Learn how empathy, what we say and how we say it can dramatically affect the outcome of treatment.

Assess a practical step by step approach for being empathetic.

Understand the effects of empathic listening.


Empathy is the capacity to recognize or understand another person's state of mind. It is the ability to put one's self into another person's shoes or to experience the outlook or emotions of another being within oneself.

Listening First Aid: The Panama Canal may serve as an adequate analogy for the role of effective listening skills. As a youth, I traversed the canal several times as we sailed in a freight ship from the port of Valparaiso in Chile, to New York. Massive lock gates are utilized to manage the water levels in the canal, so that ships can move from one direction to another. The water level behind one set of closed locks can be much higher than that of the next compartment through which a ship will travel.

We can compare this scene to the state of mind of an individual suffering from deep emotional wounds, or involved in a serious interpersonal conflict. With disparate water levels there is a buildup of pressure behind the closed locks. If one were to open these lock gates, the flow would be mostly unidirectional. Likewise, a party who is holding in her emotions needs a release. Such an individual is unlikely to (1) think clearly about the challenge or (2) be receptive to outside input from another.

The role of the listener or helper is to allow such an individual to open the lock gates. When he does, the water gushes out. During this venting process, there is still too much pressure for a person to consider other perspectives. Only when the water level has leveled off between the two compartments, does the water begin to flow evenly back and forth. The role of the listener is to help empty the large reservoirs of emotion, anger, stress, frustration and other negative feelings until the individual can see more clearly. Not until then, can a party consider the needs of the other. Perhaps we can think of it as listening first aid.

At one enterprise, I had just been introduced, by the proprietor, to one of the parties involved in a conflict where I would be the mediator. (Rather than bringing both of these individuals together immediately, I instead met with each separately in a pre-caucus.) As soon as the owner left us alone, the individual broke into tears. A similar situation took place at a different enterprise, where one of the managers began to cry, ostensibly because of other issues pressing heavily upon him. Had these men come immediately into a joint meeting with their respective contenders, their feelings of vulnerability might just as easily have turned into anger and defensiveness.

In another organization, I was informed that the pre-caucus would be quite brief, as the person I was about to listen to was not a man of many words. Yet this individual spoke to me for almost two hours. By the time we finished, he felt understood and had gained confidence. During the joint session, this same employee was able to laugh when it was appropriate. I have found that these “silent types” will often open up when there is someone who will truly listen.

The process of listening so others will talk is called empathic listening. Empathy, according to some dictionary definitions, means to put oneself in a position to understand another person. Certainly, this is an aspect of empathy. We prefer to define empathy, however, as it is often used in psychology: the process of attending to another so the individual feels heard in a non-judgmental way. Empathic listening requires that we accompany a person in her moment of sadness, anguish, self-discovery, challenge (or even great joy!). This approach to listening was developed by Carl Rogers, author of Client-Centered Therapy.1 Rogers applied the method to therapeutic as well as human resource management skills. When an individual feels understood, an enormous emotional burden is lifted; stress and defensiveness are reduced; and clarity increases.

Listening Skills in Interpersonal Communication

We spend a large portion of our waking hours conversing and listening. When two friends or colleagues have an engaging dialogue, they will often compete to speak and share ideas. Certainly, listening skills play an important role is such stimulating exchanges. When it comes to empathic listening, we do not vie to be heard, nor do we take turns speaking. Rather, we are there to motivate and cheer the other person on.

Empathic listening skills require a different subset of proficiencies than conversing, and it is certainly an acquired skill. Many individuals, at first, find the process somewhat uncomfortable. Furthermore, people are often surprised at the exertion required to become a competent listener. Once the skill is attained, there is nothing automatic about it. In order to truly listen, we must set aside sufficient time to do so. Perhaps the root of the challenge lies here. People frequently lose patience when listening to another’s problem. Empathic listening is incompatible with being in a hurry, or with the fast paced world around us. Such careful listening requires that we, at least for the moment, place time on slow motion and suspend our own thoughts and needs. Clearly, there are no shortcuts to empathic listening.

Some of the dialogues in this paper are videotape transcripts made possible by generous volunteers. It is my goal to give life to some of these clips, so as to better illustrate what it means to indeed listen empathetically.

The purpose of this paper, then, is to further explicate and describe empathic listening, as well as some of the skill subsets involved. We challenge the reader to temporarily put aside any preconceived notions about effective listening. In order to more clearly illustrate empathic listening, we will portray both positive and negative examples.

Effective listening and attending skills can be applied to all of our interpersonal and business relationships. We will become more effective listeners as we practice at home, in our business dealings, and in other circles. One of the greatest gifts we can give another is that of truly listening.

