Empathy as dialectic imagination

Abstract

The importance of relationship processes for humanistic and psychodynamic therapists makes empathy a critical concept in psychotherapy. Experimental work suggests that learning occurs only when the subject is actively and cooperatively engaged in the learning process. Similarly, psychotherapy is only effective when the client is willingly active in the therapeutic process. A crucial aspect of the therapist's activity is empathic imagination, defined here as the use of “dialectic” thinking capacities‐the recognition of conceptual alternatives in a given situation. These processes are at the heart of a humanistic view of agency. The therapist's use of this capacity allows imaginative projection into aspects of the client's experience, helping the client to feel understood in the relationship and emboldened to consider new possibilities in life.     

Clinical supervision in cognitive behavior therapy improves therapists’ competence: a single-case experimental pilot study

ABSTRACT

Clinical supervision is a cornerstone in psychotherapists’ training but there are few empirical evaluations on the effects of supervision on therapists’ competencies. The aim of this study was therefore to evaluate the effects of standardized supervision on rater-assessed competency in Cognitive Behavior Therapy (CBT). Six therapists with basic training in CBT were provided with protocol-based clinical supervision in CBT in a single-case experimental multiple baseline design. The supervision focused on specific CBT competencies and used experiential learning methods such as role-play. Each therapist recorded weekly treatment sessions during phases without and with supervision. The therapists’ CBT competence was assessed by third-party raters using the Revised Cognitive Therapy Scale (CTS-R). Statistical analyses showed that the therapists’ CTS-R scores increased significantly during the phase with supervision with a mean item increase of M = 0.71 (range = 0.50–1.0) on the supervision focus areas. This is one of the first empirical studies that can confirm that supervision affect CBT competencies. The results also suggest that supervision can be manualized and that supervisees have a positive perception of more active training methods. Further studies are needed to replicate the results and to find ways to improve the impact of supervision.     

Announcement

Abstract

Empathy has consistently been identified as an important quality of psychotherapists. Understanding unique ways that empathy emerges in group therapy may assist group therapists in fostering empathy. Rogerian and selected psychodynamic and interpersonal perspectives on empathy are discussed. Group psychotherapy poses a challenge for empathic responding, but also a rich opportunity for utilizing a more varied embodied approach to empathy.     

The effects of clinical supervision on supervisees and patients in cognitive behavioral therapy: a systematic review

Clinical supervision is a central part of psychotherapist training but the empirical support for specific supervision theories or features is unclear. The aims of this study were to systematically review the empirical research literature regarding the effects of clinical supervision on therapists’ competences and clinical outcomes within Cognitive Behavior Therapy (CBT). A comprehensive database search resulted in 4103 identified publications. Of these, 133 were scrutinized and in the end 5 studies were included in the review for data synthesis. The five studies were heterogeneous in scope and quality and only one provided firm empirical support for the positive effects of clinical supervision on therapists’ competence. The remaining four studies suffered from methodological weaknesses, but provided some preliminary support that clinical supervision may be beneficiary for novice therapists. No study could show benefits from supervision for patients. The research literature suggests that clinical supervision may have some potential effects on novice therapists’ competence compared to no supervision but the effects on clinical outcomes are still unclear. While bug-in-the-eye live supervision may be more effective than standard delayed supervision, the effects of specific supervision models or features are also unclear. There is a continued need for high-quality empirical studies on the effects of clinical supervision in psychotherapy.     

Transcendental empathy in the therapeutic encounter

Abstract

The experience of many therapists suggest that most contemporary conceptions of empathy underestimate empathic potential. This paper describes deep or transcendental empathy as a more direct knowing of the client's world. The author examines the epistemic process or the activity of knowing of transcendental empathy by considering two broad forms: transcendental countertransference and psychological resonance. Difficulties and distortions are explored as well as characteristics of an individual that correspond with deep empathy.     

Empathy a common ground

Though empathy remains a central concept in psychoanalysis, attempts to explain the operations and functions in the empathic process have been as divergent as the various meanings associated with the term itself. Any explanation of the mechanism of empathy must include how we have access to the inner experience of others or account for the link between the empathizer and the inner state of the object.

