Improving Clinician’s empathy skills with ACT Matthieu VILLATTE, PhD, Jean-Louis MONESTES, & Roger VILARDAGA ACBS WORLD Con VIII RENO
Dec 14, 2015
Improving Clinician’s empathy skills with ACT
Matthieu VILLATTE, PhD, Jean-Louis MONESTES, & Roger VILARDAGA
ACBS WORLD Con VIIIRENO
Some clients puzzle us
• Clients that are difficult to help, that confront us with failure
• who seem to judge us• who present opposite values comparing to ours• who made actions that are shocking to us, that
seem unforgivable to us• who we think they don’t really need help; (we don't
think they have serious issues)• who try to involve us in a kind of relationship we
don’t want (try to be our friends…)• …
A few words about language and ACT
• 1- ACT is based on Behavior Analysis– Focus on learning mecanisms (functional approach)– Focus on the role of context in learning and
maintaining behaviors (contextual approach)• 2- Built on the behavioral model of language
proposed by RFT– Relational properties of language lead to:
• Cognitive fusion (verbal events evoke emotions + insensitivity to environment),
• Loss of contact with present moment (fear of future and rumination of past),
• Difficulty to durably suppress psychological events without deleterious consequences on values.
A few words about language and ACT
• 2- Built on the behavioral model of language proposed by RFT– Relational properties of language lead also to:
• Building new directions of life (in terms of values and not only of goals)
• Commiting in behaviors which consequences can be distant or absent, in presence of difficult psychological events.
In interactions with others, language has also problematic effects
• The Conceptualized Self
(clinicians' and clients'…).– Verbal definition of the self.– Effects of fusion and insensitivity.
• I behave according to this definition• I perceive others through my verbal
conceptualization of them (ex. « He’s old, he can’t understand »; « She did long studies, she must look down at others »; « He has written books, he must be right »…)
In interactions with others, language has also problematic effects
• The Conceptulized Self (one’s and others’…).– An effect also present in therapy
• What therapist am I? (« I am a man/a woman »; « I am xx years old »; « I practice therapy x »
• Who is my client? (frequently perceived through their « symptoms »)
These effects constitute barriers to empathy and compassion (acceptance of others’ emotions)
• Partial perception of the client– He’s a schizophrenic, he can’t be autonomous– She’s a depressive person, she can't value anything – He’s been an alcoholic for 15 years, he can't change.
• Difficulty to identify and accept emotions of the client
• Interferes with pratice
Therapeutic relationship in ACT• We don’t need to be empathic because it’s our
job or just because it is how a therapist must be.
• We need to be empathic because a main part of
therapy is to shake client’s behavioral repertoire.
This change comes with difficulties for the client
(creative hopelessness)
• Client’s life is not hopeless, experiential
avoidance strategy is. Therapist’s empathy helps
the client to perceive the difference.
• When introducing creative hopelessness to clients, it’s essential that:– They feel they are not judged– On the opposite, that they perceive their suffering
is received and accepted unconditionally – They know that it’s normal to feel what they
currently feel, to think what they currently think, because of their past and because of language properties
– They perceive that the therapist is on the same boat as they are: we have to be acceptant (empathic) to shape acceptance
Therapeutic relationship in ACT
Definition of the therapeutic relationship
• BORDIN (1979) described the therapeutic alliance as a composite of three different aspects:– the relational bond between therapist and
client– the tasks of psychotherapy– the goals of psychotherapy (or the outcomes
that are sought)
Psychologicalflexibility
Acceptance
Defusion
Self as context
Commitment
Values
Contact with the present moment
An empathic tour of the hexaflex for therapists
Why developping empathy and compassion ?
• Utility of empathy and compassion
– For the client:• Favors identification and acceptance of their own
psychological events• Favors change (my problems are caused by universal
processes; like others, I can change)
– For the therapist:• Better identification of emotions felt by the client.• Better identification of the function of behaviors (reduces the
filter of language in the search of useful cues).• Reduces the tendency to change the client's psychological
events
How does ACT develop empathy competencies?
• Identifying psychological events of the client… Different possible ways:
– Gathering cues + rulesWorks, but still language (with its potential limits…)
– Changing perspectiveUses language but more direct access to psychological
events of the client
A word about RFT and perspective taking skills…
• Language= relating events arbitrarily (or not!)
• Different ways of relating events:– Frame of equivalence, opposition, hierarchy, etc. – and frames of perspective taking (=DEICTICS)
• Deictic frames:– I / You (interpersonal perspective)– Here / There (spatial perspective)– Now /Then (temporal perspective)
This particular type of relational responding is learned through multiple exemplars of questions/answers involving different perspectives (What do you see from there? Yesterday, did you know I would come today?)
(Hayes, 1984; McHugh et al., 2004)
Perspective-takingDeictic framing
Psychological flexibilityContextual control over deictic and other relational functions
Effective therapeutic relationship
I/YouHere/There
Now/ThenI/YouExciteme
ntAffection
Joy
I/You Sadness
Fear
Hate
Contextual control
EmpathyTransformation of functions of deictic relations
3 step model of the therapeutic relationship
• Competencies in relating the self to others, time, and space are correlated to identifying others’ mental states (Villatte et al., 2008, 2009, 2010)
The more I am skilled in taking the perspective of others, the more I am able to identify what they think and feel.
Objective : Developing our competencies in changing perspective
• Multiple exercises that employ various contexts and each time, a change of perspective.
• Exercise n°2 (Finish the sentences)
Exercise n°3 (Live other's emotions)
How does ACT develop compassion ?
• Changing perspective leads to contacting emotional states of the client
– Triggers emotional states in the therapist
– Can trigger avoidance of the therapist (with problematic effects of experiential avoidance…)
Exercise n°4
Negative judgment
Use on yourself the same techniques you employ with your clients (all the hexaflex!).
Knowing the past to develop acceptance of the other
• According to behavior analysis, our next behaviors are the product of history of previous behaviors and consequences
• « Past is the future of our present »
• The more you know one’s past, the more you can accept it, since you understand why one behaves that way.
Knowing the past to develop acceptance of the other
• It’s a deterministic, but also a probabilistic model: history of previous behaviors and consequences causes our futur behaviors, but …
- hazard can play an important role
- huge number of variables in interaction
- each consequence has different effects depending on history of behaviors and consequences
• Some important variables (hence important to know to improve empathy), notably repetitive or emotionally loaded ones
• Some « hazardous » learnings: superstitious behaviors reinforced randomly (ex BPD)
Important variables to know, but also hazardous learning
• Understanding these mechanisms allow to improve acceptance of the client, even if it’s impossible to exactly know the whole story, neither to predict exactly how the client is going to behave
• Most importantly, implications of determinism are :– Absence of responsability of one’s behaviors– Anybody else with the exact same behavioral
history would behave exactly the same (including the therapist)
Knowing the past to develop empathy