Different approaches to listening

There are different approaches to providing assistance. One helping model involves a three-step process: 1) attentive listening, 2) asking effective diagnostic questions, and 3) offering a prescription, or solution. Slowly, or sometimes quite abruptly, people move from listening to prescribing. It is not uncommon, under some circumstances, for a person to focus on the third of these steps: offering advice (sometimes even when none is sought). In other situations, individuals may utilize the first two steps. Perhaps most uncommon is an emphasis on listening alone.

You can probably imagine situations where each of these approaches may make sense. When there is little time, or in dangerous situations, people may offer advice even when they were not asked. For matters of a technical (or medical) nature, the three-way process of listening, diagnosing, and prescribing is often preferable. After prescribing, it is helpful to take a step back and determine how the individual feels about the proposed solution. A related approach involves going through the first two steps and then involving the troubled person in examining alternative solutions. Finally, for more personal matters, where the solution is owned by the individual facing the challenge, a listening approach is most advantageous. This is where empathic listening fits in. Let us consider these phases in reverse order.

Prescriptive Phase

The majority of individuals, while they may fully begin with intentions of listening, often quickly transition into the diagnostic and prescriptive phases. People are accustomed to solving problems and often listen with this frame of mind. Others, instead, focus on sympathy. Sharing a story of how we had to face a similar challenge is not much better. Nor is being quiet so a person will hurry up and finish. None of these are helpful responses to venting. Each reflects, among other things, a certain amount of impatience. When people are not listening we can often see it in their body language: “The automatic smile, the hit-and-run question, the restless look in their eyes when we start to talk.”2

It seems easier to solve other people’s problems rather than our own. Individuals habitually say, “If I were in your position, I would do such and such.” Perhaps. Maybe we would have solved the dilemma had we been in her place. Different personality types certainly approach specific challenges in predictable ways, with likewise foreseeable results. For instance, some would not dream of confronting a friend, but instead would let an irritation fester inside. Others might have trouble keeping their opinions to themselves.

Have you noticed that some of your acquaintances seem to repeatedly fall into the same types of predicaments, giving the impression they did not learn from the last episode? Each of us has different personality traits and skill sets that permit us to solve some challenges easier than others.

Occasionally, of course, we think that we would have solved a person’s dilemma, had we had the chance to do so. Instead, when we find ourselves in the same predicament, we often feel just as unsure about how to proceed.

On the way home from a father-daughter date, I asked one of my daughters if I could give her some free advice. "I certainly don't plan to pay for it," she quipped. On another occasion, another young woman came to see me. Sofía could not perceive how giving the cold shoulder to Patricia—who had been her best friend at the university—was not only a cause of pain to the latter, but also a way to further escalate the growing conflict between the two.

“I no longer speak to Patricia when I see her,” Sofía began. “Her cold attitude toward me really hurts. She never greets me, and that hurts. She used to be very kind. But you know, now, when she tries to come over and speak to me I pretend I haven’t noticed her and look away.”

“How do you expect your friend to act in a warm way toward you if you give her the cold shoulder when she tries to speak to you?” I inquired, stating the obvious.

I should have instead kept that comment to myself. Sofía was upset by my counsel and avoided me for some time. A few weeks later she came to see me again. This time I listened empathically. It meant not stating the obvious, but rather, being attentive while Sofía described, in full detail, the ache she was feeling, the history of the conflict, her suffering and hopes. Sofía felt heard and was able to take some preliminary steps towards resolving her challenge.

Our effectiveness as a listener is often lost if we solve the problem before the person we are attempting to help does. Some try unsuccessfully to disguise their advice-giving tactics through such questions as, “Don’t you think ...?” or, “Have you tried ...?”

Aaliyah is very concerned about her grown daughter, and has been openly disclosing her worries with her friend, Shanise. Let us listen in on their conversation.

“These are the problems I have with my daughter,” Aaliyah shares, anguish punctuating each word. “I want to seek her out, try and speak with her, try and have her understand, but she does not mind me. [Pause] I simply don’t know what to do, I feel incapable of helping her.”

“If you would get her professional help, would she go?” Shanise proposes.

“Hmm. Eh. [Pause] As I was telling you, she doesn’t mind me. When I try and speak to her, give her advice, then she… changes topics. That is the problem I have, that I seek her out but she does not mind me.” Aaliyah insists.

Aaliyah considers Shanise’s contribution a distraction, and momentarily loses track of what she was saying. Aaliyah, however, takes control of the conversation once again. Because Shanise has been showing empathy to this point, Aaliyah forgives the interruption.

