The Other Kind of Empathy. A Key to Teaching CBT Skills.

When one teaches, two learn. – Robert Heinlein

Empathy is an important component of therapy. We usually think of empathy as the therapist listening to a patient’s story with the quality of attention and awareness that allows them to experience just what the client is going through.

I think this kind of empathy can be understood as a more passive, connecting kind of empathy – one that is a feeling that you hold onto and let unfold as the client talks, without necessarily doing anything about it.

But what about the kind of empathy where you actually put yourself in the client’s shoes? This more active, experiential form of empathy can occur when you notice the situations in your own life that mirror your clients and use them as opportunities to apply the skills you are trying to teach them. Then you truly approximate an experience of what it might feel like to have this kind of problem, to have to apply a skill in the moment, and it helps you learn about the obstacles a client might face in using the skill in real life. Then, your teaching of the skill can be informed by that experiential knowledge, making it all the more relevant to the client and articulating and addressing potential obstacles, which only builds the other kind of empathy and strengthens therapeutic alliance.

This is the kind of empathy that I got to experience today. Here’s what happened

Part of cognitive-behavior therapy is a helpful skill we call cognitive restructuring. The idea behind CBT is that at the root of many kinds of dysfunction is problematic thinking – thinking that is not necessarily reflective of facts but more so of your own deep-seated negative core beliefs that were shaped early on in life – and this dysfunctional thinking directly impacts your emotions and behavior. Given that events don’t cause emotions, but rather, your thoughts about those events do, if you can start catching your automatic thoughts, you can start evaluating them rather than automatically taking them as facts. In that evaluation process, we often find that thoughts are distorted – they don’t reflect reality completely accurately … rather they reflect our insecurities. The power of noticing this is that then you are in the position to modify them so they become more adaptive, more fully reflecting reality, which then positively influences how you feel and how you behave. This, in a nutshell, is cognitive restructuring.

So this week, I’ve been preparing to teach this skill of questioning and evaluating automatic thoughts to a client with social anxiety. The task has felt a little overwhelming, in all the typical rookie therapist ways, reflected in my own automatic thoughts: “Will I be able to explain it in a way that makes sense? Will I be able to answer the client’s questions? Will I be able to convey everything I mean to?”

And another pesky one: “Will it work?”

This last question, in particular, had been very active in the back of my mind. I hoped it would work. But how could I be sure? Research said it would, the books I read said it would, but still, how could I be sure?

Today I found a way that increased my own confidence that it would work. And that’s because today, it worked for me. Empathy.

So what happened? Rewind to group supervision. I was put on the spot to talk about one of my clients. I was happy to start, because I was asked to talk about my favorite client, and I had just gotten through a session that had felt really good – our discussion had been fruitful and certain insights resonated with the client, who left feeling visibly hopeful about her future and our work together. So I had walked into supervision feeling good too and was happy to have an opportunity to share my experience. But as I began to explain what happened in the session, I suddenly felt the flutter. The butterflies. The slight tightness in my throat. The brush of panic against my chest. And then my attention narrowed. What did they think? Could they see I’m nervous? These are the typical social anxiety symptoms my client has described.

I braved through the discomfort and finished talking about my client by zeroing in on a moment in therapy that I thought was really nice. No one said a word. I caught a glimpse of a brow furrowing. Then we moved on. A few minutes later, supervision ended, and we all walked back to our offices.

As I walked out, I felt the first seeds of shame forming inside me. I went back to my office and sat at my desk and felt shame noticeably simmering. And some regret. Shame and regret. Such a painful feeling.

I replayed the incident in my mind and searched for the moment when shame really began.  I remembered that brow furrowing. That was my cue. In the space of ambiguity, I explained the furrowed brow as a sign of confusion, the confusion symbolic of that person’s belief that I had actually just done a terrible job at therapy and at describing it, and of the associated idea that perhaps everybody in the room thought that, all of which my mind distilled into one brief statement I recalled flashing ever so briefly in my mind: They think I’m stupid.

There was no time to do anything about the thought because the next client was about to arrive. So I pushed it to the back of my mind and made a mental note to get to it later. Later came, and when I checked in with myself, I noticed the shame had now increased. I watched my mind go back to the thought over and over again, like a record needle gently placed back into the soundtrack by a compulsive hand. They think I’m stupid. Over and over again. A process we call rumination. Which tends to fan the flames of shame.

