Cross-Cultural Empathy and Training the Contemporary Psychotherapist

The diversity of today's client population has required that psychotherapy training confront the importance of cultural competence in graduates. Approaches in this area of education create dynamic tensions between stressing therapist openness to diversity and therapist knowledge of clients' cultures. This paper proposes that this attitude-knowledge dilemma in psychotherapy education can be reconciled by helping trainees develop an empathic response capable of transcending cultural differences. Cross-cultural empathy helps provide the therapist with a coherent and familiar means of maintaining affective receptivity in the therapeutic encounter with clients while making use of a repository of information about clients' cultures. Such empathy can also be a base for building the skills needed to develop collaborative relationships with clients who are often disempowered and distrustful. The paper examines approaches and resources for training psychotherapists in cross-cultural empathy.     

The Therapist's Imagination of Self in Relation to Clients: Beginning Ideas on the Flexibility of Empathic Imagination

The therapist's capacity to imagine is one specific part of the endeavour of empathy which lies at the heart of the processes of the therapeutic relationship. This article offers beginning ideas about the significance of therapist's imagination of self in relation to her/his clients in the task of trying to understand their experience. In seeking to ‘understand’ the experience of others, the therapist is able to move between an imagination of sameness/identification with the client/s, and an imagination of difference/‘foreignness’. The family therapy orientation of curiosity and ‘not‐knowing’ relies on the imagination of self as different to our clients; more traditional understandings of empathic connection rely more heavily on the imagination of sameness/identification with clients. This article argues that flexibility in the therapist's use of self in moving between these positions allows an expanded capacity for therapeutic connectedness. These ideas have special valence in the practice territories of impasse and intercultural therapy.     

Single-Session One-At-A-Time Therapy: A Personal Approach

The terms ‘Single-Session Therapy’ (SST) and ‘One-At-A-Time’ (OAAT) therapy are both used to indicate a situation where the therapist and client set out with the expressed intention of helping the client in one session while acknowledging that additional sessions are available to the client. Both terms have their advantages and disadvantages and thus the author uses the blended term ‘Single-Session One-At-A-Time’ (SST/OAAT) therapy to highlight the advantages of both. It is a core feature of SST/OAAT therapy that it is client-centred especially where the session’s focus and goal are concerned. However, in an attempt to avoid SST/OAAT therapy being highjacked by therapists who operate from the ‘expert’ source of influence, the field has downplayed the contribution of the therapist’s expertise. In this paper, I make clear that the expertise of the therapist when allied to the expertise of the client can be a potent force for good in SST/OAAT therapy. My main task, however, is to outline my own approach to SST/OAAT therapy which is a blend of general principles that are likely to be held by the majority of SST/OAAT therapist and specific ideas that are derived from working alliance theory, pluralism and Rational Emotive Behaviour Therapy.     

Engagement: Who's Engaging Whom?

A definition of ‘engagement’ in therapy is developed, based upon the proposition “the client engages the therapist”. Engagement is then distinguished from ‘joining’, and a consideration of the relational power between client and therapist, implied by this definition, shows it to be consistent with systemic theory for therapy.     

Partners in the Spiritual Dance: Learning Clients’ Steps While Minding All Our Toes

We present four case illustrations highlighting the complex interplay of therapists’ and clients’ spirituality in therapy. Complexity, in these cases, results from (a) degrees of similarity and difference, both real and perceived, between clients’ and therapists’ spiritual beliefs and practices; (b) degrees of spiritual disclosure; (c) characteristics of the therapeutic relationship; and (d) geographic and cultural influences. Practicing therapists and therapist training programs can benefit from addressing how therapist and client spirituality intersect and influence therapy, how both similarity and difference present obstacles and opportunities, and how ambiguity and assumptions can contribute to misunderstandings. We believe that both the therapist’s and the client’s spiritualities are key influences in therapy that can contribute to the frustration, and the growth, of clients and therapists alike.     

The Intersubjective Experience of the Physical Body in the Clinical Setting of Eating Disorders

This paper will illuminate one dimension of self-disclosure as it relates to the inescapable presence of the body in treatment, and the female clinician’s ability to bring her physical body into clinical discussions during an encounter with a female client with an eating disorder. Although the clinical literature on eating disorders validates that transference and countertransference issues are particularly powerful, it generally neglects the exploration of these issues specific to the body’s physical presentation. Since body dissatisfaction is increasingly normative for women today, female clinicians need to have a theoretical road map on which to rely when they encounter a shared body experience. Thus, in order to encourage discussions of the therapist’s body in clinical social work practice, the body needs to be situated in a larger theoretical framework within which it can be explained and located; this framework is object relations theory viewed through an intersubjective lens. Concepts from object relations theory will demonstrate the importance of the body in the clinical exchange by highlighting the parallel between Winnicott’s ‘good enough’ mother and the ‘good enough’ therapist’s body. When the therapist is able to judiciously invite discussions of her body into the clinical arena, the client is given the opportunity to move from object relating to object usage. A case presentation exemplifies how this conceptual framework can be applied to clinical social work practice, strengthening the relationship between knowing and doing.     

