Empathy & Conscience

Those who aren't in touch w/their own feelings aren't likely to have a sense of conscience. They may feel no remorse, no guilt for causing harm to others.

About 1 person in 6 exhibits this pattern. Being so unaware of their own pain, is it possible that they could understand or empathize with what someone else may be feeling? Being unable to empathize, how can they live complete lives?

When we practice mindfulness, one of the qualities that we're developing is empathy. As we open to the full range of experiences within ourselves, we become aware of what we perceive in each moment, no longer denying some feelings while clinging to others.

By coming to know our own pain, we build a bridge to the pain of others, which enables us to step out of our self-absorption & offer help. And when we actually understand how it feels to suffer - in ourselves & in others - we're compelled to live in a way that creates as little harm as possible.

With empathy acting as a bridge to those around us, a true morality arises within. Knowing that someone will suffer if we perform a harmful action or say a hurtful word, we find we do these things less & less. It's a very simple, natural & heart-full response. Rather than seeing morality as a set of rules, we find a morality that is an uncontrived reluctance to cause suffering.

In Buddhist teachings, an image is used to reflect this quality of mind: a feather, held near a flame, instantly curls away from the heat. When our minds become imbued w/an understanding of how suffering feels & fills w/ a compassionate urge not to cause more of it, we naturally recoil from causing harm.

This happens w/out self-consciousness or self-righteousness; it happens as a natural expression of the heart. As Hannah Arendt said,

"Conscience is the one who greets you if & when you ever come home."

Two qualities are traditionally attributed to this beautiful & delicate sense of conscience that gives rise to harmlessness: in Pali they are known as biri & ottapab, traditionally translated as "moral shame" & "moral dread".

The translation is somewhat misleading, as these qualities have nothing to do w/ fear or shame in the self-deprecating sense. Rather, they have to do w/that natural & complete turning away from causing harm.

Ottapah, or moral dread, comes from a feeling of disquietude at the possibility of hurting ourselves or others. Hiri, moral shame, manifests in the form of a reluctance to cause pain in others because we know fully in ourselves how that feels.

In this sense, opening to our own suffering can be the source of our deep connection to others. We open to this pain, not for the sake of getting depressed, but for what it has to teach us: seeing things in a different way, having the courage not to harm, recognizing that we aren't alone & could never be alone.

Sometimes we're afraid to open to something painful because it seems as though it'll consume us. Yet the nature of mindfulness is that it's never overcome by whatever is the present object of awareness.

If we're mindful of a twisted or distorted state of mind, the mindfulness isn't twisted or distorted. Even the most painful state of mind or the most difficult feeling in the body doesn't ruin mindfulness. A true opening, born of mindfulness, is marked by spaciousness & grace.

The Importance of Empathic Parenting

By Jan Hunt, M.Sc.

Swiss therapist & author Alice Miller doesn't mince words: "Any person who abuses his children has himself been severely traumatized in his childhood... there's no reason for child abuse other than the repression of the abuse & confusion once suffered by the abuser himself."

How, then, does an abused child overcome painful experiences enough to give his own children more love than he himself was given?

Are such children, as they reach adulthood, doomed to repeat an endless cycle of anger, abuse & retaliation?

Or are there ways to stop the cycle & learn more empathic, responsive ways of treating children?

While every hurtful parent was himself hurt in childhood, repetition of this pattern isn't inevitable: some abused children grow up determined to give their own children the childhood they missed. My father, who was sometimes beaten & sometimes belittled, by his father, expressed it as the desire "to give my children a better life than I had."

But the apparent simplicity of this statement is an illusion. It actually encompasses 2 complex steps:

First, the parent must gain an awareness that he or she did indeed experience abuse in childhood. This is the most difficult step, because abusive experiences of childhood are so painful that we suppress them; they may thus become unavailable to us even when we feel ready to confront our emotional limitations.

As Dr. Miller explains, "Many people can scarcely remember the torments of their childhood because they've learned to regard them as a justified punishment for their own 'badness' & also because a child must repress painful events in order to survive."

However, it's not inevitable that every abused child become an abuser himself, "if, during childhood, he had the chance, be it only once, to encounter someone who offered him something other than pedagogy & cruelty: a teacher, an aunt, a neighbor, a sister, a brother.

It's only thru the experience of being loved & cherished that the child can ever discern cruelty as such, be aware of it & resist it." Awareness isn't enough, though, to stop the cycle of abuse.

The 2nd step toward this goal is that the parent must learn new ways of relating to children, ways that she may have seldom, or never, witnessed as a child herself. How can such a parent learn to treat her own children with dignity & respect?

Dr. Elliott Barker, Director of the Canadian Society for the Prevention of Child Abuse, recommends 4 critical steps which all prospective parents can take to raise emotionally healthy children, "no matter how inadequate their own past experience of nurturing has been":2

1. A positive birthing experience. As Dr. Barker explains, "If both parents are present at the birth & there's a positive birthing experience, the mother & father are very likely to fall in love with their baby ... the hard work of looking after their child feels much less like hard work; they're obsessed with how wonderful their baby is."

2. Extended breastfeeding. "Breastfeeding until the child no longer requires it is another of those things a mother can do which will cause other good things to happen... as if by magic. Breastfeeding keeps you in love with your child.

Extended breastfeeding can help the mother-infant attachment survive rough times which might otherwise lead to emotional unavailability & detachment."

3. Minimal separations & consistency of caregivers. According to pediatrician William Sears, only the parent "is perfectly attuned to the child's needs. Being away from him during stressful times deprives him of his most valuable support & also deprives you of a chance to further cement your friendship... Babies learn to accept unfulfilled needs, but at the cost of lowered self-esteem & the capacity to trust."3

4. Careful spacing of children. According to Dr. Barker, "it requires an enormous amount of time & energy on the part of both parents to adequately nurture one child under the age of 3.

Spacing children is one important thing that parents can do to prevent the exhaustion that occurs when well-intentioned parents take on the very difficult task of trying to meet the emotional needs of closely spaced children."

These 4 steps have a profound effect on the entire family. Not only do they establish the capacity to love & trust within the child, they also help the parents to heal from the pain of their own childhood.

By establishing a close bond of love & trust between parent & child, these steps can halt the cycle of abuse in one generation. Dr. Miller assures us that "It's absolutely impossible for someone who's grown up in an environment of honesty, respect & affection ever to feel driven to torment a weaker person...

He's learned very early on that it's right & proper to provide the small, helpless creature with protection & guidance; this knowledge, stored at that early stage in his mind & body, will remain effective for the rest of his life."

Such a child will grow up with a profound conviction that it's wrong to hurt another human being.

Unfortunately, many new parents are unaware of these 4 critical steps. Abusive parents, who have themselves never experienced unconditional love & trust, may find it difficult to learn new ways of relating to their children. What can be done for these families?

Dr. Miller believes that changes in legislation can force parents to "come to terms with their past" when "the child's no longer available as a legal scapegoat."

In Scandinavia, there are laws prohibiting child abuse, not only physical & sexual assault, but also spanking & bullying. These laws don't carry penalties; they're intended to raise public awareness of the legitimate needs & rights of children.

Will such legislation be effective, when all else has failed?

Dr. Miller believes that "every human being caught in a trap will search for a way out. And at heart he's glad & grateful if he's shown a way out that doesn't lead to guilt or to the destruction of his own children...

In most cases, parents aren't monsters, they're desperate children who must first learn to see reality & become aware of their responsibility."

Thru the loving treatment of children by those who interact with families, educational programs that emphasize the 4 steps of empathic parenting & new legislation, the relentless cycle of abuse can be stopped.

Fortunately, the capacity to love & trust, once established within a child, can transfer down thru the generations as readily as can mistrust & cruelty. Dr. Miller assures us that "It's quite simply not true that human beings must continue compulsively to injure their children...

The caring child: How to teach empathy
Approved by the BabyCenter Medical Advisory Board
                                   

By Mary VanClay

Empathy Not Just an Idea

Seeing loved ones in pain actually activates some of your brain's emotional circuitry, researchers say.

By Amanda Gardner
HealthDay Reporter

THURSDAY, Feb. 19 (HealthDayNews) It turns out that when Bill Clinton uttered those immortal words, "I feel your pain," he may well have.

Researchers in Britain have shown that feeling empathy for another person's pain actually does activate some, if not all, of the emotional circuitry in the human brain.

The findings appear in the Feb. 20 issue of Science, along with additional research showing, for the first time, that the placebo effect also involves changes in the brain.

"There have been doubts over the years about whether [the placebo effect] is a physiological reality or whether people are simply reporting the benefits of treatment because they want the physician to be pleased," says study co-author Dr. Kenneth L. Casey, a neurology consultant at Ann Arbor VA Health Care System in Michigan.

