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Act Nerv Super Rediviva 2011; 53(2): 72–83
PSYCHOTHERAPY
Activitas Nervosa Superior Rediviva Volume 53 No. 2 2011
Empathy in cognitive behavioral therapy and supervision
Jana V 3, Jan P 1,2,3,4, Milos S 5
1 Department of Psychiatrics, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic;
2 University Hospital Olomouc, Czech Republic; 3 Prague Psychiatric Centre, Czech Republic; 4 Centre of
Neuropsychiatric Studies, Prague, Czech Republic; 5 Psychagogia, Liptovsky Mikulas, Slovak Republic.
Correspondence to: Prof. Jan Prasko, MD., PhD.,
Department of Psychiatrics, Faculty of Medicine and Den-
tistry, Palacky University Olomouc, Czech Republic
; -: prasko@fnol.cz
Submitted: 2011-05-04 Accepted: 2011-06-01 Published online: 2011-06-25
Key words:
empathy; cognitive behavioral therapy; neurobiology; therapeutic relation;
transference; countertransference; supervision
Act Nerv Super Rediviva 2011; 53(2): 72–
83
ANSR530211A03 © 2011 Act Nerv Super Rediviva
Abstract
Rogers found empathic reflection useful and around it constructed his notions of individu-
ation. Active listening requires therapists to paraphrase what the client has just said, using
the emotional tone in which it was said. Empathic reflections are intended to confirm the
client´s experience by helping him or her know more precisely what it is and to make it
more acceptable. In recent years social neuroscience made considerable progress in reveal-
ing the mechanisms that enable a person to feel what another is feeling. During empathic
reaction the therapist is intervening not only in a psychological manner to connect, heal,
and share burden but also in a neurobiological level. Shared neural representations can
play a main role in understanding of mental states of other person.
Cognitive behavior therapists examine the thoughts, feelings, and behaviors related to
a wide range of situations (including reactions to the therapist) and relevant childhood
experiences to understand the underlying core beliefs and conditional assumptions of each
client. Empathy helps them to understand both emotional reactions and the meanings
of experience for the client and helps them also to understand how these elements are
interconnected in concrete client. Understanding of transference and countertransference
is crucial to effective listening. Empathy could help to recognize and understand transfer-
ence and countertransference and for their appropriate using during the therapy. Empathic
ability may be part of sensitivity to one´s own feelings, including countertransference feel-
ings, which in turn ought to prevent the acting out of countertransference.
I
Therapeutical interest in empathy has been remarkable
spread since its introducing by Freud. Also, Rogers
has put much emphasis on empathy in nondirective
therapy approach and the topic has been a focus of his
psychotherapy research (Rogers & Dymond 1954).
Rogers found empathic reflection useful and around it
constructed his conception of individuation. Rogerian
technique of empathic reflection or “active listening”
is probably the most widely known method of express-
ing therapist willingness to comprehend the ongoing
experience of the client. Active listening requires the
therapists to paraphrase what the client has just said
by using the emotional tone in which it was said. As
Rogers (1951) taught active listening, he gradually
discovered that trainees tended to parrot back client
utterances without really entering into their frames
of reference. He switched therapists training to learn
them enter into the client’s world and to describe this
world from that internal reference point. Empathic
reflections illustrate the way in which interventions
may appear to have one function but also have next. As
summary statements of client here-and now emotional
73
Act Nerv Super Rediviva Vol. 53 No. 2 2011
Empathy in cognitive behavioral therapy
experience, empathic reflections are intended to con-
firm the client’s experience by helping him/her know
more deeply what experience is and to make it more
acceptable. Therapist can not reflect all client emotions
and therefore must be selective. By reacting to certain
content and not to others, clients are encouraging to
continue in the manner that has elicited the therapist’s
responses. If the function of questions is to direct client
attention to certain area, then empathic reflections
seem to exert a similar function.
Somewhat different development was described
in the work of Kohut et al (1959) in which a “central
position” of empathy in both human development and
therapy has been accentuated. Kohut defines empathy
as “vicarious introspection”. While emphasizing an
observational and data-gathering aspect of empathy, he
explained how this type of introspection actually leads
to understanding and knowledge. Goldberg (1973)
described empathic approach in short-term therapy,
which relies on Kohut formulation of a psychology of
the self (Kohut 1971). Goldberg suggested that a thera-
pist’s empathic stance can help clients recover from
acute narcissistic injuries, that is, damaged self-esteem.
Goldberg provided an empathic “mirroring” relation-
ship to reflect and strengthen the client’s injured self-
esteem. Empathy is particularly important in complex
interpersonal behavioral problems in which the envi-
ronment (family, friends, colleagues etc.) may to expel
the client, and the client has therefore lost hope.