There will be times when people seem to be asking for a solution, such as Aaliyah’s comment, “I simply don’t know what to do.” Perhaps they will even ask for advice, “What should I do?” The listener ought not to rush in with a prescription. It is worthwhile, at least, to say something like, “You are unsure as to how to proceed.” If the person says something like, “Exactly!” and continues to speak, we know we have hit the mark. If instead, the individual continues to ask for suggestions, we can help them explore options.

In a listening skills workshop, John, one of the participants, had shared some concerns facing his enterprise: “Our top supervisor seems quite unsure as to how to proceed with such a delicate issue,” John explained. “He simply does not know what to do about these two guys who will not speak to each other.” After a while, I stopped the role-play to give the listener some ideas on how to keep John talking. John interrupted to say that he did not want to play the listening game—he simply wanted a solution.

This was an ideal opportunity to illustrate some vital points. When workshop participants listen to people with real hardships, everything they have learned so far often flies out the window. Rather than analyze the quality of the listening, participants are all too often ready to suggest additional solutions. It is not difficult to obtain “three opinions out of two persons!”

Seminar participants were permitted to go around the table prescribing solutions. But not before being warned that they were entering the prescribe phase, which I have labeled red, for danger. Suggestions started flying.

“Obviously, John,” the first participant began, “you must insist upon having the supervisor speak with both individuals.”

“What I would do instead,” another piped in, “would be to… ”

It soon became clear that despite John’s request for a ready made solution, these suggestions were irritating him. John admitted that he would have preferred to continue to think aloud with the support of the class participants.

Sympathy is quite different than empathy. It often springs more from our desire for normality, than for helping someone. One of my favorite illustrations comes from Alfred Benjamin: “When Lucy said, ‘I’ll never get married now that I’m [disabled],’ what did you do? You know you felt terrible; you felt that the whole world had caved in on her. But what did you say? What did you show?”3 If Lucy was your seventeen year old daughter, niece, or younger sister—I often ask—what would you like to say to her? Some of the most frequent responses include:

  • Your internal beauty is more important than outward appearances.
  • I still find you beautiful.
  • If a young man cannot see your beauty, he is not worthy of you.
  • Modern medicine can work miracles and perhaps you can recover beyond expectation.

Alfred Benjamin continues, “Did you help her to bring it out; to say it, all of it; to hear it and examine it? You almost said: ‘Don’t be foolish. You’re young and pretty and smart, and who knows, perhaps…’ But you didn’t. You had said similar things to patients in the hospital until you learned that it closed them off. So this time you simply looked at her and weren’t afraid to feel what you both felt. Then you said, ‘You feel right now that your whole life has been ruined by this accident.’ ‘That’s just it,’ she retorted, crying bitterly. After awhile she continued talking. She was still [disabled], but you hadn’t gotten in the way of her hating it and confronting it.”3

In my opinion, it is not about withholding comments about the beauty of the young lady, or about how much we care about her. Many of these comments may be shared, but later, after Lucy feels truly heard and does not have more to say herself.

There are numerous ways we discount the needs of others, even when we think we are being good listeners. For instance, we may attempt to share our own story of loss, disappointment, or of success, before the individual has had the opportunity to be heard in his story. We may feel that sharing our own story is proof that we are listening, but instead, the other person feels we have stolen the show.4 Once again, this is not to say that there is no room to share our story with others, but rather, we should hear them out first.

Some persons confuse empathic listening with being silent. First attempts to listen empathically are often betrayed by facial and body language that say “be quiet so I can give you advice.” Have you ever tried to speak to someone who is silent and gives no indication of what he is thinking? We do not know if the person has lost interest or is judging us.

When people have deep sentiments to share, rarely do they expose their vulnerability by getting to the point right away. Ordinarily, the topic is examined through increasingly constricting circles. We may also compare it to an iceberg. Only an eighth protrudes to the surface while the rest remains submerged—buried—under the surface of the ocean. When someone says, “I am worried because…” and another responds, “Don’t worry so much,” the worried person does not cease to be concerned. Rather, it becomes clear that the apprehension cannot be safely shared with this individual. Likewise, when a person proceeds to give a suggestion before understanding the situation, individuals will frequently pretend to go along with the proposal simply to get rid of the problem solver.

Diagnostic Phase

Perhaps the greatest danger with the process of diagnosing is the natural tendency to move from listening, to diagnosing, to prescribing. Rarely do people reverse the process and return to listening after entering the diagnostic phase. It is much more likely that they will move on to prescribe mode. A plus of the diagnostic process, is that the listener can, at least at the superficial level, gain a better idea of what the challenge entails.