Empathy — Still at the Heart of Therapy; The Interplay of Context and Empathy

Developing skilled and delicate approaches and interventions aimed at assisting families (or systems) to solve entrenched problems has been an exciting and stimulating aspect of family therapy over its relatively short existence. Recently, more and more authors have re-emphasised the need for respect and mutuality in dealing with clients, the need for the therapist to be aware of the clients' frames of reference and idiosyncratic solutions, some arguing that it is preferable to take less of the expert, interventionist stance. The necessity for empathy underlined in many earlier approaches to therapy is mentioned, though generally ‘in the small print’, in the reports of the processes being investigated and developed. This article re-considers empathy, always known to be at the heart of the counselling/therapy¹ process, but perhaps too easily assumed at present. It contends that empathy remains essential, that it can be understood more fully, and thereby used more effectively. Some of the traditional understandings of empathy, mostly from writings on individual therapy, are considered. Working with families and systems demands a broader understanding and different applications. The therapist must be capable of empathy with the context and the relationships as well as with individuals. While asserting that human beings are generally capable of empathy, the article examines some particular aspects of its use in therapy, particularly with families; it contends further that a fuller understanding of empathy can enrich the whole process of therapy. The article argues that empathy remains an indispensable guide to intervention with the family, the system or the person, whatever form the intervention (or non-intervention) may take.     

A Pilot Use of Letters to Clients before the Initial Session

This paper explores the nature of engagement in the therapy process, and proposes that engagement may be facilitated when both client and therapist are able to develop an appreciation of each other's position within the therapeutic relationship. Some ways that a therapist can assist in this process are explored. An experiment is described in which information letters are sent to clients before the initial therapy session, as a possible way to enhance the engagement process.     

THE CLIENT'S INTERVIEW OF THE THERAPIST

This paper presents a framework for thinking about interactions between client and therapist systems in terms of the participants' personal explanatory systems and models of reality. The therapist's contribution to forming structures throughout the therapy is examined. The elements of a covert interview of the therapist performed by the client system are described. A model is presented for training therapists to think systemically about client/therapist fit in the context of the client's interview. A case presentation illustrates the value of the interview.     

Lockdown Learnings: No Longer the Mirrored Room

During the COVID‐19 lockdown in Aotearoa/New Zealand, a discussion panel was convened comprising of family therapy students and experienced family therapists to investigate the effects of the use of online digital mediums for family therapy. This article discusses the learnings from that panel. It seems that the use of a screen can change the power dynamic between therapist and client family, perhaps levelling the field slightly and resulting in implications for the therapeutic relationship. Suggestions for practice are given and the situation is likened to that of the ‘mirrored room’ proposed by Hare‐Mustin (1994).     

Systemic alliance in individual therapy: factor analysis of the ITAS-SF and the relationship with therapy outcomes and termination status

Clients providing systematic feedback to therapists via self-report measures of psychological distress and working alliance have been shown to increase therapy outcomes. However, there are few systemic-based measures that are feasible for therapists to use. Recently, Pinsof et al. (Family Process, 2008, 47, 281) developed a brief systemic alliance measure (ITAS-SF) for individual therapy. The current study tested the factor structure of this measure and examined whether the subscales related to clients' therapy outcomes and termination status (N = 570). The results demonstrated supported a 3-factor model for the ITAS-SF (as compared to the seven factors proposed by Pinsof et al.). In the first factor, content combined the goals for therapy, the tasks or methods to reach those goals and bond between the client and therapist. The second factor reflected how clients perceive the relationship with the therapist (i.e., interpersonal dimension-self/therapist), and the third factor reflected how clients perceive the alliance between their social network and the therapist (i.e., interpersonal dimension others/therapist). The two interpersonal factors were related to therapy outcome and termination status.     