In this paper, the authors review different models (Freud, 1921; Kohut, 1959; Basch, 1983, 1988; Buie, 1981; Schafer, 1968; Klein, 1946, 1963) of empathic understanding and note that while these models rely on imitation, identification, merger, projection, or inference as the basis of empathic understanding, each implies only an indirect understanding of the states of others. The authors propose a two‐phase model of empathy that differs from those models reviewed in that their position assumes that the perception of emotion in the other is immediately accessible through isomorphic psychological and physical processes that often result in an experience of resonance of the same emotion inthe self (Beebe, 1990). According to this view, the empathic process consists of an initial perceptual phase that generates affective resonance and a second phase in which complex cognitive‐affective operations contribute to the construction of meaning. We posit that empathic understanding affords the observer direct access to certain qualities of the other's experience. The model borrows from Wolfgang Köhler's (1947) concept of isomorphism and Rudolph Arnheim's (1949) theory of the perception of expression.

Evidence for this model is presented from experimental psychology. A discussion of a case from an earlier paper on empathy by Beres and Arlow (1974) illustrates how the operations underlying empathy contribute to understanding a patient in a clinical setting. Finally, we conclude the paper with a brief discussion of some of the clinical implications of this model.     

A narrative social constructionist approach to therapeutic empathy

The concept of empathy has been a centrol conceptual element in approaches to counselling and psychotherapy that emphasise exploration of meaning in the context of a facilitative relationship. However, the existing literature on therapeutic empathy lacks theoretical coherence. a narrative social constructionist perspective represents a theoretical approach that enables the integration of diverse strands of clinical observation and research into the creation of empathic understanding in counselling. From a social constructionist position, therapeutic empathy can be understood as a relational process, a step-by-step co-construction by counsellor and client of the life-narrative of the client. In this paper, the Barrett-Lennard (1981) cyclical model of empathy is used as a fremework for examining the counsellor and client actions, strategies and tasks that constitute empathic engagement around the task of emploring and re-authoring life-narratives. Constructionist analysis of the cultural origins of the concept of empathy suggest some limitations of this way of conceptualising what happens in therapy. The implications of these ideas for theory, training and research are discussed.     

Interweaving the Symbolic and Nonsymbolic in Therapeutic Action: Discussion of Gianni Nebbiosi’s “The Smell of Paper”

Gianni Nebbiosi’s paper speaks to therapeutic action in a new key in the challenges of finding communion with a hard-to-reach patient. He achieves this through the creative interweaving of the nonsymbolic, his mime and music, and the symbolic, which attains greater purchase through painful personal reckoning in concert with his increasing awareness of previously unformulated states within and between each member of this particular analytic dyad. Central to this paper is the move from an empathic stance to greater complexity for each of the dyad. Distinguishing between empathy and recognition is germane. Particularly as we witness the transformation through therapeutic action of empathic presence to recognizing presence that permits the emergence of a more complex empathy—an achieved empathy that incorporates feeling and knowing the multiple, more deeply held, and often paradoxical aspects of our patients and indeed of ourselves as these play out in intersubjective space.     

Understanding Forgiveness as Discovery: Implications for Marital and Family Therapy

This article explores the concept of forgiveness in relationship systems and examines various conceptualizations and definitions found in the literature. Forgiveness is described as a complex psychological and relational process that is more a discovery than an act of will. A rationale for viewing forgiveness in a contextual, historical, and relational attachment paradigm is presented, and the association of forgiveness with empathy and emotional intelligence is discussed. Marital and family therapists are encouraged to attend to contextual family of origin issues and to facilitate an empathic relational environment where ambivalence is expected and tolerated for enhancing the process of forgiveness. Relevant clinical cases are shared to illustrate the process of forgiveness as discovery.     