We do not wish to imply that the diagnostic process is useless. All too often people give too little attention to diagnosis, but in the process of empathic listening, the diagnosis needs to be carried out by each party, rather than the mediator. An emphasis on diagnostics betrays a perspective in which the listener is to provide wisdom, understanding, and solutions.

Often, individuals listen and ask questions with the idea of confirming their own observations. A much more effective method is to be moved by a spirit of curiosity. Such an approach has been called a stance of “deliberate ignorance.” Instead of assuming that a certain experience is the same as another we have lived or heard of in the past, we listen with interest and curiosity. Inquisitive listeners “never assume that they understand the meaning of an action, and event, or a word.”5

Let us return to the conversation between Aaliyah and Shanise.

“My husband does not help me resolve my problem with my daughter,” Aaliyah laments.

“What would he like you to do? Not to have any contact with her?” Shanise asks a couple of investigative questions.

“Well, we quarrel a lot because I tell him I’m a mother. [Pause] And he does not feel what I feel. And he does not want me to seek her out because, after all, she does not listen, and the situation will not improve. But I always seek her out. [Long pause] And I told her not to be running about… to come to my home, but she will not, she says that…,” Aaliyah continues her story, a narrative born of a mother’s pain.

The questions have helped Shanise understand the situation a bit better. Observe, however, that Aaliyah, after answering, returns to speak about that which hurts her the most, her inability to help her daughter.

Next, we give another example of an investigative question. Once again, we pick up in the middle of a conversation:

“I have that problem with one of our engineers,” says Raymond.

“In the morning or afternoon?” inquires Paul.

“I have been wondering if there is a pattern indeed… if this happens on Mondays, or if there is anything predictable in all of this,” Raymond answers. “The truth is that I have not found anything obvious that stands out.”

“Have you ever sat down with him and spoken about your concern?” Paul asks.

This conversation follows a pattern. Paul asks a question and Raymond answers and then waits for Paul’s next inquiry. Pauses become an excuse to interrupt. Paul has control over the conversation and it is uncertain as to whether he will take it in the right direction. While Raymond may feel heard, to a certain extent, such comprehension tends to be somewhat superficial. Raymond is not working as hard as he could and expects an answer to his problems. Upon observing Raymond, one gets the idea that he is saying, “Go ahead, be my guest, see if you can solve this mess! I sure haven’t been able to.”

There are other types of questions, such as those that promote the talking about feelings. Manuel tells his wife, Magdalena, that despite the recognition that his work has received in New York, he is unsure as to whether they should remain in the USA or return to their native Argentina. While Magdalena has heard her husband in the past, her focus here has been to let her husband vent and find clarity to his own thinking:

“That is the problem, to stay or return to Argentina?” Manuel sighs.

“What is it that you really miss from Argentina?” Magdalena inquires.

“Well, that is what we were talking about recently… one misses the family… family relations… Sundays with the extended family and the kids… but I also miss my friends. I had a huge group of friends…,” Manuel continues sharing his feelings.

This question has permitted Manuel to explain what he truly feels. Other such questions could include, “How do you feel when that happens?” “What are you feeling at this moment?” We will generally note quite a different expression coming from a person who is answering affect-type questions. Another inquiry that gives the client a chance to expand is, “What, then, do you plan on doing?” Despite the merits of such a probe, it is best to leave it towards the end of the conversation. Unless, of course, it is asked in a much less abrupt way, such as, “What options are you leaning toward and which ones do you like the least?”

When a question is asked to help someone take control of the conversation, I like the expression, “prime the pump.” These old fashioned water pumps functioned through a lever and a vacuum. One needed quite a bit of effort to make them start pumping water, but much less once the water started flowing. Prime-the-pump type questions are especially useful to help the person with the challenge:

  • Start speaking.
  • Take back control over the conversation, especially after an interruption (e.g., after the conversation stops when a third person momentarily walks into the room; the conversation is being renewed after a few days; or when the listener realizes he has interrupted or taken an overly directive approach to listening).

There are several types of questions, comments, or gestures that can work under the prime the pump category. These may include, for example:

  • Investigative questions.
  • Analytical comments.
  • Summary of what has been heard.
  • An invitation for the person to say more.
  • Body language that shows interest.
  • Empathic comments.