M “”
The term “empathy” has aggregate a number of mean-
ings and these overtones are not necessarily intrinsic
either to the psychological properties of the phenom-
enon or to its therapeutic action. On the level of vicari-
ously felt responses, we have to distinguish between
empathy, sympathy, empathic concern, and compas-
sion. In all these cases, emotional changes are induced
in the observer in response to the perceived or imag-
ined emotional state of another person. The word
empathy comes to be used as a virtual synonym for the
word sympathy, but it is important to distinguish these
conditions with respect to psychotherapy. While empa-
thy includes feelings that are isomorphous to those of
the other person, sympathy, empathic concern, and
compassion do not necessarily involve sharable feel-
ings. Sympathy refers more to a feeling of compassion
for and active sharing of the client’s pain. Whereas sym-
pathy means to feel the same as someone else, empathy
means to understand as well as to share in a way that
exceeds having the same surface feelings. For example,
empathizing with a person feeling sadness will result in
a feeling of sadness in the self, whereas sympathizing
with, being empathically concerned, or feeling compas-
sion for a sad person will result in either pity or compas-
sionate love for the person, but not sadness. Also, when
an observer notices that someone is jealous of him,
he/she will most likely not start feeling jealous himself –
though he/she might show sympathy or compassion for
the jealous person (de Vignemont & Singer 2006). On
overly sympathetic reaction may vitiate the therapist’s
attempts to relieve the sources of the client’s distress or
anxiety (Beck et al 1979). Empathy, on the other side,
includes an intellectual (as well as an emotive) com-
ponent, namely, understanding the cognitive basis for
the client’s feelings; it also implies the ability to detach
oneself from the client’s feelings in order to maintain
objectively toward his problems. Therefore, the crucial
distinction between the term empathy and those like
sympathy, empathic concern, and compassion is that
empathy denotes that the observer’s emotions reflect
affective sharing (“feeling with” the other person) while
compassion, sympathy, empathic concern means that
the observer’s emotions are inherently other oriented
(“feeling for” the other person) (de Vignemont & Singer
2006). Empathy is also often associated with love and
warmth. In therapy, warm intervention is often auto-
matically described as empathic one. Although there are
intrinsic connections between warmth, love and empa-
thy, there are not simple or direct. Therapist´s empathy
may be experienced by a client as warm, or even loving,
but warmth or love does not directly generate empathy
and empathic understanding. Usually, also, empathy is
considered similar to the intuition. Intuition is similar
to empathy because both are, in some way, sources of
knowledge. While intuition consists of drawing con-
clusions from minimal cues and tends to be primar-
ily a cognitive skill relative to all realms of knowledge,
empathy pertains primarily to human experience and
has strong emotional components (Rothenberg 1988).
In therapeutic process, empathy is an active motivated
function which leads to specific understanding of the
client’s inner psychological state. As a result of creative
process empathy produces useful interpersonal knowl-
edge which did not exist before. In cognitive behavioral
therapy tradition, according Beck et al (1979), accu-
rate empathy refers to how well the therapist can go
into the client’s world and see and experience life the
way the client does. The therapist will to some degree,
experience the client’s feelings. To the extend that his/
her empathy is reasonably accurate, the therapist will
be able to understand how the client structures and
responds to certain events and relations. Therapeutic
empathy includes the cognitive and emotional compo-
nents of lived experience. At a basic phenomenologi-
cal level, empathy denotes an affective response to the
directly perceived, imagined, or inferred feeling state of
another being (Batson 2009). De Vignemont and Singer
(2006) define empathy as follows: We “empathize” with
others when we have (1) an emotional state (2) which
is isomorphic to another person’s emotional state, (3)
which was elicited by observing or imagining another
person’s emotional state, and (4) when we know that the
other person’s emotional state is the source of our own
emotional state.
74
Copyright © 2011 Activitas Nervosa Superior Rediviva ISSN 1337-933X (print), e-ISSN 1338-4015 (online) www.rediviva.sav.sk/
Jana Vyskocilova, Jan Prasko, Milos Slepecky
E
Using empathy in psychotherapy has two distinct steps
that are often blurred in the minds of those consider-
ing it. The phenomenon of empathy entails not only
listening but also the ability to share the emotional
experiences of others (Singer & Lamm 2009). The first
step, gaining empathic understanding, and the second,
expressing the empathic understanding, each may be
approached in a number of ways. Therapeutic empathy
begins with listening of the client. Listening and hearing
are often seen as equal. But listening includes not only
hearing and understanding what the speaker said, but
also attending nonverbal issues and context, sequences
of associations, specific selections of words, metaphors,
contents of imagery etc. (Mohl 2008). Traditionally, this
kind of listening has been known as “listening with the
third ear” (Reik 1954). Because inner human experience
is so complex, therapist must choose restricted levels
through which to enter the other’s world. Here and now
affective state is the most common empathic target.
Therapeutic listening requires interpersonal sensitivity,
sensitivity to the storyteller, ability to integrate whole
story to logical conceptualization. Client is invited to
cooperate as an active informer and rewarded after any
meaningful information. Therapist, hearing the client
story, experiences the world of client and his situation
from the client perspective. Good listener hears both the
client and the disorder or problems clearly, and regards
every encounter as potentially therapeutic. During the
dialogue the listener is on a journey to discover who
the client is a person with his narrative, helping carry
the burden of loss, lightening and transforming the
load (Rogers 1967). Therapist may use also his/her
thoughts to enter any level of the other’s experience.
By avoiding only use or his/her own feelings, therapist
maintains an objective perspective but lose some of the
ongoing experience. When using objective thought to
gain empathic understanding, therapists may attempt
to categorize client emotional state. They may also con-
sider clients to be members of specific groups, inclu-
sion in which seems to predict typical experiences. For
example, age, class or ethnic predicts biocultural mile-
stones (Haley 1973), diagnosis predicts certain though
patterns (Beck 1976), and social role predicts common
conflicts (recent immigrant, divorcing man or woman).
Theoretical assumption about human psychological
dysfunction help therapist to filter data of the client’s
presentation in manners that support these theoretical
patterns and lead to a kind of empathic understanding.
Therefore listening is part of diagnosis as well as heal-
ing. Symptomatic listening look like traditional medical
anamnesis – the focus is on the presence and absence of
specific symptoms. During symptomatic listening CBT
therapists or supervisors typically focus on thoughts,
behaviour patterns, beliefs, emotions, somatic reac-
tions, antecedents and consequences of behaviour. Nar-
rative-experiential listening is based on the theory, that
all people are constantly interpreting their experiences,
attributing the meaning to them and integrating a story
of their lives with themselves as the central character
(Mohl 2008). This includes personal history, repetitive
behaviours, rules and learned assumptions about client
himself, about other people and world, and interper-
sonal roles. To listen and understand requires that the
language used between client and therapist be shared
– meanings of words and sentences are commonly held
(Kimmerling et al 2000). The Sapir-Whorf hypothesis
suggests that what we are able to think is determined
by the language in which we are working and it is the
basic mechanism for developing and maintaining social
organization (Shapir 2000; Dunbar 2004). Therapists
may also choose to permit their clients to help them
emotionally by allowing client words and nonverbal
signals to enter into their ongoing experience and by
sharing how they are affected by these sounds and
rhythms. The ability to comprehend the client through
attention to inner reactions is based upon “what seems
to be a universal capacity for unconscious perception
and sensitivity” (Langs 1976, p.562).