My day of clients was over, but I still had several hours of work before leaving the practice. I thought to myself, “Perhaps I should restructure” but I pushed that idea away because I just didn’t feel like it. “Who wants to face this shit fully when the emotions linked with those thoughts are so freaking painful?” I thought to myself. Then I got back to work.

My feeling continued to be strong, and it continued to haunt me, even as I worked. Thoughts of things we tell clients crossed my mind. “Shouldn’t I practice turning the mind [a skill from DBT]? Shouldn’t I do opposite action [also from DBT]? Shouldn’t I use the cognitive restructuring skill I’m preparing to teach my social anxiety client in a few days?”

“You most certainly should do all of that,” my mind responded. And then I did none of it. Because emotions won. I was paralyzed. I just didn’t feel like it.

Interestingly, in those moments, I also understood the behavior of DBT clients, who struggle with mood-dependent behavior – when certain emotions rear their heads, they just can’t get themselves going on the things they know they need to do. Along with this realization came another: If it was THIS hard to get yourself to do skills in the moment, how in the world would I be able to convince them to try these skills in real time in the future? A new worry for the rookie therapist. My turmoil increased.

I wish I could say that like a brilliant therapist who walks the walk and eagerly approaches and applies the things she encourages clients to do, I shortly thereafter stopped all this aimless rumination and tried the skill. Any skill.

But no. My emotions were so strong, I let a whole day pass before finally starting. Eventually, on my train ride home, I had finally had enough. Mentally and emotionally xhausted, I begrudgingly decided to give cognitive restructuring a try. And then I asked myself the classic questions we use to question and evaluate automatic thoughts in CBT:

1. What is the evidence for the thought?

My evidence for the thought “They think I’m stupid” was that after I finished talking, someone looked confused and no one said much. Clearly, they thought I was stupid, definitely not good at any of this, and inside, they were probably laughing too.

2. What is the evidence on the other side (i.e., against the thought)? Any alternative explanations?

Well, only one person looked confused is the truth, not everyone. And also, people have been quiet after hearing about others’ cases too. And come to think of it, I did get one or two questions – I just discounted them and forgot about them because they didn’t fit the story I was telling myself (that they think I’m stupid). And actually, neutral looks or looks of confusion don’t necessarily equate to thinking I’m stupid.

3. What is the worst-case scenario?

They really do think I’m stupid.

4. What is the best-case scenario?

They don’t think I’m stupid. They think I’m brilliant.

5. What’s the most realistic scenario?

They think I’ve had 7 days of face-to-face client experience and that I’m not quite exceptional yet at doing therapy or at explaining my cases in the way I will be at the end of this year, but perhaps that I am trying and I am doing well enough. They think I’m doing just fine for my level of training.

6. What is the result of me thinking this way?

I feel SO much better.

I really did. The most powerful was my answer to question No. 2. That’s when, for the first time, I was able to get unstuck from my limited perspective and see that there were actually other interpretations. See that my thoughts were not facts. They were distorted conclusions I had come to that reflected my deepest insecurities rather than reality. And then I felt better, and I was able to let go of the shame and the incident. I felt renewed. And marveled at how I had just spent a whole day suffering when I could have tried this instead.

Another thing I noticed is that two reasons why it worked:

1. It got me to see that there are more than one interpretations.

2. It got me to see that even if it was true that my colleagues and supervisors thought I didn’t do so well in my therapy session or my description of it, it didn’t mean all that I feared it meant. It didn’t mean I’m stupid or have no future. It just meant that I was just starting out at this, that I was learning, and everyone on the team knew that. No big deal.

As I walked home, feeling relief, I realized that the skill I’m going to be teaching my social anxiety in a few days does work. I didn’t have to just believe it based on research anymore. I also felt it, based on my own experience. And although research has shown that it works for various disorders and especially social anxiety, because I was able to discover on my own in a really deep way with a very real problem that it works, I suddenly felt confident in selling it to my client.

Experience breeds empathy, I think. It makes it that much easier to step into your client’s shoes, to anticipate the obstacles your client will face toward trying new skills, and to learn, naturally, that it’s worth the effort anyway. I think it takes a very empathetic therapist to do CBT well, in the full sense of that word.