Promoting Attachment and Mentalization for Parents and Young Children in the Foster Care System: Implementing a New Training and Treatment Approach in an Agency

The Building Blocks Program is an innovative psychodynamic treatment approach that was designed to fit within a social service agency structure. It is based on concepts of attachment, attunement, and mentalization and builds on the research of Beatrice Beebe (2003), Peter Fonagy and colleagues (2002), Arietta Slade (2005), Howard and Miriam Steele (2008), and Dan Stern (1985). The Building Blocks Program targets birth mothers and their young children under age 5 who have been or are in danger of being removed from their families. In the beginning of the program, the Building Blocks therapists faced many challenges. As noted (Remez, this issue), many of the therapists were unfamiliar with a Reflective Supervision model of learning. They were accustomed to a more traditional pedagogical approach that emphasized critiquing their work, with a focus on their clients’ pathology. The Building Blocks model focuses on therapist and client safety and support, prompting a paradigm shift in the therapists’ thinking about supervision and how to conduct therapy.     

共情可控?以自上而下视角考察共情的可调节性

以往研究表明共情的特点包括自动化与情境依赖性。但是, 有关共情的理论模型与潜在神经机制仍存有争议。为更好地适应现实需求, 研究重点从共情的结构和功能角度逐渐向塑造和调节共情发展。近年来, 有研究者提出自上而下的心理过程与共情调节有关, 特别是共情的目标表征形式, 以及目标的价值权衡。因此, 考虑到共情的目标导向性对于共情的内部构建与外部表现形式的影响, 建议未来研究考虑从自上而下视角考察共情的可调节性。     

Finding focus in a difficult landscape: Therapists’ experiences with challenging video guidance processes for parent–infant dyads

Marte Meo video guidance uses filmed interaction of the actual parent–infant dyad in the guidance of caregivers. Exploring the challenges that therapists meet in the guidance of parent–infant dyads may illuminate important aspects of the method itself as well as the therapists’ role and requirements. This could lead to method development and improved practice, but is hitherto little addressed. In this paper, we explore how skilled therapists experience and handle challenging or failing guidance processes with parent–infant dyads. We analyzed interviews with 13 Marte Meo therapists/supervisors using team-based reflexive thematic analysis. Four main themes were identified: promoting relational growth in a coercive context, building an alliance that feels safe for the parents, looking at positive moments in difficult lives, and handling intense feelings as a therapist. Our findings show that therapists experience specific therapeutic and ethical challenges with a vulnerable subgroup of parent–infant dyads where child protective issues arise, where caregivers’ insecurities impede the therapeutic relationship, and where caregivers have unsolved relational or mental health problems. The therapists’ role becomes pivotal and demanding with regard to the therapeutic alliance, the therapeutic interventions in the guidance process, and their own need for regulation, supervision, and structure. Identification of these vulnerable dyads early in the process could facilitate a better adaptation and practice of video guidance. Our findings suggest a need for supporting structures, clinical supervision, and training that address these challenges.     

团体成员共情的影响因素及作用模型——基于扎根理论

本研究旨在探索团体咨询成员共情的概念、影响因素及其作用。运用扎根理论对11名团体咨询成员的访谈资料分析,共形成11个轴心编码。根据编码间的关系得到如下结果：1. 团体成员共情包括共情理解、共情表达和共情感知;2. 团体成员共情理解的影响因素为相似性、观点采择;共情感知的影响因素为相似性和共情表达;3. 团体成员共情通过促进成员关系、认知领悟和情感支持提升团体效果。据此构建了团体成员共情的影响因素及作用模型。     

Attachment-Related Mentalization Moderates the Relationship Between Psychopathic Traits and Proactive Aggression in Adolescence