R
Traditionally cogniti v e -behavioral therapists listen
e.g. for emotional expression, stimulus associations,
pattern of behaviour, cognitive distortions, irrational
assumptions, maladaptive schemas, narrative con-
text or global inferences, family structure, myths and
environment etc. (Beck 1979; Leahy 2003; Young et al
2003). Qualified cognitive behavioral therapists dem-
onstrate the competencies of any good psychotherapist:
genuine empathy, respect, caring, regard, and accurate
understanding. They value a collaborative working
relationship and fine-tune their style and the process
of therapy to suit individual clients (Beck 1995). Cog-
nitive behavioral therapists would agree with Rogers
concerning the importance of therapist empathy in
helping clients. However CBT therapists would not
only offer their clients emotional empathy (i.e. showing
their client that they know how they feel), but also offer
them philosophical empathy (i.e. showing their cli-
ents that they understand the underlying philosophies
(beliefs or rules) upon which their emotions are based
(Dryden & Ellis 1988). The special meanings of words,
sentences and images can be one of the central focuses
of the therapy. Therapists have to at the same time
listen symptomatically and narratively/ experientially.
It also involves seeing – facial expression, gestures,
movements, mimics and so on. Therapist constantly
compares what is said with what is seen, seeking dis-
harmonies, and comparing what is being said and seem
with was previously communicated and observed. They
must also have access to different theoretical views,
not only cognitive behavioral theory, but sometimes
also sociocultural, existential, gestalt, psychodynamic,
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Act Nerv Super Rediviva Vol. 53 No. 2 2011
Empathy in cognitive behavioral therapy
system and narrative theories. Further, it is essential to
be aware of what might been said but was not (Mohl
2008).
B
In last twenty years s o c ial neuroscience has made con-
siderable advances in understanding the mechanisms
which enable one person to feel what another is feeling
(Singer & Lamm 2009). Attachment and social sup-
port are psychobiological mechanisms which provide
important physiological regulation to human beings
(Hofer 1996; Heim & Nemeroff 2001; Meaney 2001).
Several works support the notion of the client’s capac-
ity to perceive empathy through the powerful nonver-
bal, universally understood communication of facial
expressions (Ekman 1992). Considerable verification
shows that sharing the emotions of others is associated
with activation in neural structures that are also active
during the first-hand experience of that emotion. Part
of the neural activation shared between self- and other-
related experiences seems to be rather automatically
activated (Singer & Lamm 2009). Facial expressions of
the listener may generate autonomic and central ner-
vous system changes not only within the listener but
within the person being heard. There is neurobiological
basis for empathy, transference and countertransference
and also biological basis for the power of listening to
heal, to change psychological burdens, to remoralizate,
and to help with emotional regulation in clients, who
felt out of control in their strong emotions like panic,
anger, despair, depression etc.
Our understanding of r o l e of mimicry (tendency
to automatically synchronize affective expressions,
vocalizations, postures, and movements with those
of another person) as a low-level process contrib-
utes toward empathy comes from studies using facial
electromyography. These studies show that when one
person perceives another person’s emotional facial
expressions, such as a smile or a lour, corresponding
emotional expressions result in the observer (Dim-
berg & Oehman 1996). According the facial feedback
hypothesis (person appraises his own emotions by per-
ceiving their bodily concomitants), Sonnby-Borgstrom
(2002) suggested that mimicry enables one person to
automatically share and understand another’s emo-
tions. Some studies demonstrate the influence of top-
down processes on mimicry, such as those associated
with the relationship between empathizer and target
(Lakin & Chartrand 2003), the emotional state of the
observer (Moody et al 2007), or the perspective from
which pain in others is witnessed (Lamm et al 2008).
Mimicry seems to serve a social function in increasing
rapport and affinity between self and other, raising the
question whether this function evolved for commu-
nicative rather than for epistemological reasons (van
Baaren et al 2004). Emotional contagion (“primitive
empathy”) is next process which is related to but dif-
ferent from empathy. It means automatic tendency to
“adopt” other people’s emotions (Hatfield et al 2009).
For example, babies start cry when they hear other chil-
dren crying. No long ago, the evidence for involuntary
pupillary contagion has been found in an fMRI study
(Harrison et al 2006). Experimentees were presented
with pictures of sad faces with various pupil sizes.
Their own pupil size was significantly smaller when
they viewed sad faces with small as compared to larger
pupils. Edinger−Westphal nucleus in the brainstem,
which controls pupil size, was specifically engaged by
this contagious effect. Pupillary contagion occurs out-
side of awareness and may constitute a precursor of
empathy. This study can also demonstrate the overlap
between mimicry and emotional contagion (Hatfield
et al 1993). However, that there are situations in which
mimicry occurs without an affective component and
other situation in which affects are automatically elic-
ited by observing others’ affective states without motor
mimicry. But neither emotional contagion nor mimicry
cannot answer for the full-blown experience of empa-
thy (Singer & Lamm 2009). The empathy fundamen-
tally relay on self-awareness and self/other distinction
– distinguishing between whether the source of our
emotional experience lies within us or was triggered
by the other (de Vignemont & Singer 2006). Without
this ability, witnessing someone else’s emotions could,
for example, result, purely, in personal distress and
a self-centered response in the observer. The crucial
distinction between the term empathy and those like
sympathy, empathic concern, and compassion is that
empathy denotes that the observer’s emotions reflect
affective sharing (Singer & Lamm 2009).