Wrapping and Unwrapping Emotions: Clinical Practice with East Asian Immigrant Elders

Using the cultural norm of the way gifts are wrapped, unwrapped, and exchanged as a metaphor for interpersonal connections, this paper presents the way therapists can establish therapeutic relationships with East Asian clients who do not express emotions openly. We first discuss the ways in which emotions are conceptualized, experienced, and expressed in East Asian cultures. We then present vignettes of our work with older Chinese and Japanese immigrant women to illustrate the importance of therapist authenticity and co-construction of the therapeutic relationship. Using the framework of relational/cultural theory, which posits that healing takes place in the context of mutually empathic growth-fostering relationships, we illustrate the importance of establishing mutuality between therapist and client as a form of cultural empathy.     

Persons and Hypotheses: The Use of the Therapist in the Hypothesising Process

Although hypothesising has been strongly criticised by postmodern and narrative theorists, it plays a major role in any therapy. This article aims to investigate the hypothesising process, first revisiting the concept of hypothesis in semiotics and Schön's theory of the professions, then examining some features of hypothesising within systemic therapy. The article takes into account the relationship between hypotheses and therapists' basic theories, to arrive, finally, at an examination of the role of the person (both therapist and client) in shaping hypotheses within the therapeutic interaction.     

Cognitive-Behavioral Family Therapy with a Family in High-Conflict Divorce: A Case Study

Children who live in families with high-conflict divorce situations are increasingly coming to the attention of clinicians. This paper explains the nature of the impasse of high-conflict divorce. It presents a brief theoretical overview of cognitive-behavioral family therapy as an effective approach to treatment for high-conflict divorce families. A case study that successfully utilized a cognitive-behavioral approach to family therapy is presented. Specific techniques such as parent training, communication and empathy skills, problem-solving skills, assertiveness training, role-modeling on the part of the therapist and application of the concept of reciprocal inhibition were included in the cognitive-behavioral family treatment. An N=1 research design is graphically illustrated for evaluation purposes.     

The client's affective impact on the therapist: Implications for therapist responsiveness

Affective authenticity, a modulated, shaded registration of a client's affective impact on the therapist, may provide one component of a reparative opportunity in therapy. Building on infant studies that indicate early forms of sociability and empathy, the author argues that having an impact is a lifelong need. She draws on feminist critiques of abstinence to support her view that therapy can repeat the power imbalances characterizing many clients' historical contexts, if the therapist does not respond to her client's affective influence in an attuned way. A case example of a client with AIDS illustrates some of these ideas.     

The Ecological Perspective Revisited*

Family therapy inaugurated a radical change in the way many emotional and psychiatric problems are understood. ‘Systems thinking’ dictated that the individual needed to be seen within a larger systemic context if his/her behaviour was to be understood and effective intervention carried out. The logical extension of this way of thinking is to argue that the family itself must be viewed within a wider context. This perspective has appeared a number of times in the family therapy literature, particularly in the ‘ecological’ tradition. Utilising an ecological perspective can, however, lead to a new and less clearly defined role for the therapist, and there are thus good pragmatic reasons working against its adoption.     

What works for whom: The link between process and outcome in effectiveness research

Abstract

To date social work effectiveness research has focused on establishing if social work interventions work without much consideration of why interventions work. This tendency is largely the result of effectiveness research being driven by agendas other than those aimed at enhancing practice. This research tradition is reviewed and contrasted with the similar field of psychotherapy where there has been considerable research into why interventions work. Factors common to a range of treatment modalities have been shown to have a positive impact on client improvement, particularly the therapeutic relationship. Given the central place of the ‘helping relationship’ in social work practice and the commonalities between these fields, it is imperative that social work researchers face the challenge of investigating the process factors impacting outcomes. In the absence of this research, effectiveness cannot be honestly attributed to particular intervention techniques.     

You are what you read. The use of bibliotherapy to facilitate psychotherapy

1. In the course of therapy with individuals or couples, it is sometimes helpful to suggest reading specific material to assist in the therapeutic process. 2. It is important that the therapist be totally familiar with the recommended material and have a specific purpose for the recommendation. 3. The therapeutic interaction, rather than the reading of material, is the focus of the treatment. 4. Such reading may prove helpful because it becomes an educational experience and comprehension of a concept is increased; the material can be "validating" when written by someone unknown to the client who has had a shared experience; and it can remove a struggle for control from the therapeutic relationship by giving information or opinions directly to the client.     

A Case of Enhancing Sexual Confidence: Both the Client and the Therapist Are the Experts

This case study demonstrates the challenges and possibilities of working on a sexual relationship with a single client and provides an example of integration of sex therapy within the ethical and theoretical framework of a collaborative systemic approach. It illustrates the author's view on the therapeutic relationship involving the expertise of both the client and the therapist. A model for integration of systemic approach and sex therapy is proposed.