"We were able to demonstrate that the pain pathways in the brain show reduced activity during the placebo effect, which can be interpreted to mean that they are actually are experiencing less pain," he adds.

Both studies relied on advanced imaging technology to prove their points.

Empathy refers to the ability to feel what others feel & is part of the glue that holds together relationships & societies.

According to the study authors, empathy may have two evolutionary functions: to create attachments between mother & child & later between mates & to help people predict the actions of others.

Until now, however, there has been very little research into how the brain actually responds to empathy.

Tania Singer, lead author of the empathy study & her colleagues decided to use functional magnetic resonance imaging (fMRI) to look at the brain activity of volunteers who experienced a direct painful stimulus (electrode to the hand) & then observed a loved one experiencing the same painful stimulus.

Sixteen couples were asked to come to the lab. While the female partner lay in the scanner, her partner sat in a chair next to the scanner. Both had electrodes attached to their right hands, which delivered short painful or non-painful stimulation. Both partners could see their own electrodes & those on their partner.

The researchers were mainly interested in the differences in brain function when the woman was experiencing the pain directly & when she was witnessing her partner feel pain.

As it turned out, only part of the pain matrix was activated when feeling empathy for others. It appears the affective section was activated, while the sensory component was not.

Empathy was activated by an emotional cue, such as a facial expression & also by a less personal cue, such as an arrow indicating whether the pulse was painful or not.

"One question was whether this whole big network was involved & what we found is that it's only the emotionally affective section & not the sensory section," Singer says.

In other words, the partner feeling empathy didn't feel the actual bee sting of the electrode on the right hand (the sensory component). "That is about the source of the pain, where it comes from," Singer explains. "This information only lights up when you actually have pain."

They did, however, feel emotion at the sight of their partner in pain. "That is what we call the affective component," Singer says.

There were also different degrees of empathy, indicated by differing levels of brain activity. "Women who scored high on empathy questionnaires had higher brain activity in empathy-related areas," Singer says.

These findings open up many possibilities. Next, Singer plans to try to answer the question of whether people have any control over their empathy.

"This has implications for medical personnel or therapists who can't automatically feel the pain of others because they would be rushed at the end of the day," Singer says.

There are also implications for sociopaths & others who show particular cruelty towards groups of people.

While sociopaths may be "hard-wired" not to feel, other individuals may be inhibiting their empathy.

The new knowledge of the placebo effect may help researchers come up with new treatments for chronic or acute pain, the study authors say. It also reinforces the need for the physician to portray a treatment in a positive light. If the patient expects that it will work, he or she may then reap at least some benefit.

More information

The American Psychological Association has more on how concern for others develops. The American Pain Society has more on pain.

SOURCES: Tania Singer, Ph.D., researcher, Wellcome Department of Imaging Neuroscience, London; Kenneth L. Casey, M.D., neurology consultant, Ann Arbor VA Health Care System & professor, neurology & of molecular & integrative physiology, University of Michigan Medical School, Ann Arbor; Feb. 20, 2004, Science

Beyond Empathy: A Therapy of Contact-in-Relationship

 Richard G. Erskine

*Note: To facilitate the readers comprehension of this article all references to psychotherapists are in female gender language & all references to clients are in male gender language.

In Beyond Empathy: A Therapy of Contact-in-Relationship (Erskine, Moursund, & Trautmann, 1999), we've characterized the skills of inquiry & the qualities of attunement & involvement as central to effective psychotherapy. 

Empathy is the foundation for inquiry, attunement & involvement. Each of the three, however, goes "beyond empathy" in some way - or, at least, beyond the definitions of empathy that one finds in the general psychotherapy literature. 

It's likely that truly empathic therapists are also skilled inquirers, sensitively attuned to their clients & appropriately involved in the therapeutic process. If so, then attunement & inquiry & involvement aren't extensions of empathy so much as subdivisions:  aspects or facets of the overall empathic frame within which change & growth are nurtured.

Whichever they are, extensions or subdivisions, attunement & inquiry & involvement are central to the therapeutic process. To the degree that we can provide them, our therapy is likely to be more effective & satisfying to both our clients & ourselves.

As is true for nearly every other effort to describe or define some important aspect of psychotherapy, discussing attunement or inquiry or involvement alone requires an artificial & unrealistic teasing apart of what  is  essentially  indivisible. Inquiry  without  attunement  & involvement is sterile & inquisitorial; involvement & attunement without inquiry have no sense of direction or purpose. 

All three, moreover, are useful only when they're guided by therapeutic intent:  a committment that the client's growth & healing take priority over anything else that may happen in the therapy session.

Inquiry

Of all the things that therapists do, asking questions & listening to the answers is probably the most common. Questions are asked at all stages of therapy, from initial diagnosis to the final termination process. 

By "questions," we don't refer just to those sentences which end in a question mark; questions include any sort of intervention that requests the client to search internally to discover one's self. 

Replying with an "Oh?" or a "Hmmm," repeating what the client has just said, lifting an eyebrow or smiling encouragingly, even waiting patiently for what may come next - all of these are forms of inquiry.  Indeed, insofar as the essence of therapy is to help the client explore his internal world & re-establish contact with self & others, most of what we do as therapists can be seen as a kind of inquiry.

Asking questions is easy. Questions occur naturally in conversations between friends, in consultations with professionals, in the classroom & in the workplace. Children learn to ask questions as soon as they learn to talk, as anyone who has faced the endless "why" of a pre-schooler can tell you. 

Inquiring therapeutically, on the other hand, requires skill.  It requires, among other things, that we know - & remember - the purpose of our inquiry.  

Questions can be asked for a variety of reasons: 

• in order to provide the questioner with some information  ("Where do you keep the napkins?")
• to continue an argument ("Why won't you let me have the car tonight?")
• as an implied criticism ("Why are you watching TV when you have homework?")
• simply to demand attention ("What are you doing, Mommy?"). 

In a relationship-focused integrative psychotherapy, inquiry has but one purpose:  to assist the client in expanding his awareness, increasing internal & external contact & enhancing the sense of self-in-relationship.

If the purpose of inquiry is to expand the client's awareness, it follows that what the therapist may learn from the client's answer is secondary.  While we certainly listen to the answers to our questions (verbal & nonverbal) & learn from those answers, what the client learns is much more important. 

Part of the skill involved in therapeutic inquiry is that of getting out of the client's way, postponing our need to understand fully in order not to interrupt his process of discovery.  It also follows that the easily-answered question, the question to which the client already knows the answer, is generally less valuable than the question that requires him to search for a response. 

Clients don't learn much from stating what they already know; they learn by being challenged to discover something new or something that has been forgotten. Uncertainty & ambiguity stimulate people to learn more, to solve the problem & clarify what's happening. 

Questions that ask about what isn't yet known tend to invite the client into his areas of uncertainty & ambiguity & challenge him to explore those areas.  Well-executed inquiry is a spiral process, with each response leading to a new question & each question opening the door to a previously out-of-awareness response.

Characteristics of effective inquiry

The most basic characteristic of therapeutic inquiry is that of respect. The questions the therapist asks & the way in which she asks them, must be respectful - respectful of the client's needs, of his problem-solving efforts, of his internal wisdom. 

Her respect springs from what Rogers (1951) has termed "unconditional positive regard," a fundamental conviction that every client is doing & has done, the best he is capable of at any given moment. 

Without this kind of respect, inquiry is likely to turn into interrogation, the therapist becomes "she-who-knows-better" & the whole process can disintegrate into advice-giving or sermonizing. 

Respecting the client's wisdom & intentions, in contrast, leads to genuine interest & healthy curiosity about how the client experiences his world. Interest & curiosity, in turn, are vital in helping the therapist to frame the sorts of questions that will further the client's explorations.

Inquiry should be open-ended. The therapist's questions & her questioning behaviors, invite the client to search for answers; they do not restrict him or demand that the answer meet the therapist's expectations. Indeed, willingness to abandon expectations & let go of preconceived ideas is another hallmark of successful inquiry. 

Even though the therapist's theoretical training & clinical experience may lead her to expect a certain kind of answer (& may have suggested her question or comment in the first place), she's glad to be surprised. 

Getting a response that she didn't expect whets her curiosity, pops her out of the rut of the conventional, allows her as well as her client to discover something new. 

Neimeyer  (1995) recommends "a willingness to use the client's personal knowledge system, to see the problem & the world thru his or her eyes, though not necessarily to be encapsulated by it. To this is added ... a curiosity or fascination with the client's perspective & its implications." (p. 114) 

The therapist's theoretical & clinical expect provide a background for this fascination, but must not blind her to what the client is really telling her. Open-ended questions help to keep the therapist open to learning something new from the client, something not predicted by her past experience.

What does a therapist do when the client tells her something that she finds difficult to believe?  When he changes the subject, insists on telling long, rambling stories, or simply says "I don't know" & then waits? 