During empathic reaction the t h e rapist is interven-
ing not only in a psychological manner to connect,
heal, and share burden but also in a neurobiological
level (Mohl 2008). When clients feel safety, accepted,
respected and valuated, the response is also remark-
able in the level of brain substrate. LeDoux (1996) was a
pioneer in identifying the neurobiological basis for pri-
mary emotions. Brothers (1989) using this findings and
findings from own studies with primates, developed a
hypothesis about the biology of the empathy based on
seeing as well as hearing. Brothers (1994) and Dam-
ascio (1994) identified the amygdala and the inferior
temporal lobe gyrus as the neurobiological substrate
for recognition of and empathy for other person. The
discovery of mirror neurons has added to our under-
standing of the neurobiology of empathy (Harris 2007).
Schore (2001) has identified that these parts are pre-
determined to recognizing facial expression, gestures
etc, but require effective maternal-infant interaction in
order to do so. Preston and de Waal (2002) described
a neuroscientific model of empathy, one which sug-
gests that observing or imagining another person in a
particular emotional state automatically activates a rep-
resentation of that state in the observer, and activated
also its associated bodily reactions. There was proposed
76
Copyright © 2011 Activitas Nervosa Superior Rediviva ISSN 1337-933X (print), e-ISSN 1338-4015 (online) www.rediviva.sav.sk/
Jana Vyskocilova, Jan Prasko, Milos Slepecky
also by others that shared neural representations can
play a main role in understanding of mental states of
other person. Shared representations provide us with
a simulation of corresponding sensorimotor, affective,
or mental experiences (Gallese 2003a; Goldman 2006).
The empathy is a flexible process influenced with a
number of factors—such as contextual appraisal, the
interpersonal relationship between empathizer and
other, or the perspective adopted during observation of
the other (Singer & Lamm 2009). An important aspect
of most neuroscientifically motivated models of empa-
thy is that the activation of shared representations in the
observer is initiated mostly automatically and without
conscious awareness. The most of studies on the empa-
thy used the observation of pain in others as a model
to evoke empathic reactions (de Vignemont & Singer
2006; Decety & Lamm 2006; Singer & Leiberg 2009;
Jabbi et al 2007). Singer et al (2004) recruited couples
and measured hemodynamic responses triggered by
painful stimulus of the female partner via an elec-
trode attached to her right hand. In another condition
the same painful stimulation was applied to the male
partner who was seated next to the MRI scanner and
whose hand could be seen via a mirror system by the
female partner lying in the scanner. Differently colored
flashes of light on a screen pointed to either the male
or the female partner’s hand, indicating which of them
would receive painful stimulation. The results suggest
that parts of the so-called pain matrix (Derbyshire
2000), which consists of the brain areas involved in the
processing of pain, were activated when participants
experienced pain themselves as well as when they saw a
signal indicating that their loved one would experience
pain. These areas—especially bilateral anterior insula,
the dorsal anterior cingulate cortex, brain stem, and
the cerebellum—are involved in the processing of the
emotional component of pain. Thus, both the firsthand
experience of pain and the knowledge that a beloved
partner is experiencing pain activates the same affective
brain circuits. It seems that our own neural response
reflects our partner’s negative emotion. Other authors
observed that the amplitude of an event-related poten-
tial component known to be generated in primary
somatosensory cortex (P45) is modulated by seeing a
needle piercing another person’s hand (Bufalari et al
2007). Similarly fMRI study demonstrated that (contra-
lateral) right primary somatosensory cortex was acti-
vated when participants saw another person’s left hand
being pierced (Lamm et al 2008, 2010). The common
finding of these experiments is that vicariously experi-
encing pain activates part of the neural network that is
also activated when we are in pain ourselves.
To examine the areas involved in emot i o nal sharing
during pain more precisely, detailed analyses of acti-
vation areas in the cingulate and insular cortices have
recently been investigated (Jackson et al 2006; Morri-
son & Downing 2007; Decety & Lamm 2009). These
analyses show that there is reliable overlap when activa-
tion in these areas during firsthand and vicarious expe-
rience of pain is compared, but they also show that the
majority of voxels in the insula and the cingulate cortex
do not overlap. A recent meta-analysis compared pub-
lished localizations for the experience of pain to those
reported for empathy for pain. The results show a more
posterior−midinsular activation pattern for the first-
hand experience of pain (Decety & Lamm 2009). While
this could be expected for the hemisphere contralateral
to the stimulated body part, it is surprising for the ipsi-
lateral (right) hemisphere. The same meta-analysis also
shows overlapping, yet largely distinct activation pat-
terns in medial and anterior cingulate cortex (Morrison
& Downing 2007).
Singer et al (2004) extended an inter o c eptive model
of emotions to the domain of empathy and suggested
that cortical re-representations in anterior cingula of
bodily states could have a dual function. First, they
may allow us to create subjective representations of our
own feelings. These representations not only allow us
to understand our own feelings when emotional stim-
uli are present, but also to predict the bodily effects of
anticipated emotional stimuli to our bodies. Second,
they may serve as the visceral correlate of a prospective
simulation of how something may feel for others. This
can help us to understand the emotional significance of
a specific stimulus and its consequences. In accordance
with this hypothesis, it is noticeable that the expecta-
tion of pain has been found to activate more anterior
insular regions, whereas the actual experience of pain
recruits more posterior insular regions. This confirmed
the hypothetical role of more posterior insular regions
in modality specific, primary representations of pain
and more anterior regions in the secondary represen-
tations of the anticipatory negative emotion related to
pain (Ploghaus et al 1999). In consonance with these
observations, in pain empathy studies activity in pos-
terior insular cortices was observed only when people
were experiencing pain themselves, whereas activity in
anterior cingula was observed when participants were
experiencing pain themselves and when vicariously
feeling someone else’s pain (Singer et al 2004; Lamm
et al 2007). Last fMRI study observed substantial reac-
tions in anterior insula and anterior cingulate cortex
when participants were presented with visual stimuli
depicting situations that were clearly no painful for
them but known to be painful for the target (Lamm et
al 2010).