Empathic Listening

A mother recalled of a time when her young daughter invited her to come outside and play. At first, the mother intently watched as her daughter repeatedly hit a tether ball, but soon began to wonder what her own role was in the game. So she asked her daughter. In response, the young girl matter-of-factly explained that every time she was successful in hitting the ball, the mother should congratulate her and say, “Good job!” 6 This is, essentially, the role of empathic listening, that of accompanying another person and celebrating together the fact that the other can begin to unpack and analyze the challenges being faced. In the child’s game, success is measured by the ability to have the ball and its cord wrap around the post. In empathic listening, success is measured by the ability to unpack the often pain-soaked narrative and let it float to the surface.

We shall attempt to look, in a more detailed way, at how to accompany without interfering. There is a marvelously therapeutic power in the ability to think aloud and share a challenge with someone who will listen.

A good listener has sufficient confidence in himself to be able to listen to others without fear. In contrast to a diagnostic approach to helping, the listener:

  • Takes an empathic posture (motivates the other to speak without feeling judged).
  • Does not use pauses as an excuse to interrupt.
  • Permits the speaker to direct the conversation.

Through this process the individual—if we earn her confidence—begins to speak more, to control the direction of the topic, to increase self understanding (by first reviewing that which is known and later by digging deeper), to consider possible options, and often, by choosing a possible outcome. We will consider some specific tactics that will help us accomplish these goals. A warning is in order. We must keep in mind that empathic listening is dynamic. It is not sufficient to have an interest in another, but we must also show it. And it is not sufficient to show an interest, we must feel it. The person being heard immediately notices if we get bored, seem distracted, or become upset.

In the words of Alfred Benjamin, “Genuine listening is hard work; there is little about it that is mechanical… We hear with our ears, but we listen with our eyes and mind and heart and skin and guts as well.”7 Let us look at some specific techniques that are helpful.

Dangling questions

An incomplete question has the advantage of leaving much in the air and giving the client control over the direction he wishes to go. Let us return to our Argentine couple.

“And the children… miss…?” Magdalena asks, prolonging the word miss.

“And the children miss… much, especially the… affection of the grandmothers, cousins, undoubtedly they miss the whole family structure…” Manuel explains and continues to uncover the issues that are troubling him.

Indications that we want to know more

There are many ways we can signal an interest in listening and learning more. One of the most typical is to simply say, “Tell me more.” We could also say something like, “How interesting!” or simply, “Interesting.” What is important in all this is that we are not stuck with one monotonous and irritating technique.

Repeating a phrase or key word

One of the most important empathic listening techniques is to let the client know we are accompanying him by repeating, from time to time, one word, or a few, in the same tone of voice that he has used. Aaliyah continues to share with Shanise the pain she is feeling because of her daughter.

“And she moved and now lives in a nearby town… [Aaliyah raises her left hand while she speaks and indicates the direction, and then pauses]. With a friend…”

“Friend,” Shanise repeats.

“Yes, but she does not last long because as she does not work and she won’t be able to simply live there for free,” Aaliyah continues. “She must contribute something, too.”

Such empathic expressions or key words, contribute to the process without overly interrupting. There are times when the speaker may leave the thought process to reflect on the words the listener has repeated. But normally this happens in a very natural fashion that allows for fluidity. The speaker has the option of continuing what he is saying or further reflecting on the comment. Let us look at this same technique in the Argentine couple.

“It is true that… while… the cost of education in this country is high… [pause], yet the possibilities are infinite,” Manuel declares.

“Infinite,” Magdalena pronounces the word using the same tone that her husband had used.

“Infinite… infinite in the sense that if one can provide the support for the children and motivate them to study…” Manuel continues to develop his thinking.

Some have accused Carl Rogers of being directive. According to the critics, these empathic responses reward the speaker for focusing on the topics the listener wants him to focus on, and thus it is the listener who directs the conversation. This is not the case. When a person is interrupted by an empathic listener—with an observation or comment that is distracting—the speaker makes it clear that this was an interruption. Unless, the interruption constitutes a more serious breach of trust, the party continues to speak and control the conversation.

Mekelle, a young African-American professional, is telling Susan, that her best friend, Palad, is mad at her because her fiancé is Caucasian. The conversation is proceeding normally, until Susan asks a question that distracts Mekelle.  

“My friend Palad… it bothers me—as bright and perceptive as he is—that he cannot see that in reality… if one were to educate more people,” Mekelle is expressing her frustration.

“Yes,” Susan adds, following the conversation.

“Then he would not feel the way he feels, you understand?” Mekelle asks a question that rather means, “Are you listening to me? Are you following my logic?”

“Where is Palad from?” Susan interrupts. The question has no relationship to the pain that Mekelle is feeling at the moment. People often take back control of a conversation with the use of the word “but,” as we see below.