These sorts of behavior suggest that the client may be retreating into an old defensive system, rather than being honest with himself.  The first rule of good inquiry is:  don't argue. The therapist should never try to persuade the client that his answer is wrong.  How could it be "wrong" when it came from him? 

It's his response & the therapist's job is to help him understand it.  She may express curiosity, or confusion; she may ask him about what he means or what lies behind his response. 

"You surprised me; help me to understand how you came to that conclusion,"  "What happened inside, just before you said that?" "How is this story related to the problems you were talking about earlier?"

Inquiry grows out of a constant attention to contact. Its goal is contact-enhancement; all of the therapist's questions are designed to help the client establish & maintain contact of some sort. 

The focus at one point may be on his internal contact ("What are you experiencing?") or at another on his external contact ("Tell me what you're noticing & attending to right now"); often we deal with the contact between therapist & client ("What's it like for you to hear me say that?"). 

Contact leads to health & growth & lack of contact to fragmentation & constriction & shutting down. To the degree that our inquiry promotes the former & moves away from the latter, it'll be therapeutic.

Areas of inquiry

Attending to contact & remembering that her purpose is to enhance it, helps the therapist to construct & frame her inquiry. She must be careful, though, not to neglect one aspect of contact as she pursues another. Therapeutic inquiry is like a web, spun out of many strands; the therapist follow first this strand, then that, but eventually all must be woven into the pattern. 

Let's look, for a moment, at these strands. 

One of the most obvious strands is that of affect:  therapists are used to asking clients about their feelings, helping clients to explore & deepen their emotional responses. Many clients, though, are relatively closed to affect. They don't know what they're feeling; they've learned to disavow or close off their awareness of painful emotions & don't know how to open those doors. 

For such clients, inquiring about physical sensations & reactions can be useful. The therapist can invite her client to be aware of his body & of what his body is doing.

• Is he breathing shallowly & what does that shallow breathing feel like? 
• Is he aware of a swinging foot or a balled fist? 

Simply noticing & talking about, physical experiences is a first step toward increased contact with self.

Cognition is another natural area of inquiry.  What is the client thinking? What are those thoughts connected to & how does he get from one thought to another? 

What is he remembering?  What decisions is he making & how is he making them? Thoughts & memories & decisions (past & present) often weave back into affect, just as affect can take him into thinking & remembering.

Inquiry about fantasies provides another window into the client's phenomenological world. Fantasies involve thinking, feeling, sensation. They're not only the client's daydreams & night dreams; they also include the client's hopes & fears & expectations. 

They're his imaginings about what has happened in the past & about what's yet to come. Because they're built upon past experience, experience that has often been blocked from awareness, they can help him re-connect with himself, with long-buried thoughts & feelings. 

Fantasies & expectations determine the way in which he makes & maintains relationships with others & they shape the therapeutic relationship as well. Clients use fantasy to transform painful internal experiencing into that which can be born; to provide substitute gratification of needs that can't be met in reality; to manage behaviors that they fear may run out of control. 

It's a rich vein of information & mining it can lead to rich rewards.

Inquiry is a basis for forming a therapeutic relationship. The experience of being in a relationship that is qualitatively different from past, script-forming relationships is a key factor in dissolving that script. The impact of this relationship experience is heightened when inquiry is used to call attention to it. 

Questions like "What are you wanting from me right now?" or "How do you feel about what I just said?" or "What do you think my response would be if you told me the whole story?" invite the client to explore his reactions to what the therapist is offering. 

Is he defending against a level of contact that would be too threatening?  He & the therapist can talk about the threat & the means of defense as well. Does he disagree, disbelieve, or discount what the therapist says? 

The therapist asks about his disagreement or disbelief or discounting. She's open to the client's criticism, cares about his disbelief, is interested in the ways in which he supports the discount.  She's also interested in how the client experiences her support & concern. She asks about it all.

As the therapist improves her inquiry skills, learns to gather up the various strands of experiencing & help the client to explore their interrelationships, she's guided by attunement. She notices the client's rhythms, his thinking & feeling, his developmental level, his moment-to-moment relational needs; & what she notices directs what she asks about & how she does the asking. 

But there's another element at work here. Therapists aren't simply skilled machines, taking in information & forming interventions.  The therapeutic process is a relationship, formed in the in-between of two living, thinking, feeling human beings. 

Attunement

Attunement involves sensitizing oneself to the client and responding accordingly. Kohut (1977) defined empathy, as a kind of "vicarious introspection," in which the therapist understands the client by finding something akin to the client's responses within himself. 

Attunement involves using both conscious and out-of-awareness synchronizing of therapist and client process, so that the therapist's interventions fit the ongoing, moment-to-moment needs and processes of the client. It's more than simply feeling what the client feels: 

it includes recognizing the client's experience and moving - cognitively, affectively and physically - so as to complement that experience in a contact-enhancing way (Erskine & Moursund, 1988/1998).

In this sense, attunement isn't a subdivision of empathy but does extend the concept: 

Attunement goes beyond empathy: it's a process of communion and unity of interpersonal contact. It's a two-part process that begins with empathy - being sensitive to and identifying with the other person's sensations, needs, or feelings; and includes the communication of that sensitivity to the other person. 

More than just understanding or vicarious introspection, attunement is a kinesthetic and emotional sensing of the other - knowing their rhythm, affect and experience by metaphorically being in their skin and going beyond empathy to create a two-person experience of unbroken feeling connectedness by providing an reciprocal affect &/or resonating response. (Erskine, 1998a, p. 236)

The attuned therapist leads by following. Her interventions often feel, to the client, more like confirmations than questions:

they direct his attention to what he is ready to know but hasn't yet quite realized.

She anticipates and observes the effects of her behavior on the client; she decenters from her own experience in order to focus on the client's process. Yet she also is aware of her own internal responses, her thoughts and feelings and associations. 

She's "multi-tasking," simultaneously following both the client and herself, as well as noting the intricate interactions between self and other. And she communicates this synchrony: 

• with body language and voice tone as much as (or more than) with words
• she weaves a fabric of understanding and concern
• at the same time conveys her belief in the client's ability to grow and change 

"I know where you are," she seems to be saying" and we'll travel from there together." 

To the degree that the therapist is attuned to the client and conveys that attunement, the client feels respected. "This therapist not only understands me - she's really with me! Maybe the things I'm thinking / feeling / doing / wanting aren't so hopeless after all." 

Attunement conveys interest, as well: 

one of the ways we know if someone is interested in us is by their interest and understanding and involvement, their close attention to our story and their acknowledgment of our needs and wants.

Respect and interest, in turn, create a climate of safety. The therapist who respects me won't turn on me, laugh at me, be disgusted by me. She's interested enough to take the time and make the effort to understand, all the way through, what I'm trying to say; she won't leap to the wrong conclusions and steer me in a wrong direction. 

It's okay to be here, okay to be who I am, okay to (maybe, just a little) let the defenses down and peek at the things I really haven't wanted to see.

A client who feels respected and secure in the presence of his therapist can get on with the primary aim of therapy: 

• reclaiming that which has been closed off
• healing that which has been fragmented
• making both internal and external contact where contact has been interrupted

Attunement reaches beyond the client's concern with an immediate problem, down into the hopes and fears and beliefs that keep the problem from being fully solved. Attunement encourages the client to come to grips with those deep hopes and fears and beliefs, to explore them and update them in the light of more recent learnings.

And attunement provides a constant invitation to contact, a gentle but firm and dependable "I'm here" when the client is feeling overwhelmed and hopeless.

One last benefit of attunement:  when the therapist does get it wrong and makes that inevitable error, her previous level of attunement will ease the process of re-synchronizing and re-establishing a climate of trust. 

The general level of attunement sensitizes the therapist to the client's reaction to having been missed and allows her to catch her error quickly, acknowledge it and request clarification. 

Acknowledging and apologizing for an error are usually, in fact, another demonstration of attunement; when the therapist goes off the track, what the client most needs and wants is that the therapist admit it, apologize and re-establish contact. (Giustalise, 1997)

Attunement comes in many varieties, for there are many aspects of the client's experience with which to be in tune. Let us attend particularly to 5 areas of attunement: 

• affective
• cognitive
• developmental
• rhythmic
• relational (i.e., attunement to relational needs)

Affective attunement

Most therapists are trained to be aware of & even encourage, clients' affect. 

We learn to be comfortable with our clients' tears, anger, fear & joy. We help clients to deepen their affect (or heighten it, depending on whose vocabulary is being used) & to access emotional responses that they had previously closed off & hidden from others & even from themselves. 

The therapist's ability to respond empathically helps clients to do this affective work. We've talked a lot about empathy already - so what does affective attunement add?

