Accurate Empathy is the Heartbeat of Rogerian Psychotherapy

• Accurate Empathy
• When Evidence-Based Claims and Person-Centered Practices Collide
• Leaving Room for Clinical Expertise and Patient Values
• Accurate Empathy in Action

Person-centered therapy (PCT) is a radical therapeutic ethic that leads to therapeutic discipline. It is not purely idiosyncratic, with therapists doing anything willy-nilly with their clients, reacting to compulsion or fancy. That is not person-centered therapy in the slightest. Person-centered therapy is a refusal to either disempower clients or to kowtow to scientism. It is a commitment to seek understanding over giving advice and to express genuine regard for humanness.

Unfortunately, critics of PCT often cast it as a kind of therapeutic anarchy or as lacking an empirical research base. While I do not intend this as an opportunity to refute baseless critique, I do wish to convey a more objective view, at a glimpse, of one of the pioneering PCT models: Rogerian therapy. I will also share, acknowledging my own bias against it, a contrast to PCT by one of the many CBT-like therapy models currently being held out as an “evidence-based practice” therapeutic approach. And I’ll provide a glimpse into accurate empathy in action.

Accurate Empathy

Carl Rogers had a highly disciplined view of the person-centered approach. He said many times that therapists should be careful to “reflect the emotionalized attitude being expressed.” In his 1942 volume, Counseling and Psychotherapy, he used this phrase again and again. What he also said again and again is that you should not reflect emotions or aspects of the client's mindset that you think are there but have not yet been revealed—Rogers said that although you may suppose a client feels a particular feeling or that you suppose a client thinks a particular thought, you should stay with what we now term the intersubjective experience between you and the client. As these “attitudes” surface—not as you surface them—you reflect them in a way as a hypothesis. “When you say _______, or when I experience you _______, you're bringing in this therapeutic material in a way that we can work with together. Am I getting this right?”

Those outside the fold who don't understand the person-centered approach may wrongly assume such therapists think of themselves as clairvoyant empaths—that they claim psychic intuition. Person-centered therapists don't believe they're clairvoyant; quite the opposite. They deeply value checking their intuitions with clients as necessary for promoting true understanding. At the same time, no model can be purely logical, rational, or objective, and so that perhaps hints at the dialectic inherent in a person-centered paradigm.

The most powerful condition that Carl Rogers talked about was an intersubjective experience that he called “accurate empathy.” What Rogers meant by accurate empathy wasn't that sometimes there is a kind of clairvoyance—that a therapist who is super-empathic can sense someone's emotions better than someone else or can better identify with someone else's experience than another. Rather, he was talking about this way of checking in with the client in an open-handed way: “When you say _______, is _______ what you mean?” “When I felt _______ from you when you said _______, I get a sense from you but want to better understand: are you feeling _______? Or maybe kind of _________?” And if you learn from the client that you were wrong, you gain in trust and in insight; and if you learn that you were right, you gain in trust and in insight.

It's this careful dance of intersubjective experience—respectful warmness, genuineness, not presuming to know another's experience—that is what Carl Rogers described when he spoke about “accurate empathy.” It’s why he cautioned us to reflect only the emotionalized attitude being expressed and not to reflect other things—other thoughts, other feelings that we think that the client might be having that they have not said anything about explicitly and would amount to mere conjecture. If we’re truly Rogerian, we can conjecture on the basis only of what the client has expressed to us, not on the basis of what the client has not expressed to us. By doing so, we stay firmly in the flow of the dance with a client rather than putting ourselves in the position of expert, as if we have on one extreme, pure logic, or on the other extreme, clairvoyance. Accurate empathy is the bullseye of Rogerian psychotherapy.

When Evidence-Based Claims and Person-Centered Practices Collide

There is a kind of protocol, then, within a Rogerian approach, but it is important to contrast this with the kinds of protocols we see within “evidence-based practice (EBP)” therapy manuals. One model, which is an offshoot of CBT for which I received training, provides clinicians with a literal “intervention flow.” In the model, called the Common Elements Treatment Approach (CETA), clients experiencing “predominantly anxiety problems” should be treated by (1) Engagement/Encouraging Participation, (2) Psychoeducation, (3) Cognitive Coping, (4) Gradual Exposure: Memories and/or Live, and (5) Cognitive Reprocessing. This explicit ordering directs clinicians in how to provide the moment-to-moment therapy, and these intervention protocols correspond to semi-scripted guidance for the clinician to follow.

To the extent that the clinician diverges from this semi-scripted methodology, they are considered noncompliant with the model's so-called “evidence-based” methodology. There are similar intervention flows to be utilized with clients who are predominantly experiencing depression symptoms and for those predominantly experiencing symptoms of both anxiety and trauma, for instance.

