIC SKILLS The absence of judgment can be surprising to clients, particularly in contexts where they have been coerced into treatment and expect harshness, like students summoned into the principal’s office. Clients can be particularly sensitive to perceived blame or disapproval. Couples who come for relationship counseling may expect or fear that the therapist will decide which of them is more at fault. Feeling blamed or shamed is a recipe for defensiveness and the status quo. When clients offer vulnerable content without receiving judgment, disapproval, or immediate direction, they often are surprised and relieved. One way to refrain from overt judgment is to keep quiet, but silence is not inherently free of judgment. The problem, as mentioned in Chapter 3, is that people may project into your silence their own worst fears and imaginings. Rather than remaining distant and silent, actively communicate acceptance in a way that reassures clients and averts imagined judgment. One good way to communicate acceptance is through the skill of accurate empathy as described in Chapter 3. Working hard to understand someone’s meaning implies respect, and is quite different from the common conversational style of listening just long enough to interject a reply, often a roadblock. Actively communicate Here, the underlying attitude of acceptance matters, because disacceptance in a way that approval can creep into reflections reassures clients and averts just through voice tone. A mindimagined judgment. ful attitude of curiosity without judgment tunes the music behind reflective listening. Acceptance is a context within which empathic understanding can be communicated. Mindfulness practices are ancient and have been incorporated in a wide range of modern therapeutic methods (Benson & Klipper, 2000; S. C. Hayes et al., 2011; Kabat-Zinn, 2016; Thich Nhat Hanh, 2015; Witkiewitz et al., 2014). Various forms of meditation involve centering of attention (e.g., on breath, a stationary object, or a mantra) while observing and accepting one’s experience without judgment. If you want to help clients learn such practices as coping skills, it is advisable to be a practitioner of the method yourself. Beyond the integrity of “practice what you teach,” developing the discipline of mindful meditation may offer benefits for you as well. Practicing mindful acceptance as a state can generalize and promote trait mindfulness (Kiken, Garland, Bluth, Palsson, & Gaylord, 2015). Acceptance 41 Counseling itself can be done within a state of mindful acceptance, and the discipline of practice may help to foster acceptance as a normal response to what you experience. In this way, acceptance can become a default way of being rather than a skill to be called out as needed. Beyond empathic listening and mindfulness, another concrete way to communicate acceptance is through the practice of affirmation, to which we will return in Chapter 5. Affirmations are direct statements of regard and appreciation for a client’s positive attributes and actions. In this chapter, we focus primarily on the more general therapeutic stance of nonjudgmental acceptance, though of course it is the therapist’s communication of this attitude that matters most (Horvath, 2000). Research on Therapeutic Acceptance There is an immense scientific literature on the benevolent effects of meditative and mindfulness practices themselves (Gotink et al., 2015; Keng, Smoski, & Robins, 2011). Our focus here is on the effects of therapist acceptance on client outcomes. In extensive reviews of the relationship between therapist acceptance and client outcomes, David Orlinsky, Klaus Grawe, and Barbara Parks (1994) found that 56% of 154 effects were positive; still higher (65%) when therapist attributes were judged from the client’s perspective. When therapist acceptance was rated independently from recordings by nonparticipant observers, and client outcome was judged from objective measures, 62% of findings showed a positive relationship (Orlinsky & Howard, 1986). Positive outcomes were also high when therapist and client were mutually accepting (79% of findings). An interesting observation was a trend that the positive impact of acceptance increased with the proportion of racial/ethnic minorities in the sample (Orlinsky et al., 1994). This parallels a meta-analytic finding that the effect size of motivational interviewing, a personcentered therapeutic style, was tripled (d = 0.79 vs. 0.26) in samples predominantly from racial-ethnic minority groups, relative to nonminority samples (Hettema, Steele, & Miller, 2005). In both reviews, therapists in the studies were primarily nonminority. It may be that 42 THERAPEUTIC SKILLS an accepting, empathic style is even more important with marginalized clients who are less accustomed to such treatment, and when counseling across significant sociocultural differences. In sum, there is ample evidence that clients whose therapists manifest and communicate acceptance generally have better outcomes. This is just one attribute An accepting, empathic style of counselors that by itself is modmay be even more important est in effect, but in combination with disadvantaged clients. with others can contribute to the large differences often observed in therapists’ outcomes, even when allegedly using the same treatment techniques. KEY POINTS • Implicit in the therapeutic attitude of acceptance is a belief that human beings have inherent worth and deserve respect without having to earn it. • The experience of being accepted as one is at present can facilitate positive change. • Beliefs regarding the essential quality of human nature in general or of a particular individual can be self-fulfilling prophecies. • Client defensiveness or resistance is an interpersonal phenomenon, and is usually diminished by an accepting, empathic, and respectful therapeutic style. • Acceptance is communicated, in part, by what the therapist does not do: disapproving, criticizing, disagreeing, labeling, warning, or shaming. • An accepting and respectful style may be even more impactful when working with marginalized groups and when counseling across significant sociocultural differences.