In an empathetic response, the therapist feels what the client is feeling. She metaphorically crawls inside the client's skin & shares the client's affective experience. The affectively attuned therapist goes beyond empathy, meeting the client's affect with her own personal & genuine affective response. (Erskine, Moursund & Trautmann, 1999) 

Moreover, affective attunement requires that the therapist attend not only to the emotion itself, but also to the message being sent by the emotional display. Emotion is a two-person phenomenon; it's a way of communicating with others who are present physically or in fantasy. 

Attunement - being in resonance with the client - allows us to distinguish between, i.e., tears that plead "please take care of me & make things better" & tears that say "I'm ashamed to be so upset about this," & to respond appropriately.

An attuned response, by the way, is really a 3-stage phenomenon -- although the stages may follow each other so rapidly that they're difficult to distinguish. The first stage of an attuned response is that of noticing, recognizing & empathizing with the client's affect:  the client's eyes fill with tears, i.e. & the therapist recognizes & sympathizes with the client's sadness. 

The second stage involves the therapist's internal reaction: perhaps first one of vicariously feeling the client's emotion, or a less intense echo of it & then moving to her uniquely personal response to that emotion. Recognizing that the client is sad, the therapist finds herself feeling compassionate, wishing she could make things better & at the same time glad that the client's sadness is finally breaking thru the defensive barrier that has kept him stuck & miserable for so long. 

Finally, the third stage of the therapist's response is what she communicates to the client. She may simply reflect that the client looks sad, or she may share some of her own feelings - or she may simply wait quietly, or hold out her hand in a gesture of comfort.

Affective attunement is achieved in a variety of ways. The first of these is simply attending to the cues that signal an emotional response in our clients. It's easy to get so caught up in the content of the client's story, or in our eagerness to find a solution to his problem, that we fail to notice the tiny facial, gestural, or voice tone changes that often accompany a feeling response. 

It's equally easy to attend just to the display of affect & ignore the message that the emotion is sending. When we make either of these errors, the usual result is that the affect goes underground:  the client either decides that it was inappropriate (because we didn't validate it), or that the therapist is insensitive & therefore not safe to be emotionally vulnerable with.  Not only is the current opportunity lost, but the therapist may have to prove herself all over again before regaining the client's trust.

Lee (1998) has suggested that emotional tuning in between two individuals involves one person unconsciously imitating the other's facial expression & in so doing setting up a similar affective response in himself. 

Affectively attuned therapists probably do some of this sort of unconscious imitation, but the imitation quickly gives way to a more authentic & personal response to what has been sensed in the client. Tuning in to oneself is as important as tuning in to the client; internal contact combines with external contact to take affective attunement an important step beyond empathy.

Some internal responses to someone else's feelings, of course, may not be therapeutic. Partners who become enraged at each other, or parents who are either over-critical or over-protective of their children, may be observing the other person's emotion quite accurately & responding to it quite authentically - & hurting the other person in doing so. 

In order for affective attunement to be therapeutically useful, it must be combined with therapeutic intent & with clinical competence. Therapeutic intent keeps us focused on the client's welfare & competence helps us to understand what sorts of things the client may need from us at any given moment & how to create a response to that need. 

Together, therapeutic intent & clinical competence provide a framework for our internal response to the client, ensuring (in most cases) that that response will be helpful - or at least not destructive.

Each general class of affect seems to call for a certain kind of reciprocal response, whether the responder be a therapist or someone else in close relationship to the "sender" of the emotional message.

Sadness, i.e., requires compassion - not a gushy, "oh you poor thing" sort of sympathy, but a genuine sorrow that the other person is in pain. Anger involves a request to be taken seriously:  the attuned therapist will attend, will be respectful, will not make light of or try to diffuse or explain things away. 

Anger is a serious thing & in order to take it seriously the therapist must see the world from the perspective of the angry client & allow herself to be impacted by his anger. It isn't necessary that she too feel angry, but it's certainly unhelpful (& relationally destructive) to be amused by or frightened of what the client is experiencing.

The most appropriately attuned therapeutic response to a client's fear is a sense of protectiveness. This doesn't mean that the therapist acts so as to protect the client - in most cases, such behavior would get in the way of the client's working thru his fear - but rather that the impulse to protect is stirred in her. 

The impulse to protect stems from the therapist's sensitivity to the nuances of the client's feelings. Taking those feelings seriously, she is roused to activate her clinical skills, to figure out what sort of intervention will be most useful in helping the client deal with his fear; her efforts also convey to him that she is contact-available, that she has received & is responding to his message.

We've talked about the 3 most common uncomfortable affects - what about the pleasant ones?  How do we appropriately attune ourselves to a client's feelings of happiness, joy, triumph? 

Here the answer is simple: share them. Feel the joy ourselves - but slightly less intensely than the client does. It's the client's joy, not ours; the client leads & we follow (Erskine, 1998b).

Cognitive attunement 

Humans are thinking creatures.  How we experience our world is largely determined by how we think about it, by what meanings we make of it.  A given event can be experienced as amusing, frightening, boring, or exciting - watch people emerging from a carnival "fun house" & you'll see variants of all of those reactions. 

Our emotions do affect how we think, to be sure, but equally strong is the effect of our thoughts on how we feel.  Cognitions, says Lee, interact with affects so as to magnify or attenuate the affective processes. (1998, p. 145). 

We can talk ourselves out of experiencing a strong emotion ("I just won't think about it; it really isn't so bad; I'll feel better in the morning") or, as Ellis & the rational-emotive therapists (Ellis, 1997) are fond of pointing out, we can "awfulize" a situation & make ourselves feel intensely bad about it.

Cognitive attunment involves understanding & temporarily borrowing the process by which a client makes meaning - not only as those meanings affect his emotions, but as they affect his whole way of making internal & external contact.  How does he "sort out" his world?  How clearly does he distinguish between his various perceptions, suppositions & memories? 

How does he go about solving problems - or avoiding them?  What are the rules that determine what he allows himself to think about, and what is forbidden ground?  In Beyond Empathy: A Therapy of Contact-in-Relationship (Erskine, Moursund & Trautmann, 1999), we  described cognitive attunement in this way:

Cognitive attunment is more than simply attending to content. It's not the same as "understanding the client's cognitions" because it goes beyond simple understanding. It involves attending to the client's logic, to the process of stringing ideas together, to the kinds of reasoning that the client uses in order to create meaning out of raw experience. 

It's about what the client is thinking; but more importantly, about how the client is thinking it. As we attune to the client's cognitions, we enter the client's cognitive space, moving into a kind of resonance with the client & using our own thoughts & responses as a sounding board to amplify the tiny cues that the client is giving. 

We bring the client's words & nonverbal expressions into ourselves; take on their meanings, implications, connections; experience this way of thinking ourselves in a kind of internal "as if." (p. 54)

Just as affective attunement requires a kind of alternation between attending to the client's affect & attending to our own affective response, so cognitive attunement requires that we alternate between the client's way of thinking & our own. We adopt the client's thought process, as closely as we are able, in order to see the world through his eyes, experience its events as he does, discover what it is like to live with his blind spots & his defenses. 

But we can't allow ourselves to stay in that place; it's the contrast between his cognitive process & our own that allows us to note those distortions & defenses. Without such a contrast, we would be as blind to his process as he is & as unable to imagine any other way of thinking. 

We move back & forth, thinking about the client's frame of reference, then thinking within that frame of reference, then thinking about what it was like to be within it.

Because we are attuned to the client's cognitive process, we can better understand & respond to what he is trying to tell us. Indeed, sometimes we will understand even before he spells it out: thinking in the same way, we often know where he is going & what conclusions he may reach. 

With the trust & the sense of safety that comes from being understood in this way, the client is increasingly open to pushing the boundaries, both by exploring new areas on his own & thru our invitations & suggestions that he review a memory, consider a possibility, examine an interaction. 

Sometimes, of course, we will be wrong.  Cognitive attunement can never be perfect; we can never fully enter into another person's stream of thought. We must constantly remind ourselves that our understanding of the client's cognitive world is a hypothesis, not a fact & that our trying on of his meaning-making process is an experiment that requires validation from the client himself before it can be fully trusted. 

If we do get it wrong, the most important thing we can do is acknowledge our error & ask the client to help us get back on track.  Sometimes these sorts of error-&-correction sequences are extraordinarily helpful:  they signal the therapist's willingness to respect the client's wisdom & to admit her own fallibility & they invite the client into a process of shared exploration in which he & the therapist each make a uniquely valuable contribution (Giustalese, 1997).

Developmental attunement 

"In all therapies, including psychoanalysis & psychodrama," write James & Goulding (1998), "regression occurs whether it's planned by the therapist or client or whether it's spontaneous." (p.16) 

Regression has been defined in a variety of ways; for our purposes we shall define it as a return to patterns of thinking, feeling, &/or behaving that were present for the client at an earlier time in his life. 