Most recent models of empathy accentuate the
importance of top-down control and contextual
appraisal for either the generation of an empathic
response or for modulating an existing one induced
by the above-mentioned bottom-up processes (deVi-
gnemont & Singer 2006; Decety & Lamm 2006).
Decety and Lamm (2006) proposed a model in which
bottom-up (i.e., direct matching between perception
and action) and top-down (i.e., regulation, contextual
appraisal, and control) information processes are fun-
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Empathy in cognitive behavioral therapy
damentally collaborated in the generation of empathy.
In their hypothesis, bottom up processes are respon-
sible for direct emotion sharing which is automatically
activated (unless inhibited) by perceptual input. On
the other end, executive functions implemented in the
prefrontal and cingulate cortex serve to regulate both
cognition and emotion through selective attention and
self-regulation. This meta-cognitive level is continu-
ously updated by bottom-up information, and in return
controls the lower level by providing top-down feed-
back. Thus, top-down regulation, through executive
functions, modulates lower levels and adds flexibility,
making the individual less dependent on external cues
(Hein & Singer 2008).
I
There is a growing body of process research suggest-
ing that therapists must customize their approaches
to clients (Lambert & Barley 2002). Another way to
conceptualization of these processes, influenced from
the research studies involves basic factors important
to outcome in all forms of psychotherapy: empathy, no
contingent positive regard, and therapist authenticity
(Rogers 1967; Traux 1963). The experienced therapist
listens to the words, watches the behaviour, engages
in and notices the ongoing interaction, allows him or
herself to experience his or her own inner reaction to
the process. The art is hearing the client’s inner experi-
ence and then addressing it empathically; enabling the
client to feel heard and affirmed. To know oneself is to
be aware that there are certain common human feel-
ings, fears, needs, wishes, and reactions. Every human
being must deal in some manner with authority, inti-
macy, selfish, dependence, values, love, hate, work, envy
and loss. It is unlikely that the therapist can understand
the client without his own self-awareness (Mohl 2008).
Therapist invites the client to collaborate as an active
informer. The interviewer may focus not only on the
facts of the client’s symptoms, problems and interac-
tions with others but also on the feelings, fantasies, and
thoughts with such relationships (Tab . 1) (Silberman et
al 2008).
Therapist who listen carefully and actively and con-
firm the client help also created a new level of under-
standing of client’s symptoms and story (Edelson 1993).
Helpful therapeutic listening requires a complicated
attitude toward control and power in the dialogue. If the
therapist can accurately perceive and share the client’s
expectancies, he/she is more likely to be able to make
sense out of client’s unproductive behaviours and to be
less judgmental about them (Beck et al 1979). Further-
more, the therapist can convey that he can share some
of the client’s distress. This expression helps the client
regard the therapist as understanding and facilitates
further disclosure of feelings and cognitions. These are
not necessarily new skills for experienced therapists,
but the client’s shoes perspective creates an enhanced
empathy and sensitivity for the client’s situation, which
results in a more careful approach to therapy, attuned
to the subtle nuances of situations (Bennett-Levy et al
2003).
The ways and tools of listening also change, accord-
ing to the purpose, the nature of the therapeutic dyad.
The ways of listening also change depending upon
whether of not the therapist is preoccupied or inat-
tentive. The development of common goals fosters the
therapist and client seeing them as having reciprocal
responsibilities (Tab . 2 ).
Many factors influence the ability to listening. Ther-
apists come to the client as the product of their own life
experiences (Prasko et al 2010; Prasko & Vyskocilova
2010). Although the word “transference” is not part of
the jargon of cognitive behavior therapy, examination
of the cognitions related to the therapist with respect to
past significant relationships is an integral part of the
assessment and treatment in cognitive behavior therapy
(Prasko & Vyskocilova 2010). As cognitive behavior
therapy supervisors, we often find that supervisees and
psychodynamic therapy therapist have the perception
that transference is not examined in cognitive behavior
therapy. In our opinion, this is false myth about cogni-
tive behavior therapy that has been identified by various
experts (Beck et al 1979; Persons 1989; Gluhoski 1994;
Beck 1995; Sudak et al 2003). The act of listening could
be influenced or blocked by similarities and differences
between the therapist and client. Sometimes thera-
Tab. 1. Feeling-oriented interventions in the interview (modified according Silberman et al 2008).
INTERVENTION EXAMPLES
Questions about feelings in specific
situations
• Some people might have been angry in the situation you told me about. Did you feel that way?
• How did you feel when your doctor told you that you had a heart attack?
• I’ve notice your voice got much quieter when you answered my last question. What were you
feeling just then?
Questions or comments about
emotional themes or patterns
• Growing up, you never felt like you measured to your mother’s expectation. Do you feel that
same way in your marriage?
Questions or comments about the
personal meaning of events
• You are concerned about becoming enraged at your daughter. When she disregards your
wishes, what do you feel that means about you as a parent.