At the CETA training I participated in, we role played. It was a humorous experience for me and my therapist colleagues as we literally read through scripts and were then evaluated by the trainers on the basis of how we pieced together modular scripts—that is, on the basis of whether the flow of scripts we utilized matched well with the recommended treatment “flow” prescribed by the name-brand EBP treatment model. It felt artificial. It felt antithetical to a person-centered approach. That was a great example of the kind of collision I think many therapists are experiencing within managed care systems that are increasingly requiring fidelity to evidence-based practice models.

These sort of “evidence-based practice” therapies are clearly antithetical to intersubjective experiencing, the fundamental therapeutic factor in a person-centered approach. Imagine how much room a semi-scripted approach like CETA, with its prescribed intervention flow, leaves for personal choice, for client agency, and for intersubjective experience. Almost none.

Leaving Room for Clinical Expertise and Patient Values

In 2005, the American Psychological Association published their Report of the 2005 Presidential Task Force on Evidence-Based Practice. This report is frequently cited as a defense of evidence-based practice. I have heard many who defend the sort of approach that I am criticizing here cite this very report. I am a bit baffled by that when I read from the report myself, which provides this definition of EBP: “Evidence-based practice is the integration of best research evidence with clinical expertise and patient values.” Here lies the hope that EBP does provide space for clinical expertise and patient values. Hope, anyway.

The report also says “the use and misuse of evidence-based principles in the practice of health care has affected the dissemination of health care funds, but not always to the benefit of the patient.” It goes on: “Even guidelines that were clearly designed to educate rather than to legislate, were interdisciplinary in nature, and provided extensive empirical and clinical information did not always accurately translate the evidence they reviewed into the algorithms that determined the protocol for treatment under particular sets of circumstances.”

And, finally, I’ll share this third excerpt: “The goals of evidence-based practice initiatives to improve quality and cost-effectiveness and to enhance accountability are laudable and broadly supported within psychology, although empirical evidence of system-wide improvements following their implementation is still limited. However, the psychological community—including both scientists and practitioners—is concerned that evidence-based practice initiatives not be misused as a justification for inappropriately restricting access to care and choice of treatments.”

I really appreciate this APA report. They provide the cautions, caveats, and contours of getting it right—of the necessity of integrating clinical expertise and patient values. But unfortunately, what I've seen is that many times evidence-based practice initiatives are misused.

For those who would defend the promise within evidence-based practice research and implementation efforts, I would have a very difficult time doing anything else but agreeing with the ideals and the shining examples of EBP. My greatest concern is the way that the research on EBP is systematically used to promote scripted approaches that do not leave room for a person-centered approach. Misunderstandings about EBP have been translated into manualized practice and into public managed care contracts, which shapes the terrain of outpatient systems of care and, consequently, the types of therapeutic modalities that in actual fact are being practiced across the world. These contracts have power to reshape our field in really significant ways.

In December 2017, I attended the Evolution of Psychotherapy conference in Anaheim, California, which was attended by many psychotherapy pioneers, including Aaron Beck, the father of cognitive behavioral therapy. Interestingly, in a workshop of Beck’s, he expressed a lot of caution about some of the directions of CBT as a field in itself, and about some of the ways that managed care has misused some of the research findings. But I was utterly stunned by his statements during the Q&A portion of the workshop, when someone asked 96 year-old Aaron Beck what wisdom he might give to young therapists just entering the field. His response? “Read Carl Rogers.”

Unfortunately, many of the so-called evidence-based practice therapies we see in the market now do not leave sufficient space for the type of therapeutic relationship that is most therapeutically beneficial. Some agency settings will provide the space and bandwidth that are necessary to practice with fidelity to your own training, values, and the disciplines within the therapeutic relationship. If you are fortunate to practice in a setting that allows you such space—to practice at a level of integrity—then you are fortunate indeed. I must be careful to acknowledge that honing great skill in this practice requires a great deal of intention and discipline. Some settings simply will not provide the space and support necessary to develop the craft of a skillful person-centered approach. Therapists must evaluate their values and act accordingly.

Accurate Empathy in Action

I can remember that initially Karys was not too happy to sit with me during our weekly sessions. Having experienced a childhood of broken trust and sexual trauma, and after having bounced around between too many foster homes over too many years, she—an older middle schooler—was understandably reluctant to relax into my couch and lean into our relationship.

I administered a simple self-assessment that helped me learn whether Karys had any enjoyment of expressive activities such as writing stories, poetry, and song lyrics, sketching drawings, or sculpting clay. She indicated a particular interest in drawing.

As I maintained a collection of colored pencils and drawing paper in my office, I offered them to her, and, another common practice of mine, I showed her an array of different colored folders she could choose to keep her drawings in at my office, so they would be available to her each week. She was welcome to take any of her drawings home, but I asked that she allow me to make a copy of any piece she would be taking with her. If she did not wish for me to have a copy, I would honor her decision.