It occurs not only in psychotherapy, but in daily life: whenever we find ourselves responding as we did in a previous developmental period, we have regressed. Regression is a common phenomenon; it occurs most often under stress but may also be observed during states of childlike joy or excitement.

Psychotherapeutically, regression is of therapeutic interest when it represents a fallback to old patterns of dealing with the world, patterns which were learned earlier in life & remain available to us when our current strategies aren't working. 

The therapist may invite a client to regress ("take yourself back to a time when...") in order to facilitate discovering what those old patterns are & how they relate to the client's current difficulties. 

Other therapeutic regressions may be spontaneous, a response to the "safe emergency" (Perls, 1973) of the therapy session. The client may be aware that he has regressed & indeed be actively cooperating in achieving & maintaining the regression, or  may be quite unaware of it. 

In either case, it's important that the therapist be attuned to the level of regression & respond accordingly. We refer to this sort of attunement as "developmental attunement" because it requires sensitivity to the developmental level to which the client has returned, cognitively or emotionally or behaviorally.

Depending upon one's theory of psychotherapy, regression may be seen as useful, as irrelevant, or as an impediment to achieving the client's goals. Therapists who take a strict behavioral or cognitive-behavioral position are likely to discourage regression, seeing it as interfering with the client's ability to evaluate, problem-solve & follow thru on a plan for change. 

Others, more psychodynamically oriented, believe that regression is useful in that it allows clients to access defended memories & experience otherwise forbidden affect. We believe that the value of regression depends upon when & how it occurs & how the therapist chooses to use it. 

Contact is the key here: a regression in which contact between client & therapist is lost (usually because the therapist is still responding to a here-&-now adult client, rather than to a psychologically younger person), is likely to interfere with the therapeutic process. 

In contrast, the client who experiences the therapist's contactfulness throughout a regression is likely to feel deeply understood. Developmental attunement helps us to maintain contact with a regressed client & either invite him back to a more here-&-now appropriate level of functioning or support his continuing regressive experience.

Recognizing that a client has regressed & identifying the level to which that regression has taken him, is essential for maintaining contact. Using adult language with & expecting adult responses from someone who is experiencing the world the way a 4- or 8- or 12-year-old does, isn't likely to enhance the client's sense of connectedness or trust. 

Children, like adults, yearn to be understood; the phenomenological child that is the product of a client's regression wants to be seen & heard & respected, not ignored or missed altogether. How, then, can we recognize & identify a client's level of regression? How can we keep ourselves developmentally attuned?

Obviously, in order to attune oneself to a client's developmental level, one must have a sense of what that level is.  Eric Berne (1961) has suggested 4 ways in which a therapist can assess the client's developmental level of functioning. 

The first of these is the client's own phenomenology. We may ask the client how old he is feeling at this moment, or the client may spontaneously report a regression: "I feel like a five-year-old," or "I'm scared, just like when my Dad used to come home drunk." 

A second aid to identifying regression & maintaining developmental attunement is the therapist's awareness of the client's unique developmental history. If we know that the client was raped when he was in high school, or that he was sent to live with his grandmother when he was 10 years old, it can help us to interpret the meaning of verbal & nonverbal communications & of the developmental level from which they spring. 

We can also call upon our general understanding of child development to relate the client's current behavior to behaviors typical of a younger stage or - & it behooves us to have a good knowledge of the typical stages & phases thru which young children move. 

This is particularly important when the client is regressing to a relatively early stage of life & his ability (& desire) to communicate verbally may be limited.

Probably the most important set of guidelines, though, comes from our own intuitive, emotional response to the client's behavior.  How old does the client feel to us?  What sort of younger person seems to be looking out of his eyes?  If we put to one side the adult body in front of us, what seems to be the most natural way of responding to what he is doing & saying? 

We are often able to pick up tiny cues, cues of which we are consciously unaware, from the nonverbal behavior of our clients; such cues can aggregate out of our awareness & make themselves known as a general hunch about how to respond most effectively. 

Spending time with children, learning to interact with them at their level & sensitizing oneself to one's own reactions to them, is a good way to hone one's ability to attune in this way.

Developmental attunement, if it's to be useful, must be communicated. You may know that your client is, at this moment, seeing the world & responding to it as he did when he was a toddler; but this knowledge will be of little use unless the client feels your understanding & your support. 

At the same time, the client also needs to know that you're aware of the adult, here-&-now self who is also participating in the process.  Maintaining attunement with a regressed client requires a kind of therapeutic "double vision," an ability to recognize & acknowledge both the regressed-to-childhood (or adolescence, or young adulthood) person & the self-observing adult. 

Both are present, both require contact & both play an important part in the client's growth.

One of the most potent ways to maintain developmental attunement is to use the client's own language & language patterns. As he regresses, his vocabulary is likely to shift too - the developmentally attuned therapist shifts with him. If the therapist senses that the client is moving into the psychological world of a 6-year-old, she talks to him as she would to a 6-year-old. 

Her own body language is keyed to his: not imitating it, but responding to it as an adult responds physically to a child. The therapist can facilitate a client's regression by encouraging childlike gestures & movements; conversely, she can invite him out of the regression by requesting that he assume a more adult posture & by using adult language & phrasing in her responses to him.

We've found, over years of working with clients, that therapeutic regression is a powerful tool in enhancing contact with self & eventually, with others as well. It's useful in overcoming the unconscious defenses which prevent full awareness of thoughts & feelings & memories. 

Developmental attunement is the single most vital factor in developing & therapeutically facilitating a client's regression.  Without developmental attunement, regressions are likely to be short-lived & therapeutically sterile; with it, they can lead to the corrective emotional experience that lies at the heart of a relationship-focused integrative psychotherapy.

Rhythmic attunement 

In a sense, it's odd to give rhythmic attunement a special section of its own, since attuning to the client's rhythm is an essential aspect of cognitive, affective & developmental attunement. When we're out of synch with the client's rhythm & timing, he'll not experience us as being attuned in any other way. 

But there are some particularly interesting aspects of rhythmic attunement & dealing with it as a separate topic is one way to make sure we remain sensitive to those aspects.

The term, "rhythmic attunement," really defines itself:  being sensitive to & responding within the client's rhythmic patterns.  Rhythm is one of the primary ways in which people, out of awareness, assess the quality of their contact with each other. 

When two people are rhythmically attuned, their transactions mesh together easily.  Their silences are comfortable; there is no competition for who will speak when.  Even when they interrupt each other, it's as if one of them is stimulated by the other's thought & the interruption doesn't jar or derail their process. 

In contrast, when they're not attuned rhythmically, their conversation is jerky & their silences strained.  Neither is likely to feel at ease with the other, though they often can't explain their discomfort.

In ordinary conversations, each person is responsible for adapting to the other's rhythm, maintaining a pacing & style that's comfortable for both.  In therapy, the primary responsibility for attunement falls to the therapist.  The therapist must attune to the client, not the other way around; expecting the client to match the therapist's  rhythm will force him into an artificial way of speaking and thinking & feeling that will interefere with his work. 

Tuning in to & matching a client's rhythm requires, first, that the therapist attend to that rhythm & how it may differ from her own.  Does he use long pauses to collect his thoughts & is the therapist impatient with those pauses? 

Or does he jump from idea to idea, illustrating his words with quick gestures & appearing uneasy if the therapist speaks slowly or has to search for words?

It's relatively easy (at least in theory) to slow oneself down in order to attune to the rhythm of a client who is processing his experience more slowly than we ordinarily do. Speeding oneself up to match a rhythmically rapid client is more difficult:  how can a therapist think and feel faster, without losing important information? 

Rather than try to push herself to keep up & risk distorting or disrupting contact with herself &/or the client, it's best for the therapist to acknowledge the differences & openly request time to digest what the client has been telling her:  

"You are moving through these ideas very quickly & I don't want to miss anything.  Give me a moment to think about what you've been telling me..."

While each person does develop his or her own unique rhythm, there are some general rhythmic patterns which seem to hold for nearly everyone. Most of these involve slowing down, rather than speeding up. 

A major goal of therapy is to attend to what has been overlooked, to explore what has been defended against & this generally requires that we move more slowly than usual; indeed, racing along from one association to the next is a way to not notice things & not feel one's feelings. 

One of the paradoxes of our work is that slowing down is likely to speed up the therapeutic process, while going too fast is likely to slow the client's overall progress.

Affective work, in general, proceeds at a slower pace than cognitive work. It isn't that we experience emotions more slowly than we think -- quite the contrary; emotions spring up quickly & can shift & move with lightning speed.  

A loud, unexpected noise can create an immediate startle-scare feeling; it takes no time at all to experience tenderness & love when we look at our infant grandchild; but putting those feelings into words can be a slow & laborious process. 