78
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Jana Vyskocilova, Jan Prasko, Milos Slepecky
pists view clients as passive, manipulative and indeci-
sive. Therapist becomes frustrated, and the client feels
criticize. By trying to identify and correct the client´s
cognitive distortions which contribute to passivity or
lack of initiative, or oppositional, the therapist and
the client collaborate in trying to solve very problems
which contribute to their mutual frustrations. Positive
transference reactions may also impede the course of
therapy. The client may regard the therapist as a sav-
iour and exaggerate his/her positive attributes. Such
high expectations have to be discussed and the posi-
tive distortions pointed out. The therapist also must be
careful not to project his/her own attitudes or expecta-
tions onto the client and thereby to distort the client´s
report. On the other hand, an overreliance on empathy
may mislead the therapist into accepting the veridical-
ity of the client´s automatic negative representation of
himself and the world (Beck et al 1979). Developing a
cognitive behavior therapy case conceptualization of
clients is recommended for treating every client with
cognitive behavior therapy (Persons 1989); cognitive
behavior therapists examine the thoughts, feelings, and
behaviors related to a wide range of situations (includ-
ing reactions to the therapist) and relevant childhood
experiences to understand the underlying core beliefs
and conditional assumptions of each client. Beck argued
that the development and structure of a maladaptive
self-schema occurs in early childhood but remains dor-
mant until it is activated by negative life circumstances
(Beck et al 1979). Young (1990, 1999; Young et al 2003)
argued that the unique circumstances an individual
experiences in childhood contribute to the develop-
ment of a distinctive set of core beliefs about self and
others which he termed early maladaptive schemas.
Schemas have been defined in a number of ways, but
most definitions incorporate the idea that they consist
of both structure (i.e., an organizational component)
and content (Ingram et al 1998). According to Young et
al (2003), individuals with early maladaptive schemas
tend to also display maladaptive coping strategies that
may perpetuate their schemas which are also used in
therapeutic relationship. The children need for safety,
attention, acceptance and valuation, if no satisfied in
childhood, increase in the stress situations and typi-
cally is projected into therapeutic relationship (Dozois
et al 2009). Therapists discern meaning in that which
they hear through filters of their own life experiences,
nationality, sex roles, religion, class and unresolved
problems (Comas-Diaz & Jacobson 1991; Kleinman
2001). Filters can serve as blocks or magnifiers if some
elements of what is being said resonate within the thera-
pist (Mohl 2008). We speak about countertransference.
Many authors believe that it is important to underscore
that transference issues are examined carefully, in an
upfront fashion, in cognitive behavior therapy and
must be an integral component of the complete man-
Tab. 2. Supportive interventions (modified according Silberman et al 2008).
INTERVENTION EXAMPLES
Empathetic statements • When your boyfriend doesn´t call you, you feel completely helpless and unloved.
• It seems unfair for you to get sick so many times while others remain well.
Nonverbal communication • Smiling, firm handshake, attentive body posture, and gentle touch on shoulder.
Acknowledgement of affect • You look very sad when you talk about your brother.
• I have the impression that my question made you angry.
Reassurance • What are you telling me about may seem very strange to you, but many people have had
similar experiences.
• You feel like you will be sick forever, but with treatment you have a very good chance of feeling
better soon.
Encouragement • Client: I’m not sure I’m making any sense today doctor.
• Therapist: Your´re doing very well at describing the troubles you’re been having.
Approval • You did the right thing by coming in for an appointment.
• Your´ve been doing your best to keep going under very difficult circumstances.
Tab. 3. Blocks to effective listening in therapeutic or supervision
relationship (modify according Mohl 2008).
Therapist-client
dissimilarities
• religion
• gender
• age
• race
• culture
• nationality
• class
Similarities • may lead to incorrect assumptions of
shared meanings
Countertransference • therapist fails to hear, understand,
or react inappropriately to content
reminiscent of own unresolved
conflicts
External forces • managed care setting
• emergency department
• control-orient in client unit
Attitudes • need for control
• psychiatrist having a bad day
79
Act Nerv Super Rediviva Vol. 53 No. 2 2011
Empathy in cognitive behavioral therapy
agement of every client undergoing cognitive behavior
therapy (Tab . 3 ) (Sareen & Skakum 2005).
For instance gender can play an important role in
the experience of feeling found (with feeling of safety,
acceptance and positive appraisal) by the other person.
Some persons feels that it is easier to been open with a
person of the same sex, and other, with someone of the
opposite sex. In this period of significant change in sex
roles, a misinterpretation such as that early in treatment
could result in a permanent rupture in the therapeutic
relationship. Also therapists vary in their sensitivity to
the different gender.
Understanding of transference and countertransfer-
ence is crucial to effective listening (Prasko et al 2010).
Transference is the tendency the client has to see the
therapist as being like an important figure from his past
(Freud 1958). This process typically occurs outside cli-
ent’s conscious awareness; it is probably a basic means
used by the brain to make sense of current experience
by seeing the past in the present and limiting input
of new information (Ursano et al 2008). Recognizing
transference in the therapist-client relationship can aid
the therapist in understanding the client’s deeply held
expectations of shame, injury, help, or abandoned that
derive from childhood experiences. The therapist can
also superimpose the past on the present. Emotional,
vegetative, behavioral and cognitive reactions evoked
by a client may provide the therapist with some sense
of who the client is, how he/she related to other people,
what his/her internal world is about and what a rela-
tionship with this client may involve (Ivey 2006). Coun-
tertransference usually takes one of 2 types: concordant
countertransference, in which therapist empathizes with
the client’s position; or complementary one, in which
therapist empathizes with an important figure from the
client’s past (Ursano et al 2008). Paying close attention
to own therapist reactions while refraining from imme-
diate action can inform him in an experiential manner
about subtle aspects of the client’s behaviour that he
may overlook or not appreciate.
R
Experiential training and personal therapy have rich
traditions in most therapeutic schools as strategies to
enhance self-awareness and therapist skills. It can be
very helpful in developing the empathy skills. However,
personal experiential work has not traditionally been
part of cognitive behavioral therapy training. Bennett-
Levy et al (2003) describes the impact of personal
experiential work on cognitive behavioral skills in a
group of CBT practitioners. Fourteen cognitive thera-
pists undertook training courses utilizing a structured
approach to self-practice of CBT techniques, known
as self-practice/self-reflection. Six therapists from one
training group engaged in ‘‘co-therapy’’ sessions with
a partner, while eight therapists from another training
group practiced CBT techniques on their own. Follow-
up 1–5 months after the courses identified six areas of
self-reported skill enhancement: Refinement of specific
CT skills; Enriched communication of the conceptual
framework of CT; Increased attention to the therapeu-
tic relationship; Empathic attunement; Therapist self-
reflection; and Therapeutic flexibility. In the present
study, enhanced empathy was a common denominator
underpinning changes in a number of categories (e.g.