The lack of affective responsiveness to others’ mental states – one of the hallmarks of psychopathy – is thought to give rise to increased interpersonal aggression. Recent models of psychopathy highlight deficits in attachment security that may, in turn, impede the development of relating to others in terms of mental states (mentalization). Here, we aimed to assess whether mentalization linked to attachment relationships may serve as a moderator for the relationship between interpersonal aggression and psychopathic traits in an adolescent community sample. Data from 104 males and females with a mean age of 16.4 years were collected on mentalization capacities using the Reflective Functioning Scale on the Adult Attachment Interview (AAI). Psychopathic traits and aggressive behavior were measured via self-report. Deficits in mentalization were significantly associated with both psychopathic traits and proactive aggression. As predicted, mentalization played a moderating role, such that individuals with increased psychopathic tendencies did not display increased proactive aggression when they had higher mentalizing capacities. Effects of mentalization on reactive aggression were fully accounted for by its shared variance with proactive aggression. Psychopathic traits alone only partially explain aggression in adolescence. Mentalization may serve as a protective factor to prevent the emergence of proactive aggression in spite of psychopathic traits and may provide a crucial target for intervention.     

The Soul of Therapy: The Therapist’s Use of Self in the Therapeutic Relationship

This paper is based on the premises that the conscious, active and purposeful use of self by the therapist in the therapeutic process is an essential aptitude in establishing an effective therapeutic relationship, and that this therapeutically purposeful use of self can and should be incorporated in the training of all therapists in a explicitly systematic manner. The paper will attempt to identify the contributions of the “what and how” the use of self by therapists contributes to the therapeutic process. First of all, therapists’ use of self is meant to be viewed as a Common Factor as defined by Sprenkle, Davis & Lebow (2009), which is a perspective about the effectiveness of therapy that “asserts that the qualities and capabilities of the person offering the treatment are more important than the treatment itself” (p. 4). Secondly, the use of self by therapists emphasizes developing the skill set of the therapist in the conscious, active and purposeful use of self as is in the moment of the therapeutic engagement with clients, and does so without denying the importance of therapists working to resolve personal issues of theirs that may interfere with the therapist's professional effectiveness. Therapists’ use of self gives particular emphasis to the purposeful use of self as is in therapy’s relationship, assessment and interventions whatever the therapy model (Aponte & Kissil, 2016). Thirdly, the use of self represents an aptitude that can be developed and refined through well elaborated structures for schooling therapists in the therapeutic use of all they bring of their personal selves to the therapy relationship including through the use of their human vulnerabilities as they exist at the moment of empathic engagement with clients.

     

Imbalances and Impairments in Mental State Talk of Children with Internalizing and Externalizing Problems

ABSTRACT

The aims of this study were to investigate the associations between impairments and imbalances in children’s mental state talk, attachment security and abuse/neglect experiences, and to study how much of the variance in internalizing and externalizing problems was explained by mentalization problems. The sample included 100 Turkish children (M Age = 7.00 (SD = 2.01), 38% girls) referred to a outpatient psychotherapy clinic. Children were administered an attachment-based story stem task in order to code attachment security and different categories of mental state talk, including the extent of their direction (self vs other), balance, and appropriateness. Parents and teachers filled out socio-behavioral function scales. Findings indicated a significant positive association between externalizing problems and impaired mentalization. Internalizing problems were associated with mentalizing the other at the expense of one’s own mental states and underusing emotions. Attachment insecurity and adverse experiences were associated with mentalization impairments and imbalances. Finally, underuse of emotions and self-focused mental state talk predicted internalizing problems and impaired mental state talk predicted externalizing problems at trend level of significance. Qualitative analyses supported the results, which suggest that whereas children with externalizing problems suffer from severe mentalization deficits, children with internalizing problems undermentalize about themselves and emotions.     

A Triadic-behavioral approach to encopresis

Abstract

This paper describes the training and supervisory components of a doctoral level, pre-internship clinical experience, designed to teach Ph.D. candidates a contextual or systemic approach to therapy. The training occurred in a university-based departmental clinic which balanced the three interdependent areas of training, service and research. The therapeutic orientation was a problem-focused, goal-oriented, directive therapy candidates a contextual or systemic approach to therapy. The training designed to view and treat individuals in their social contexts. From this perspective, students were able to gain experience with individuals, couples and families. The paper discusses the function and components of the weekly supervision seminar and describes the integrative and sequential use of several innovative supervisory methods such as live supervision, peer consultation and videotape playback supervision.