Every time that she came to see me, I had art paper and colored pencils waiting for her. I sat with her and attempted to get to know her and to work with her to help her organize her emotions into reflections and her reflections into meaning. All the while, she organized her troubles into sketch art. On one occasion, while telling me the story behind something she had drawn, she fell apart into tears. In the midst of that, she cursed so loudly that I could hear the footsteps on creaky hallway floors of a coworker come to discreetly check on things at my door.

Karys entered therapy oscillating between expressive anger, reflective sadness, and emotional distance. These matched her foster parents’ reports from home. During our first two months of therapy, I observed difficult interactions between Karys and her foster parents, especially highly defensive behaviors by her. In her first several sessions with me, she had seemed emotionally rigid. As time wore along, I began to experience Karys differently. She seemed, in the context of our conversations over her sketch art, to be appropriately vulnerable, emotionally pliable, and more deeply reflective. As I tentatively checked with her my understanding of the feelings she was beginning to express—through her art and verbally—she seemed to be enlivened by the sheer honesty and authenticity of these encounters. However, her parents’ reports to me were nearly unchanged; the Karys living at home remained stuck in an alternate dimension.

The difference, in my view, between the kind of expression and interaction that Karys experienced in therapy (eventually) versus the kind frequently experienced during the rest of her weeks was a difference of control. During the week—during the course of her life, for that matter—she felt little of it. There were a number of reasons this could be said to be true. Yet during our sessions, she had a great deal of control. And she liked that.

With her permission, I invited Karys’s foster parents, Boyd and Angie, to join us for three sessions, in which I set the tone with a few rules, designed to keep Boyd and Angie from utilizing our time to provide me information or to bring any other agenda into session. In short, Karys would guide us, with the caveat that, as the therapist, I would take some liberties in providing gently offered facilitation as I saw fit. My goal for my own facilitative efforts was, in essence, to model for Boyd and Angie the rhythm and rhyme, give and take of noticing and asking, along with tentatively checking my understanding of what Karys was communicating about her own thoughts, attitudes, and feelings. According to Karys, I often got it wrong. She boldly corrected me again and again, and I’d check again to make sure I understood as fully as possible. She sometimes expressed irritation when I was “being weird” or dense, yet she was generous in spirit, even still. I’d defend myself playfully.

We’d laugh.

I wondered if Boyd and Angie noticed the elegance of empathic exchange, yet out of conviction, I took care not to slip into a mode of teaching reliant on conveying insight in a way that might be perceived as patronizing. I trusted that their experience would generate a more powerful and sustaining insight. Some time later, Boyd asked to speak briefly with me after Karys had achieved her treatment goals and was discharged from care. He said, “It's like the light in her has been turned brighter, and she's opening up in a new way. She actually has begun talking to me about past abuses, just matter-of-factly, really…and what's more, she's been kidding around with us a lot more lately.” He also acknowledged, “It really is something, how when we shifted over to what you had modeled for us with Karys, we were able to better understand what she was experiencing. And how she seemed to be able to better understand, of us, the love we had been trying so hard to show. It’s as if we were a threat before. Now we’re getting somewhere.”

*****

Beyond their use in justifying health insurance reimbursement, terms like “pathology” and “disorder” are often untenable and, more importantly, unhelpful categorizations of a person’s experience. Treatment should be no more modular than the person. A wise mentor once contrasted for me the importance of conceptualizing effective psychotherapy as a process of “puzzling through a process with someone,” rather than the kind of rote application of skills characteristic of current forms of “evidence-based practice.”

To become increasingly flexible and resilient, clients must experience freedom within felt pushes and pulls of powerful forces in which problems maintain themselves. Therapists have skillful empathy to offer, and empathy at its best has power to re-shape experience. Once clients experience themselves feeling more understood in the therapeutic setting, they often experience themselves feeling more understood in life. Do not underestimate the value of feeling understood.

Accurate empathy is the heartbeat not only of Rogerian psychotherapy, but also of all modes of psychotherapy. Whatever specific model of intervention is being employed, if a therapist is not fully present as a warm, accepting, genuine, and caring person who is truly seeking to understand, then the power center of therapy remains turned off and, for all practical purposes, ineffective. Ultimately, a person-centered process—not a manualized technique—is the most essential active ingredient in therapy.


References

American Psychological Association, Presidential Task Force on Evidence-Based Practice. (2005). Report of the 2005 Presidential Task Force on Evidence-Based Practice. Retrieved from https://www.apa.org/practice/resources/evidence/evidence-based-report.pdf

Beck, A., & Beck, J. (2017, December 16). New breakthroughs in cognitive therapy: Applications to the severely mentally ill, presented at Evolution of Psychotherapy conference, Anaheim, California, USA, December 13-17, 2017.

Merchant, L, Kirkland, C. & Ranna-Stewart, M. (2016, March 10-11). Common Elements Treatment Approach (CETA) Learning Collaborative training, Spokane, Washington, USA.

Rogers, C.R. (1942). Counseling and psychotherapy: Newer concepts in practice. The Riverside Press. 

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