Talking about feelings requires translation, from a global, wordless experience, mediated primarily through body chemistry, to a linear, verbal process. Moreover, many clients have trained themselves not to attend to their feelings & they accomplish this by rushing past them, moving on to a new thought. 

Giving such clients permission to slow down, so that they can feel & think & talk about their internal experience, will further their ability to make & maintain full contact with themselves & with others.

Developmental level -- regression -- also affects one's rhythm & developmentally attuned therapists recognize that as clients move to younger & younger psychological levels, their rhythms tend to slow.  Indeed, a slowing of rhythm may be a major indicator that the client is regressing. 

Just as we tend to talk more slowly to a young child, the therapist needs to attune herself to the slower rhythm of the client who is at this moment experiencing the world from a younger, less verbally sophisticated place.

It's easier to review what we already know than to explore what is unknown; clients who exhibit a quite rapid pace when sharing well-rehearsed material are likely to slow down as they begin to explore new thoughts & previously walled-off emotions. 

Like someone feeling their way around a dark & unfamiliar (& often frightening) room, they need to take time to find out what is there, to examine it fully. They need time to integrate the new with the old, to figure out how their discoveries fit with the familiar & comfortable parts of themselves that they've known about all along.

For all of these reasons, errors in rhythmic attunement are much more likely to involve going too fast rather than going too slowly.  As therapists, we pride ourselves on being quick to understand, being good at putting things together; we've been rewarded throughout our schooling for coming up with right answers quickly. Now we need to put that skill to one side, slow ourselves down, slip gently into the client's rhythm of speaking & moving. 

When we do so, the client is likely to feel joined, met, in contact.  Our matched rhythms will create a sense of moving together; the need for lengthy explanations will decrease; the client will feel protected by our willingness to be together in his way.

Rhythmic attunement extends beyond the sort of transaction-by-transaction rhythms that we have been discussing.  People differ in the length of time they are comfortable in spending on one topic, one idea, before moving on to the next.  They differ in the amount of "warm up" time they need at the beginning of a session before moving into full contact with themselves & with the therapist. 

There are even differences in rhythm over much longer periods of time:  clients often differ in the length of time they need between sessions to process their work.  Some do best with shorter sessions, more frequently spaced; others prefer longer sessions at greater intervals. 

The weekly, 50-minute session is convenient for the therapist, but it may not match the client's rhythm. (Efron, Lukins & Lukins, 1990) If a client would benefit by changing the length or frequency of his sessions, it is advisable to do so; when such changes are not possible, one can at least acknowledge his need.  If the therapist lets the client know that she recognize his preferred rhythm & shares her reasons for not adapting to that preference, the absence of attunement here will be less jarring.

As we said at the beginning of this section, rhythmic attunement flows thru all of the other aspects of attunement.  In order for the client to experience cognitive or developmental or affective attunement, the therapist must be operating within that client's rhythm -- his rhythm is a part of his cognition, his affect, his developmental level.

Verbal & nonverbal messages sent by the therapist are like the instrumental voices of a symphony. When one or more of those voices is off tempo, the whole performance sounds wrong. 

Moreover, just as we respond to one piece of music or another depending on the state or mood we find ourselves in, so the client will respond differently to different therapist "symphonies" depending on his or her own state -- dealing with affect or cognition, regressed or not, energized or fatigued & so on. 

It's no accident that a musical metaphor like this fits with the notion of "attunement." Hearing all of the nuances of the client's melody & rhythm & responding from & with the harmony of one's whole therapeutic orchestra, verbally & nonverbally, is what attunement is all about. (Erskine, Moursund & Trautmann, 1999)

Attunement to relational needs

Relational needs:  those needs that arise in the context of a relationship.  When I need something from you, some particular kind of response or behavior, I am experiencing a relational need.  Not surprisingly, clients have relational needs in therapy, needs to which they want their therapist to respond.  Some of these needs can be met by the therapist & some can -- or should -- not.  Whether or not the therapist chooses to meet her client's relational need, she must still acknowledge & respect it; to do so, she must be attuned to the way in which those needs come up for & are expressed by the client.

Therapists, too, of course, experience relational needs & sometimes we find ourselves needing/wanting something from our clients.  If we didn't, our relationship would be sterile & superficial:  choosing to be contactful & real in our therapeutic relationships guarantees that we will sometimes have feelings about our clients, emotional reactions to them & will want them to think & feel & behave toward us in certain ways. 

However, being attuned to & responding appropriately to their relational needs will often require that we put our own wants & needs to one side.  Calaghan, Naugle & Folette (1996) warn us that even when the therapist is expressing appropriate feelings, the client may misunderstand or misinterpret what is said.

"Therapists must be able to express their reactions & feelings in their interactions with clients while being sensitive to how this impacts the individual clients with whom they work." (p. 387) 

Attuning to the client's view of us, being sensitive to what he is needing from us at a given moment, helps us to make sound decisions about sharing our own inner experience.

The client's needs come first.  If sharing her own feelings will serve the client's interest, the therapist may choose to do so.  If decentering from her needs & wants & focusing on the client, is the most growth-enhancing choice, that is the choice the therapist should make. 

It must be emphasized, though, that focusing on the client's needs is not the same as trying to meet those needs.  Whether or not to act so as to actually meet a client's relational need will be determined by a host of factors.  The client's developmental history, the availability of other social support in his life and the way in which he uses that support, the nature of the need itself, the point in treatment at which the need is expressed, the way in which it is expressed -- all of these enter into the therapist's clinical judgement about what sort of intervention will best serve the client's interests. 

Let's review eight major relational needs, looking at how each need might arise & manifest itself in the therapy session & some of the therapist responses that may be helpful.

Security.  The need for security in relationship is the most basic of all relational needs.  The client needs to know that his therapist is trustworthy, competent, and has his best interests at heart; but beyond that he needs the visceral experience of having his physical and emotional vulnerabilities protected. He needs to know that he will be neither humiliated nor pathologized as he begins to reveal his most secret thoughts and feelings. The need for relational security is most likely to be foreground at the outset of treatment, when the client may be ambivalent about the whole process and does not yet know much about this therapist in whom he is expected to confide.  Once the therapist has established herself as worthy of the client's trust, the security need tends to recede into the background.  It will arise again if the therapist makes a mistake, or if old issues around trust and safety are being explored.  Rather than being expressed directly, the client's need for security is most often signaled by his drawing back from contact:  coming late for sessions or cancelling them altogether; becoming quiet, or talking about superficial matters; misunderstanding or accusing or blaming the therapist for things that happen both in and out of session.

A client's security needs must always be attended to, for little substantive work can be accomplished if the client does not feel safe in the therapeutic relationship.  However, direct reassurances will be of little value.  "I want this to be a safe place for you to work" or "I will never do anything to hurt you" can be mere empty words to a client who is feeling unsafe.  Acknowledging the client's concern, along with the therapist's desire to allay his fears and her recognition that words alone will not suffice, is generally helpful.  Even more important is attuning and responding appropriately to all of his other relational needs:  over time, this is the behavior that will demonstrate that the relationship is, indeed, safe for him.

Valuing.  The client's need for valuing, has to do with valuing the significance and function of his psychological processes - the "why" of what he does and says, more than the actual behavior.  This sort of valuing is conveyed through the therapist's contactful presence, and through her respectful attention to and interest in the client's phenomenology.  Rather than focusing on the client's external behaviors, the therapist talks about those behaviors in the context of the clients ongoing experience within himself and in relationship to others - including the therapist herself.  Her conviction that every behavior, every response, serves an understandable and important function, allows her to inquire with no hint of criticism or judgment.  If the client doesn't seem to make sense, if his behavior seems hurtful or silly, then the therapist (and quite probably the client as well) have simply not yet understood it fully.

While all clients need to feel valued by their therapists, the need for valuing emerges most intensely in the context of shame (Erskine, 1997/1994).  Feeling shame about something he has shared, about some part of himself that he has exposed, the client's ability to value himself is undermined; not valuing himself, he imagines that nobody else can value him either.  He withdraws, huddles inside himself -- or moves into an exaggerated, whistling-in-the-dark sort of psuedo-confidence.  Acknowledging and normalizing his need, and the sense of shame that precipitated it, will help him to re-establish contact.  Once contact is re-established, he will be more receptive to the therapist's verbal and non-verbal indications that he is indeed valued and respected.

A client who does not experience being valued in his outside-of-therapy relationships may become overly dependent upon the therapist's valuing.  He may demand frequent evaluations of his behavior and progress in therapy, or may compliment the therapist in the hope of getting some positive stroke in return.  Verbal reassurances are generally less than helpful for these clients, since they tend to reinforce the client's dependency; acknowledging the need,  engaging the client in exploring its significance, and helping him to find other relationships in which it can be met, is usually a better strategy.