Empathic attunement, Communicating the conceptual
framework, Attention to the therapeutic relationship).
Davis et al (2008) reported that highly experienced
self-practice/self-reflection participants demonstrated
significant changes in personal and therapist beliefs, as
well as measurable gains in self-reported CBT skills and
empathy (Bennett-Levy et al 2009).
H
Teaching of listening is prominently emphasized in
cognitive behavioral training and supervisory programs
(Prasko et al 2011). Listening takes time, concentra-
tion, imagination, a sense of humor, and an attitude
that places the client as and expert and also hero of his
own life story. It is especially important to maintain a
posture of attentive listening when the client is talking
about emotionally intense of meaningful issues. The
therapist´s ability to empathize, to understand in feel-
ing terms every client’s subjective experience, is impor-
tant to the development of rapport. Our client may be
depressed, hopeless, lonely, isolated, demoralized, and
desperate, regardless of the specific diagnoses. Some of
them have lost themselves and their close relationships.
They can only be found within the context of their
own experiences, histories, genders, cultures, religions,
social class and other contexts. There are no many expe-
riences as healing as the experience of being found by
another person (Mohl 2008). The earliest formulation
of this need is in early childhood referred as need of
attachment. In non-professional words, it is often sub-
sumed under the need for security, acceptance (love),
and positive appraisal. Many of our clients have lost or
never had these experiences in their lives.
Schema therapy focuses directly on fulfilling the
client´s unmet emotional needs (Rafaeli et al 2011).
In Schema therapy Young et al (2003) stressed empa-
thizing of client’s underlying schema. He speaks about
“empathic confirmation” and “limited reparenting”. The
therapist reparents the client within the appropriate
boundaries of the therapeutic relationship; this is what
schema therapist called “limited reparenting”. Within
these boundaries, the therapist tries to satisfy many
of the client´s unmet needs. For instance, the client’s
anger is usually a sense of abandonment, deprivation or
abuse. The Angry and Impulsive Child is a response to
the unmet needs of the Abandonment Child. The goal
of the empathizing is to shift the client from the Angry
and Impulsive Child into the Abandoned Child mode,
80
Copyright © 2011 Activitas Nervosa Superior Rediviva ISSN 1337-933X (print), e-ISSN 1338-4015 (online) www.rediviva.sav.sk/
Jana Vyskocilova, Jan Prasko, Milos Slepecky
so the therapist can reparent the Abandoned Child
and remedy the source of the anger (Klosko & Young
2004). Schema therapy stress optimal balance between
support and acceptance with empathy on the one hand,
and reality testing and confrontation of the other.
E
Supervision that emphasizes one´s emotional reac-
tions to clients is important way to identifying this
distinction and achieves understanding of clients more
deeply. What has been said and heard after a session
and between sessions is the most powerful and active
tool of listening (Mohl 2008). It is important to hear
our clients in out thoughts during the in-between times
in order to pull together repetitive patterns of thinking,
feeling, and behaviour, giving the therapists the closer
picture of how clients experience themselves and their
world. It is important to distinguish this “relistening”
(which is important part of therapist´s processing of
what has been experienced with the client) from coun-
tertransference. Countertransference occurs in all types
more or less mixed with the therapist´s past but often
greatly influencing the therapist-client relationship. All
above is true in supervision. Therapist speaks about
his/her clients after session and between sessions. His
understanding the client is target of the supervision.
The empathy of supervisor to therapist´s work helps in
the supervision process. In CBT candidates are taught
to employ their awareness of their countertransferen-
tial reactions as a diagnostic and therapeutic tool. In
many aspects, the supervisor may also be an example
to the supervisee of how clients should be treated.
Therefore, the supervisor’s behaviour should include
examples and models required from the therapist, such
as respect, security, acceptance, empathy, encourage-
ment and appreciation, congruence, ability to view
hidden contracts and offer them metaphorically to the
therapist for consideration and other potential solu-
tions, straightforwardness and optimism towards other
people (Greben & Ruskin 1994).
Supervision of intensive psychotherapy treatment
cases in the context of stable supervisory relationships
has long been seen as a major vehicle for training in
countertransference (Rao et al 1997). The supervisory
alliance is establish through the process of contract
development and is strengthened with added trans-
parency through feedback, evaluation, and attention
to client outcomes (Falender & Shafranske 2008).
Transference/countertransference skills have tradi-
tionally been taught in the context of psychotherapy
supervision. During the course of supervision, there
will be times when strains and even ruptures to the
relationship develop. Supervisors are responsible for
establishing this alliance and identifying and repairing
tenseness and ruptures as well as for identifying and
managing transference and countertransference of the
supervisee and supervisor (Prasko & Vyskocilova 2010;
Prasko et al 2011). We use the term countertransfer-
ence here to refer to all of the therapist´s reactions to
the client, including those of which the physician may
not be aware and those which are unconscious trans-
ference reactions to the client’s transference (Rao et al
1997). Transference and countertransference become
accentuated in caregiving situations such as the ther-
apist-client (or doctor-client) relationship, and the
therapist needs to be aware of the deep feelings aroused
in such relationships, regardless of the client´s or cli-
ent’s physical or psychological pathology. Subjectively,
countertransference is experienced as variations in the
therapist´s feelings about himself or herself, the client,
and third parties, the understanding of which can lead
to increased insight into processes occurring in the
client and between therapist and client, regardless of
treatment modality. Countertransference may also be
manifest in a lack of feeling about or recognition of
events that the average therapist could be expected to
recognize and respond to. Countertransference that has
not become an object of the therapist´s awareness and
is not coped with successfully can lead to a spectrum
of difficulties resulting from a lack of understanding of
the client or from unconscious acting out. Transference
and countertransference reactions are ubiquitous in
any mode of psychological, counseling care or psychi-
atric treatment.
