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My Daily Musings

When we listen to many mental health practitioners, it sounds like empathy is the only skill that a therapist needs. Is it, though?

Empathy is often defined as “feeling with” and contrasted with “feeling for.” Anyone who has watched Carl Roger’s demos or read his books can recognize his empathy as his ability to be with the patient at every moment of the session. It is as if they are walking together through the forest, holding hands — he shares the client’s experience.

But again, is it enough?

Here is a problem. When we fully share the client’s experience, we only see what the client sees—and miss everything they miss. We miss their own role in their drama, the peculiar similarities between their internal monologue and the voice of their mother, and other interesting unconscious dynamics.

The sole focus on empathy also leaves a question: what part of the client should we empathize with? Should we empathize with the false self or a narcissistic client? Should we emphasize the harsh and punitive superego of an obsessive-compulsive client? Seeing parts of the psyche as parts requires a meta-position — which is absent when we are “walking together through the forest holding hands.”

We can be more helpful to clients by gently bringing to their awareness what they are not seeing (or trying not to see).

We need to be able to: 


1/ Experience their world through their immediate senses — which allows us to build rapport 

2/ See their world through the eyes of the parts of the self they do not identify with—to help them discover abandoned parts of their psyche. Empathy with only ego-syntonic parts forecloses this exploration.

3/ See their world through our own eyes — to show them that there is more than one way of making meaning of their situation.

4/ Observe whatever feelings they stir up in us — to show them what impact they make on others.

We need more than empathy.

Here is my half-assed reflection on the nature of a therapeutic relationship. CBT therapists create relationships where they are experts. Psychoanalysts create relationships where they are … ethnographers.

For a while, I could not figure out why I couldn't stand CBT, but I appreciated psychoanalysis. I tried to debunk the ideas CBT clinicians communicate to their clients, but my arguments did not sound convincing. The difference is not in the content; it is in the relationship.

Different forms of therapy/coaching are quite alike in the ideas they try to illuminate for their clients. However, the way they communicate these ideas to clients is very different.

CBT therapists (and most coaches) create expert-novice or teacher-student relationships. They tell the client what is wrong with him (e.g., "dysfunctional thoughts" or "lack of self-compassion") and give a prescription for fixing it (e.g., worksheets, frameworks, exercises, etc.).

Some people like it. But I, as a client, only feel the clinician's need to be right and their lack of interest in me (because they already figured me out!). They may even be right! But I just cannot get over their attitude.

What about psychoanalysts? Freud suggested that an analyst should model himself after a surgeon. But something does not click with me in this analogy. Perhaps it is because of the intent to fix someone.

My metaphor for an analytic relationship is ethnographer-subject. An ethnographer is a curious, attentive observer trying to understand his subject's life and culture (i.e., the psychic world).

This world is quite foreign to the ethnographer and has its inner logic, values, and traditions. He observes every detail (including the subject's reactions to him) with interest and attention. Yet, he cannot fix anything in this world.

As he is doing his job, he communicates his understanding back to the subject, helping him understand himself. This understanding helps the client ("subject") to fix whatever he chooses.

This metaphor brings to the forefront something that David Bell stated in one of his lectures: psychoanalysis is not a form of therapy. It is a way of studying the mind. The therapeutic effect is a byproduct.

Indeed. Apart from the issue Jonathan Shedler discusses in this thread, the problem is that CBT ignores people's resistance to change. The idea that you can just offer the client an alternative belief (a better one, of course, because you, as an expert, know better) is naive.

People in coaching and therapy want to change, but … don't want to change. They are suffering, and, through the course of coaching/therapy, may even realize that this suffering is the result of their system of beliefs and values — and yet, they resist change.

They know everything they need to know about alternative beliefs. Knowledge is not a problem. The problem is that they cannot act on that knowledge due to their defenses.

Acting on this knowledge means abandoning much of what you know — including yourself (as you know that self). If your world has been about prestige and achievement, and you are used to judging yourself and others based on that, abandoning this belief in favor of a "better" one means admitting that you lived your life wrong this entire time. Moreover, you are faced with a scary question: who are you, if NOT your achievements? Many people discover a gaping hole where their old self used to be. This is an excruciating realization that not everybody wants to accept.

Thus, much of coaching/therapy is about overcoming this resistance to change. 1) Examining again and again whether the former beliefs were indeed THAT bad. 2) Examining the price you pay for them. 3) Grieving about all the time you lived that way. 4) Learning how to live with an alternative. 5) Finding a new self.

Moreover, sometimes, the client decides to leave things as they are instead of changing. This can be a valid choice — as long as it is mindful. Who are we to judge whether the suffering of keeping things are they are is greater than the suffering of change?

This brings us to important differences in attitude between CBT therapists and psychoanalytically trained professionals. But that deserves another post.

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