Acceptance by a dependable other.  "The degree to which an individual looks to someone and hopes that he or she is reliable, consistent and dependable is directly proportional to the quest for intrapsychic protection, safe expression, containment or beneficial insight." (Erskine, 1998a, p. 239)  The need for acceptance by a dependable other is closely related to the need for relational security, but it goes farther:  it has to do with our experience not only of the other person's competence, but of her genuine willingness to understand and to help.    And it has to do with being allowed to make the other person special to us, without having to be  ashamed of how we feel toward her. When we experience this need, we want to be with someone from whom we can draw strength, guidance, or wisdom, and who will not criticize or belittle us for wanting that kind of support.

The need for this sort of acceptance is sometimes manifested through idealization of the therapist - she is wonderful, she's different from anyone else in my life, I think about her all the time... Such idealization is a normal and natural stage through which many clients pass; it is an out-of-awareness request for protection and support, and its function should be respected and valued just as we respect and value every other aspect of the client's behavior.

When the need for acceptance by a dependable therapist is foreground for a client, it is not particularly helpful for the therapist to express her own uncertainty or concerns.  At this moment, the client needs her strength, her reliability; he needs her to be a kind of good parent who can be depended upon to care for him with wisdom and skill.   "As an example of the crucialness of responding," comments Lee (1998), "when a therapist detects a client's fear, yet responds to this fear in an anxious way, the client experiences the therapist's exacerbating response as unempathic." (p. 130)  Although the therapist in this example accurately notes the client's fear, she allows herself to be contaminated by it:  she allows her affective attunement to outweigh her attunement to relational needs and thus misses the client's need that she be able to contain his fear rather than share it.

Mutuality.  Experienced in the therapy session, this is the need to be with a therapist who has shared one's experiences:  she really understands, because she has been there herself, and her acceptance is based on that understanding. 

Moreover, the client who feels a mutuality with the therapist can experience a sense of "I'm okay, and what I do/think/feel is okay, in part because this person I trust has done/thought/felt the same sort of thing." 

Clients for whom the need for mutuality is foreground may want their therapist to have had (and dealt with) the same sorts of problems that they have, or to have shared a similar childhood history. 

The need for mutuality may be expressed through direct questions ("Do you have children too?" "Have you ever lost a job, like I just did?") or through probing comments ("I'm not sure anybody can understand this unless they've been abused themselves."  "Straight people don't know what it's like to be gay.")

While a therapist cannot possibly know first-hand everything her clients have gone through, she has had (in reality or in fantasy) similar experiences. When she senses the need for mutuality in a client, it can be useful to talk about herself, her thoughts or feelings or experiences that parallel the client's experience in some way. 

Meeting the need for mutuality, then, requires a degree of self-revealing; each therapist must decide for herself, on the basis of her personal comfort level as well as of her sense of what will be helpful to the client, how much self-revelation she is willing to provide. 

And, to the degree that she does choose to self-reveal, it is essential to acknowledge that she can never know completely what it was/is like for this client, because he is the only person who lives inside of his skin.

Asking personal questions of the therapist is not always a signal that the client is experiencing a need for mutuality.  Sometimes this sort of question is used as a smoke screen, a way for the client to avoid dealing with his own painful issues. 

And even when the mutuality need is foreground, it may not always be in the client's best interest to meet that need; the client may be trying to use his relationship with the therapist as a substitute for satisfying relationships outside of therapy.  Nowhere is the need for a discussion of the therapeutic process itself more essential than when dealing with a client's repeated requests that the therapist talk about herself.

Self-definition.  I am me.  I can think for myself.  My feelings are my own.  The need for self-definition is the need to know & express one's own uniqueness & to receive acknowledgment & acceptance of that uniqueness from others. 

Many clients come to therapy hungry for validation of their uniqueness. They have been discounted, treated as unimportant or second-best, not allowed to argue or to say "No." They aren't so much interested in other people's similar experiences as in having their own experiences attended to. 

At moments when this need for self-definition arises, therapist self-disclosure is not only irrelevant - it's evidence that the therapist doesn't understand the client's needs or isn't fully invested in the therapeutic relationship. Failure to support the need for self-definition can be a further reinforcement of the client's script belief that he is unimportant & that nobody really cares about him.

The need for self-definition is the complement of the need for mutuality.  A client experiencing the need for mutuality may want to know about the therapist in order to gain a sense of closeness & similarity; when the need is for self-definition, the client needs the focus to be on himself. 

If the client appears impatient when the therapist shares her own thoughts or feelings, or seems to withdraw, the therapist may have misjudged his state of relational need.  At such a moment, it's a good idea to shift back, ask him what it's like for him when she talks about herself & use the exchange as an opportunity to validate his need to be who he is. 

Encouraging his disagreements with or challenges of the therapist will encourage him to define himself as different & valuable in his own right.

Making an impact.  Clients can do a great deal of self-exploration by keeping a journal, or talking into a tape recorder.  One problem with this strategy is that the journal or the tape recorder doesn't answer back, isn't impacted by the client's input. 

Relationships in which one doesn't experience having an impact on the other person are one-sided if not actually abusive; just as with a thwarted need for self-definition, they foster the belief that one is unimportant & that others don't care. 

The therapeutic relationship is no exception:  just as the therapist, in order to feel valued & competent, needs to feel that her behaviors have an effect on the client, so the client needs to feel that he can make an impact on the therapist - can attract her attention & can influence the way she thinks and/or feels about things that are important to him.

Unlike the "blank screen" therapist model espoused by traditional psychoanalytic theory, relationship-focused integrative psychotherapy insists that the therapist be present as a person, caring about the client, willing to be changed by what happens in the relationship. 

If she is moved to tears, she allows those tears to show; if she is angry on the client's behalf, the client knows about her anger; if the client corrects her, she is willing to be corrected & to think seriously about what change may be required. If the client demands a greater impact than the therapist is willing or able to allow, she acknowledges his desire & shares her honest response to that desire. 

Whether the need is actually met, or simply recognized, her acknowledgment is a validation of the legitimacy of the client's need & proof that he does, indeed, have an impact on her.

Expressing love.  Of all the relational needs that are dealt with in therapy, this is perhaps the most difficult -- and how ironic!  Expressing love and appreciation and receiving that expression, should be a joyful experience. 

When the therapist has been close to the client, seen his confusion and his pain, accepted him and valued him and helped him to grow and heal, it's only natural that the client should feel loving and appreciative; to stifle such feelings would be to retreat into phoniness and fragmentation again. 

Yet most therapists have been trained to be suspicious and distrustful of their clients' gestures of affection, always looking for some underlying motivation, some toxic transferential remnant that must be rooted out and done away with.

It's usually not difficult to tell the difference between a manipulation and a genuine expression of caring.  When a client, out of such genuine feeling, thanks his therapist or tells her how much she has meant to him or brings her a gift, she should accept it gracefully and let him see her pleasure.  It does feel good to be appreciated; being real in the relationship means enjoying the good parts as well as being impacted by the bad.

Attunement Errors

Relational needs shift from moment to moment and being attuned to those shifts requires close attention to the client's responses to the therapist's behavior. 

What begins as an attuned response to, say, the need for mutuality or other - initiation can change into a failure to deal with the need for self-definition. Because therapists are human and imperfect, such misses are inevitable; when they occur, one simply goes back and talks about the miss. 

"Go back and talk about it" is good advice for failures in every facet of attunement.  Missing an affective shift, not understanding a cognitive process, misjudging the client's psychological level of development, moving too quickly or too slowly -- all are bound to occur sooner or later. 

The therapist who castigates herself internally for her error, or tries to gloss it over so the client won't notice that it happened, takes herself away from the client and distorts the contact between them. 

This sort of contact distortion, in turn, is likely to create a repeat for him of the very kinds of relational experience that support his script and have gotten him into the situation that brought him to therapy in the first place. 

In contrast, the therapist's acknowledgment of what has happened and re-attuning (to herself and to him) allow the therapeutic process to move on.

Involvement       

"Involvement" is one of those words that most of us think we understand, but that turns out to be very difficult to define. The "involved" therapist is there for her client, present in the relationship, real, honest. 

She cares what happens to this person and she's willing to put energy and effort into helping him achieve his goals. She's genuinely interested in his client's intrapsychic and interpersonal worlds and communicates that interest through attentiveness, patience and respectful inquiry. 

She risks being vulnerable: 

she doesn't insulate herself from contact, but instead allows herself to be emotionally touched. 

She doesn't hide behind a mask of phoney professionalism; she lets her caring show, talks about her feelings, admits to her errors. 

"By embracing a technique of self-disclosure," says Billow (2000), "the patient may feel the analyst's emotion, without which emotion an authentic analysis is impossible." (p. 62)

Involvement, then, involves emotion and authenticity - emotion and authenticity that arise out of commitment to and genuine caring about the client.  It's best understood in terms of the client's perception: 

his sense of his therapist as contactful and truly committed to his welfare.