“Palad is from Florida, he has lived several years in California and he is now living in Oregon,” Mekelle answers. “But… [having lost track of where she was, Mekelle seems somewhat distracted and moves her hand, as if to say, lets get back to the topic, and continues] but… and it is only about Caucasian people, he only has problems with Caucasian people, [Mekelle smiles] if the person was from any other race it would not matter, but when it is a matter of a Caucasian person…”

Empathic sayings

An empathic saying is a longer comment, of a reflective type, given to let someone know we are following them. We might say something like, “at this moment you feel terrible,” or, “I can see you are suffering.” These expressions can be very potent but only if used sparingly, and certainly not in a repetitive fashion. Here is an example of an empathic saying used properly:

A troubled youth approached me one day. “I hate life, it has treated me terribly,” he said. The loud, bitter comment filled the room. Oh, how I wanted to moralize and tell him that his own actions had placed him in the present predicament. But instead, I calmly stated, a la Rogers, “Right now, you are hating life.” I was trying to truly comprehend and letting him know that I was listening.

“Oh yes,” he continued, but the anger reduced enormously, “life right now is terrible....” With every exchange the voice tension and loudness subsided. This same youth soon recognized that he was not in the right path without my having to say it.

In contrast, I observed a speaker—a therapist by training—who freely used the line, “I can see you are hurting.” I was the conference interpreter and was in a position to observe the audience. An older man told his heartbreaking anecdote, and the speaker used his line at what seemed the perfect moment. The participant stopped talking and leaned back. I could see in his eyes and body posture that he had felt empathy from the therapist. The man had been touched and now felt understood. I was impressed. It seemed to me, however, that with each subsequent use of “I can see you are hurting,” the catchy phrase became increasingly artificial. The magic was gone. Fewer people were convinced of its sincerity and the line soon meant “be quiet, I want to move on with my talk.” The process had become mechanical and empty, rather than based on true empathy.

How does one know if the listening was empathic? Gerald Egan says, “If the helper’s empathic response is accurate, the client often tends to confirm its accuracy by a nod or some other nonverbal cue or by a phrase such as ‘that’s right’ or ‘exactly.’ This is usually followed by a further, usually more specific, elaboration of the problem situation.”8 And when one is off the mark, sometimes they will tell you, or just as likely, they will be quiet and avoid eye contact.

Empathic questions

In contrast to diagnostic questions, especially those analytical in nature, empathic questions go to the source of what the person is feeling. These questions are very powerful and less dangerous because they promote talking, rather than silence (i.e., prime the pump questions). Examples include, “What are you feeling at this moment?” Or, without completing the phrase and stretching out the word feeling, “You are fee-ling…?” The strength of empathic questions is that they help bring the pain out to the surface, feelings that often may lie deeply hidden. Often, people have been so preoccupied with analytical thinking, that they have not permitted themselves to sufficiently examine their feelings.

Body language

One of the best steps, in terms of body language, is to invite someone to take a seat, if she has not done so already. By offering a seat we let her know that we are willing to listen and ready to take the time to do so. That we are not going to ration out the time.

Persons who are very interested in what another is saying may, from time to time, lean toward the speaker, and their interest is reflected in their faces, body language, and tone of voice. We can signal with our head movement that we are listening. But as with all of the techniques we have discussed, variety is critical. Otherwise, if we keep mechanically shaking our head to let the person know we are listening, we soon look like the bobble-head dogs that were often seen in the back windows of cars.

If we are truly interested in listening, our body language shows it. Our non-verbal communication also betrays us when we get distracted. In a recent conversation I had not yet said anything, but must have shown intentions of interrupting. Before I could utter a word, the person speaking said, “Excuse me for interrupting you, but…” and she continued relating her account. This happened several times, proving what communication experts have told us all along: individuals signal their intent to interrupt before doing so.

Respecting pauses

Silence makes people uncomfortable. Yet, one of the most important empathic listening skills is not interrupting pauses, or periods of silence. When a person pauses she continues to think about the challenge. When we respect these pauses, by not interrupting, we are in essence offering the person a psychological chair to sit on; it is a way of saying “We are not going to abandon you.”

The person who feels truly heard begins, also, to speak slower and to leave more pauses. When an individual senses she will not be interrupted, she begins an internal trajectory, every time deeper, wherein she begins to intensify the process of self understanding and analytical thinking. Many listenerswho found it difficult enough to be patient when the individual was speaking at a normal speed—finding it torturous to listen to this slower pace. Yet, this is part of the gift of giving, in a listening or helping stance.  

