October 29, 2011

If You Don't Understand, Ask

Therapy Policy: If you don't know what your client is talking about, ask.

I learned this lesson during my first doctoral internship, which was my first experience conducting therapy in French. Over the course of eight years living in Quebec, I've achieved considerable fluency in the French language, as well as in the nuances of Quebec slang, politics, and culture. However, everyday French conversation and conducting therapy in French are not comparable, and the learning curve during that first internship was steep. 

At the beginning, wanting to prove myself as an Anglo therapist in a Francophone environment, I opted for the "it's no big deal" approach and ignored the language issue. To avoid drawing attention to my Anglo-ness, I didn't ask clients to repeat unfamiliar terms or to explain comments that weren’t clear to me. This strategy was not effective. In supervision, I learned that my comédien client was not a comedian but, rather, an actor. When I expressed surprise in supervision over a client’s shocked response to a rude, but not out of character, comment from her partner, I learned that choqué means angry, not shocked. When I asked a colleague what my client might have meant when she said that her mother was "the kind of person who watches Occupation Double” (a Quebec reality TV show), my colleague wondered why I hadn’t simply asked the client.

In discussion with my supervisor, I realized that I was worried my clients would reject me for being an Anglo imposter who could never understand them. But my solution--pretending to understand when I didn't--was hindering therapy. When I consciously shifted to a more open and curious approach, my clients responded positively. They appreciated my acknowledgement of our differences and enjoyed the opportunity to explain their cultural references. Who knew!

Now I'm in a new steep-learning-curve internship--at a chronic pain centre. I'm not used to working at a non-psychiatric hospital; I hear unfamiliar terminology used every day to describe pain, medical procedures, medications, etc. What's more, I've never worked with pain patients before and many of their experiences are unfamiliar. 

I'm doing much less pretending this time around. One thing that helps is seeing my superiors--physicians and psychologists alike--do things like Google a medication they've never heard of, right in front of patients! They don't seem worried that patients will think they're incompetent because they admit to not knowing everything. A second thing that helps is noticing that patients want me to really understand their experience; they're not annoyed when I say "I'm not quite sure I understand; what do you mean by...?" Rather, they appreciate it.

This time, my policy is "If you don't understand, ask" (and, where medical terminology is concerned, "if you don't know, look it up"). 

So far, so good.

October 10, 2011


A good therapist should be empathetic, right? Most people, myself included, would automatically agree--but what is empathy, anyway?

Until recently, my loose and unexamined definition of empathy was the capacity to put yourself in someone else's shoes and feel as he or she feels. So when in clinical case discussions, colleagues mentioned how awful they felt about a given client's situation, or that tears came to their eyes during a client's particularly moving story, I called that empathy. And when other colleagues reported that this never happens to them--that they never vicariously experience clients' pain or take clients' problems home with them--I called this lack of empathy. I figured that the former group were the more sensitive, more human, and all-around better psychologists, and that there was probably something wrong with the latter group.

However, subsequent to a conversation on this very topic, a friend pointed me to the Wikipedia page for empathy, which lists definitions of the term by various theorists. To my surprise, many of them were not consistent with my definition. Rather, several referred to a cognitive component of empathy, that is, empathy as the ability to understand another person's thoughts, feelings, and motivations, without necessarily experiencing them.

Examples of this type of definition include "the ability to put oneself into the mental shoes of another person to understand her emotions and feelings" and "a complex form of psychological inference in which observation, memory, knowledge, and reasoning are combined to yield insights into the thoughts and feelings of others." These definitions involve perception and appreciation of how the other person is feeling, but don't imply stepping into his or her shoes.

Other definitions suggested that empathy has both cognitive and emotional components. For example: "There are two major elements to empathy. The first is the cognitive component: understanding the other's feelings and the ability to take their perspective. The second element to empathy is the affective component. This is an observer's appropriate emotional response to another person's emotional state." Another definition proposed that empathy is "the capacity to a) be affected by and share the emotional state of another, b) assess the reasons for the other’s state, and c) identify with the other, adopting his or her perspective." 

Reading these interpretations changed my personal definition of empathy and eliminated my judgment of therapists who don't feel their clients' pain. The more I think about it, the more I believe that, in combination with warmth, compassion, and therapy and problem-solving skills, cognitive empathy is enough.

What do you think? Would you appreciate seeing your therapist wiping away tears when you describe your troubles, or is it enough if he or she can understand where you're coming from and why, and can use that knowledge to help you move forward?