Acknowledgement

There are 4 therapist activities that are especially crucial in maintaining and demonstrating involvement. The first of these and the one that tends to be called for earliest in therapy, is acknowledgement. 

The therapist acknowledges the client by means of her attunement to his thoughts, feelings, behaviors and desires and her sensitive inquiry about all of those facets of his experience. She hears what he's telling her and she lets him know that she hears.  

to learn more about acknowledgement - click on any of the underlined link words, "acknowledges, (ed)(e)(ment)"

She's willing to talk about what's important to him; she doesn't force him to deal with her agenda.  While she's listening to him she's also listening to herself, in full contact with her own internal experience and willing to acknowledge that as well. 

Again, there's no pretending, no hiding behind some sort of clinical mask. "The analyst isn't a blank screen, but a quite human other presence whose emotionality the patient both correctly perceives as well as misperceives"  (Billows, 2000, p. 63).

Acknowledgement of the client's affect, relational needs and physical sensations helps him to reclaim his own phenomenological experience. He's in the presence of a respectful other who recognizes and talks about his non-verbal responses, his muscular tensions, his feelings, even his fantasies. 

Through this kind of sensitivity the therapist can guide the client toward awareness and expression of needs and feelings; she can help the client understand that emotions and physical sensations may be a form of memory - the only kind of memory that may be available to him right now. 

In essence, acknowledgement of the client's internal experience reverses the relational failures of the past, providing permission and protection for him to express that which was ignored or punished in previous relationships.

Perhaps most importantly of all, the therapist acknowledges her part in the creation of the therapeutic relationship. 

What happens during the therapy session is jointly created; therapist and client both are responsible for the successes and the failures, the stuck spots and the leaps ahead. 

They both are responsible for the misunderstandings, the insights, the feelings of care and closeness. Acknowledging the therapist's contribution to relationship issues, as well as the client's contribution, breathes life into that relationship. 

Such acknowledgement requires, enhances and demonstrates authentic involvement.

Validation

Validation communicates to the client that his affect, defenses, physical sensations or behavioral patterns are related to something significant. The involved therapist lets the client know that what he says or does is important, that his internal experience has meaning, even though she may not yet understand what that meaning is. 

One of the tenets of relationship-focused integrative psychotherapy is that every behavior - every act, thought and feeling - has a function; people don't behave randomly. The therapist validates the function of the client's behaviors and of his reported internal experiences. 

The behavior itself may appear hurtful to self or others - telling oneself that life is hopeless, or feeling panic when crossing a bridge, or sending poison-pen letters, aren't desirable behaviors - but there is an underlying purpose to even the most irrational-appearing response. 

Moreover, that purpose is positive; ultimately, the behavior was acquired and is maintained in order to protect the client from some danger or to achieve some important goal. It's this positive function that the therapist validates.

Sometimes simple acknowledgement serves as a validation.  By attending to the client's story, believing that what he says is true as he understands it (or, if he is being untruthful, that the untruth too serves an important function), the therapist lets the client know that she values his communication.  Greenberg and Paivio (1997) characterize this aspect of the therapeutic relationship as a new experience for most clients: "... feeling that a fragile sense of oneself is heard, received, validated and accepted is a source of new transformative experience." (p. 83)

Going beyond simply acknowledging what the client is saying & doing, the therapist may explicitly validate some client behavior.  This is a particularly useful intervention when the client himself discounts the behavior.  "I don't know why I react that way," or "I keep doing the same dumb thing over & over," says the client; the therapist responds with "There's an important reason for that reaction/behavior. Part of our job is to discover what that reason is."

It's a truism that clients often experience the therapeutic relationship in the same way that they have experienced important relationships in the past. These past relationships have taught them how to be with people, how to communicate their needs & respond to the needs of others, what to expect & what to avoid in human interactions. 

It's inevitable that some of those learnings & expectations will generalize to the therapeutic relationship & that the therapist will be understood in light of how other people have behaved in the client's past. It's especially important, then, to note & to validate the client's responses to the therapist - the way the client deals with the therapeutic relationship - since these responses may have more to do with old, script-determined functions than with actual here-&-now events. 

Uncovering script-determined functions is a first step in dissolving that script & re-establishing the spontaneity & creativity of full internal & external contact.

A final aspect of therapeutic validation is confrontation.  Confrontation involves calling attention to a discrepancy:  between words & behaviors, between what the client actually does & how he or she describes it, between thoughts & affect, between expectations & actual events. 

Like geological fault lines, discrepancies signal something important going on beneath the surface. The confrontation, implicitly or explicitly, calls attention to the underlying  process. Again, we assert that a purpose is being served, that the discrepancy has a function. Far from being a punitive "gotcha!", confrontation that validates an underlying positive goal respectfully invites the client to look more closely at what he's thinking, feeling, doing, saying & to value the purpose of that behavior even as he may strive to change the behavior itself.

Normalization

The involved therapist normalizes her clients' responses. Clients need reassurance that their behavior isn't crazy, not shameful or disgusting. They come for treatment because they're doing / thinking / feeling things that they don't want to do / think / feel and because they haven't been able to change their responses; they're likely to believe that they're different from (and less than) other people, who obviously are much better able to take care of themselves. 

Normalizing interventions point out the similarities between clients and others: 

"Given the situation you were in and the resources available to you, it makes sense that you would have acted (thought, felt) as you did.  Anybody would."

The intent of normalization is to counter a client's categorization or definition of his internal experience or his behaviors from a pathological, "something's-wrong-with-me" perspective.  Instead, the therapist presents a point of view that respects the client's attempts - archaic though they may be - to resolve conflicts and to protect himself. 

The client's confusion, panic, defensiveness, memory flashbacks, or bizarre fantasies all derive from coping strategies developed in difficult and painful situations. It's imperative that the therapist let the client know that his experience is a normal self-protective reaction and that others experiencing similar life circumstances might well respond in similar ways.

Normalization involves both acknowledgment and validation.  The therapist acknowledges what the client is telling him, verbally or nonverbally. Validating the function of the behavior implies that the function is a reasonable and rational one; this paves the way for talking about how the client did the best he could do, under the circumstances, to maintain that function. 

His choices may not have been good ones, but they were the best that he - or anyone else in his situation - could have made. Now that the situation is changing, he's in a position to do something different.

Presence

Acknowledgement, validation and normalization are specific therapist behaviors that emerge naturally and inevitably from the conviction that every client is fundamentally a good person, doing the best he can given his history, belief system and current resources. 

They emerge because the therapist is present in the relationship, willing to be known as well as to know, in contact both with the client and with her own experience. Presence is the 4th ingredient of involvement and it's fundamental to the process of relationship-focused integrative psychotherapy.

Presence is provided through the therapist's sustained attunement to the client's verbal and non-verbal communication and through her constant respect for and enhancement of the client's integrity.

It's an expression of the therapist's full internal and external contactfulness and it communicates her dependability and her willingness to take responsibility for her part in whatever happens in this relationship. 

It includes receptivity to the client's affect:  willingness to be impacted by the client's emotions, to be deeply moved while not becoming anxious, depressed or angry.

There's a kind of duality to presence, a quality that we've touched on before: a simultaneous attending to other and to self. The therapist de-centers from her own needs, feelings, fantasies or desires and makes the client's process her primary focus but she doesn't lose touch with her own internal process and reactions. 

"The therapist's history, relational needs, sensitivities, theories, professional experience, own psychotherapy and reading interests all shape unique reactions to the client. Each of these thoughts and feelings within the therapist are an essential part of therapeutic presence." (Erskine, Moursund & Trautmann, 1999, p. 242)

It isn't just that the therapist has a unique history, a unique set of past experiences and present interests and needs and wants. 

She also uses her experience as a kind of reference library that sheds light upon the client, upon her responses to him, upon their interactions with each other. Most importantly, the therapist is willing to be transparent in her uniqueness, willing to let the client see who she is and what she's experiencing, willing to be impacted by that which impacts the client and willing for that impact, too, to be seen. 

The respectful interplay between self-awareness and de-centering opens the way for what Buber (1958) calls an "I-Thou" relationship, a relationship between two connected, contactful, self-and-other-aware individuals. The "I-Thou" relationship, in turn, is the primary source of the transformative potential of relationship-focused integrative psychotherapy.

One of the immediate consequences of therapeutic presence is that it serves as a model. The client, seeing that the therapist is willing to be open and vulnerable, is encouraged in his own openness and vulnerability. 

Presence also serves as a container for the therapeutic interaction (Schneider, 1998); it's a sort of psychological safety net, marking an interpersonal space that supports without constraining and protects without demeaning the client.