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…)• …

Exercise n°1

Play your most difficult client

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 empathy

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.

Exercise n°5

Client’s past

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

Exercice n°6Client's journey to session

Improving Clinician’s empathy skills with ACT

Matthieu VILLATTE, PhD, Jean-Louis MONESTES, & Roger VILARDAGA

ACBS WORLD Con VIIIRENO