The best practices for supervision consist of cog-
nizance of the role of personal factors and diversity in
all aspects of therapy and supervision, management of
countertransference issues, and identification and use
of the parallel process. Parallel process indicate to the
dynamics of the therapeutic relationship stimulating
and being reflected within supervisory relationship, or
conversely, the dynamics of the supervisory relation-
ship being shown up in the therapeutic relationship
with the client (Falender & Shafranske 2008). Empathy
is the ability to partially identify with and put one´s self
in the other’s shoes; permits the therapist to focus on
the client´s needs despite the difficulties the therapist
may experience in the work. Also, empathic ability may
be part of sensitivity to one´s own feelings, including
countertransference feelings, which in turn ought to
prevent the acting out of countertransference (Rao et
al 1997; Gelso & Hayes 2002). We teach trainees how
to foster and use their open empathic reaction to assess
the way the client sees his or her disorder and problems
also relationship with the therapist and to use empa-
thy in the treatment. Empathy could help to recognize
countertransference (Rao et al 1997). Failure to address
countertransference may lead to alliance tension or
rupture in the therapeutic alliance and potentially in
supervision alliance.
The supervisory relationship must be established
before countertransference can be meaningfully
addressed and managed. Countertransference reactions
may involve either avoidance or inappropriate overin-
volvement, which serve self-protective and defensive
81
Act Nerv Super Rediviva Vol. 53 No. 2 2011
Empathy in cognitive behavioral therapy
functions and can be influence by culture and context
(Vargas et al 2008). Management of countertransfer-
ence is best accomplished on foundation of a well-
established supervisory alliance in which consideration
of personal factors has been routinely encouraged
(Shafranske & Falender 2008). Such a foundation can be
further enhanced by supervisor empathy and modelling
in which supervisors disclose examples of the counter-
transference issues they have faced when conducting
therapy. How supervisees address and manage counter-
transference reactions is more important than the fact
that such reactions occur. By providing the supervisee
a supportive and safe environment to identify, explore
a manage his/her personal reactions with empathetic
confrontation is the best way to organize understanding
and to reinstate a productive therapeutic alliance. Sub-
jectively, countertransference is experienced as varia-
tions in the therapist´s feelings about himself or herself,
the client, and third parties, the understanding of which
can lead to increased insight into processes occurring
in the client and between therapist and client (Rao et
al 1997). Countertransference may also be manifest in
a lack of feeling about or recognition of events that the
average therapist could be expected to recognize and
respond to. Countertransference that has not become
an object of the therapist´s awareness and is not coped
with successfully can lead to a spectrum of difficulties
resulting from a lack of understanding of the client or
from unconscious acting out. These difficulties include
treatment failure, liability suits, license revocation, and
client decompensation and suicide. Alonso and Rutan
(1988) identified processes in which shame and guilt in
psychotherapy supervision may block the knowledge of
countertransference. They show that a good opportu-
nity in dealing with shame and guilt is attention to the
parallel process, that is, to the supervisor’s and supervis-
ee’s unconscious development of conflicts in their rela-
tionship that are focal in the therapist-client dyad. The
supervisor can productively keep a “third ear” open for
parallel processes. The reduction of shame and guilt in
the supervisory relationship, using the parallel process,
should also have a salutary effect on the therapist´s abil-
ity to discuss countertransference issues with the super-
visor. The problems in supervision are also influence by
personal issues that blocked empathy. Supervisors with
anancastic traits often see their supervisees as irrespon-
sible, spoiled or lazy (Prasko & Vyskocilova 2010). They
believe that expressing emotions or insecurity may
be threatening or devastating. They have difficulties
expressing warmth and empathy for the supervisee and
put too much stress on “logic” and “rationality”. The
supervisees may feel that the supervisor uses supervi-
sion as an opportunity to show that he/she is brighter
than they are. The perfectionist supervisor may try to
compensate for his/her underlying feelings of a lack of
competence by demanding perfect performance from
himself/herself or the supervisee. On the other side the
“pleasing” therapist may be highly skilled in showing
empathy for the supervisee. He/she believes the super-
visee should feel good regardless of what is going on.
The therapist’s warmth and empathy are appreciated by
many supervisees because he/she never expresses nega-
tive emotions and does not confront with faults. The
problem is that such supervisor usually avoids ques-
tions on the suprevisee’s negative emotions.
C
As summary statements of client here-and now emo-
tional experience, empathic reflections are intended
to confirm the client´s experience by helping him/
her know more deeply what it is and to make it more
acceptable. The experienced therapist listens to the
words, follows the behaviour, engages in and notices the
ongoing interaction, what allows him/her to experience
inner reaction to the process. Empathy helps him/her
to understand both emotional reactions and the mean-
ings of experience for the client and helps him also to
understand how these elements are interconnected in
concrete case. It is important to hear our clients in out
thoughts during the in-between times in order to pull
together repetitive patterns of thinking, feeling, and
behaviour, giving the therapists the close picture of
how clients experience themselves and their world. The
children need for safety, attention, acceptance and valu-
ation. If the needs are not satisfied in childhood, they
can be increased in the stress situations and typically
are projected to therapeutic relationship. For effective
listening the understanding of transference and coun-
tertransference is crucial. Empathy is very important
tool for transference understanding and sharing in the
therapy. It is important to distinguish this “relistening”
(which is important part of therapist´s processing of
what has been experienced with the client) from coun-
tertransference. Psychotherapy training and supervi-
sion have been the venues for empathy learning.
A
This paper was supported by the research grants IGA
MZ ČR
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