How long can you listen to a person and keep silence without getting nervous or impatient, and interrupting? Four seconds? Eleven seconds? One minute? Ten minutes? How long? When a party comes out of this pause, he will have often undergone some serious reflective and analytical thinking.

A young professional reported that she had put this advice to work. After a seminar she called her boyfriend, who was experiencing some difficult challenges. “I had to bite my lips several times,” she reported. “But I managed not to interrupt him. After a long pause he asked me, ‘Are you there?’” The disadvantage of the phone is that fewer empathic responses are available to the listener, as he could not see the interest with which she had been listening. She responded, “Of course, I am listening with much interest!” Once these words were pronounced, he continued talking, this time with even more enthusiasm and penetration.

In order to conclude this sub-section, I would like to share two more clips from our African-American friend, Mekelle. The first one speaks of her desire to make a decision and resolve her challenge. This comment comes after she has had a long time to vent.

“It has become clear that I must call Palad again and have another conversation with him,” Mekelle resolved. “I have not decided… yet… when I will call him. [Pause] Yeap… that is where I find myself at the moment… I will probably find a moment to call him next week. I always like to plan this type of thing. [Laughing] I am not ready to speak with him at this moment.”

Susan is accompanying Mekelle, and laughs when she laughs. “Not at this moment…”

“Right. [Mekelle laughs] Perhaps I should call him some day when I am mad. [Laughs some more and pauses] But… mm… it is beginning to weigh on me… this lets me know I ought to call now.”

In the second clip Mekelle speaks about the feelings of gratitude she is feeling for having been heard.

“The really interesting thing… to me… I… generally… am not one to share my feelings,” Mekelle clarifies. “I tend to keep these buried and let other people tell me how they feel.”

“Mmm,” Susan listens.

Mekelle makes several false starts in terms of continuing with what is in her mind, with several pauses in between. She finally speaks, “This whole process… of realizing I am still mad at him… because I did not know I was still mad at him… [pause] is very interesting… to me, that is. [Mekelle once again attempts to speak between her own pauses, and finally speaks with much strength, and drawing out the word mad each time she uses it] I ask myself, ‘Why, exactly are you mad?’ You know? Should you be mad? You could be disappointed… but mad! Especially since he did not do anything to you—by that I mean that he did not use offensive language, he did not hit me—… [pause]. I feel he disappointed me… ‘How can you be so intelligent and think like that?’”

A person who uses the empathic listening approach, in its purity, will have to dedicate large blocks of time to it. Depending on the trauma or situation involved, I have found that people can easily talk to you between one or two hours if you will listen. Before concluding this paper, I would like to share a few thoughts about reconciling empathic listening and our values.

Reconciling empathic listening to our belief system

Throughout the years I have read numerous books about empathic listening, from a number of authors. Some of its distinguished proponents suggest that there is no such thing as absolute truth. My challenge, however, was the need to reconcile such a stance with the incredibly positive results obtained by the methodology. You see, I am a strong proponent of the existence of an absolute truth; of right and wrong, and of good and evil.

For instance, Rogers would not moralize to his clients, no matter how horrible a thing they said. Nor—to his defense—did Rogers patronize people who felt troubled and tell them it was normal to feel a certain way. When a client said she really hated her mother, and would be glad to see her dead, Rogers would listen. Soon, his client would say, well, actually I do not hate her totally, I also really love her, and I would not want her to be dead. Through the several transcripts provided by Rogers, this pattern repeated itself over and over. Each time, the client seems to make good decisions, backing away from hurtful, destructive approaches.9

From experience in observing how poorly people listen, I suspect most individuals would benefit from reading Rogers. But returning to my dilemma, how could I reconcile my belief structure with being a good listener? Or, how about those situations when someone is blind to the most basic common sense? For instance, a person who says he is starving for the affection of a family member or former friend, yet is doing everything in his power to reject her?

After months of reflection, I have arrived at these conclusions: (1) when people are truly heard, they will often come to their own correct insights. But if their assumptions are still faulty, (2) by the very process of truly listening, the helper will earn the right to challenge blind spots. There will be moments when the listener has the right—or, should we say obligation?—to speak her truth.

For this listening model to work, it is necessary to have confidence in the goodness of people. That individuals, when they have had the opportunity to reflect and reconsider, will see the path that is necessary to leave the darkness behind.

Good-will deposits, earned through the listening process, are required before the helper earns the right to challenge an individual. When I have truly listened, then, if it becomes necessary, I can calmly present concerns from my perspective.

Despite all that has been said in this paper, there will be times when the mediator may have incompatible values with those of one or more of the parties involved. Helpers should not suggest that people violate their own principles or belief systems, nor should anyone expect a helper to be amoral. If a friend tells you he is thinking of being unfaithful to his wife, and if he does not reconsider during the process of being heard, I think it would be a great fault on the part of the listener to keep silent and not share his own feelings of repugnance towards such a stance.

There may be times, then, when the mediator or empathic listener may need to share her value system with another. Often, people will seek your opinion because they respect your values. One of the leading experts on empathic listening and challenging, Gerald Egan, further suggests that living by a value system may well be a pre-requisite to properly challenging others.

Genes may play a role in a person's ability to empathize with others, suggests a U.S. study involving mice.

Researchers trained highly social mice to identify a sound played in a specific cage as negative by also having squeaks of distress come from a mouse in that cage. But a genetically different strain of mice that were less social didn't make the same negative connection.

The study was published in the Feb. 11 issue of PLoS One.

The results indicate that the ability to identify and act on another's emotions may have a genetic basis, said the University of Wisconsin-Madison and Oregon Health & Science University researchers. They added that understanding empathy in mice may improve knowledge about social interaction problems that occur in many human psychosocial disorders, such as autism, schizophrenia, depression and addiction.

"The core of empathy is being able to have an emotional experience and share that experience with another. We are basically trying to deconstruct empathy into smaller functional units that make it more accessible to biological research," study co-leader Jules Panksepp, a University of Wisconsin-Madison graduate student, said in an Oregon Health & Science University news release.

"Deficits in empathy are frequently discussed in the context of psychiatric disorders like autism. We think that by coming up with a simplified model of it in a mouse, we're probably getting closer to modeling symptoms of human disorders," Panksepp explained.

"Mice are capable of a more complex form of empathy than we ever believed possible," Garet Lahvis, a professor of behavioral neuroscience at Oregon Health & Science University, said in the same news release. "We believe there's a genetic contribution to the ability for empathy that has broad implications for autism research and other psychosocial disorders."

Future studies will examine the genetic differences between the highly social and less-social strains of mice in an attempt to identify specific genes that may play a role in empathy.

Empathy constitutes one prominent ability of social cognition, which represents the human capability of understanding mental state of the other, and responding in sympathetic way. Two sets of theoretical mechanisms were designed in order to explain how empathy is possible. Theory of Mind (ToM)and Simulation.People who suffer from schizophrenia frequently exhibit social dysfunction, preventing them of a normal integration in healthy human environments. Recently it had been discovered that impairment in empathy and a specific impairment in effective TOM are mostly associated with the social malfunctioning of people who suffer from schizophrenia. One of the biological substances most connected to social cognition is the neuromodulator Oxytocin. Among its known involvement in uterine contractions and lactating females, numerous recent studies have found an indispensable role for Oxytocin in various complex prosocial behaviors such as maternal behavior, attachment, partner preference and trust. In the proposed study, we plan to examine the influence of a single dose of intranasal Oxytocin on the two primary mechanisms of empathy, namely mentalizing (Theory of Mind) and Simulation, both in healthy people and in people who suffer from schizophrenia.

Social cognition encompasses a wide spectrum of abilities, enabling us to function properly in interpersonal interactions. Empathy constitutes one prominent ability of social cognition, which represents the human capability of understanding mental state of the other, and responding in sympathetic way (Leiberg & Anders, 2006). Two sets of theoretical mechanisms were designed in order to explain how empathy is possible. Theory of Mind (ToM) is usually regarded as a more cognitive mechanism of empathy, in which a theory we posses regarding the other enable us to infer his mental state. 'Simulation' processing is another different mechanism of empathy. In contrast to the ToM perspective, the simulation perspective asserts that understanding the other's state of mind is achieved by an inner representation of that mental state in our mind, thus simulating his mental state. Therefore, the simulation theory may be associated with more affective aspects of empathy.

Schizophrenia encompasses a wide spectrum of psychotic disorders, characterized by severe cognitive, emotional and behavioral impairments. People who suffer from schizophrenia frequently exhibit social dysfunction, preventing them of a normal integration in healthy human environments. Recently it had been discovered that impairment in empathy and a specific impairment in effective TOM are mostly associated with the social malfunctioning of people who suffer from schizophrenia.

One of the biological substances most connected to social cognition is the neuromodulator Oxytocin. Among its known involvement in uterine contractions and lactating females, numerous recent studies have found an indispensable role for Oxytocin in various complex prosocial behaviors such as maternal behavior, attachment, partner preference and trust. It was suggested that Oxytocin may mediate the beneficial affect of social support, and is found strongly involved in different kinds of attachment. In a recent study, Domes et al. (2006) found that an intranasal administration of a single dose of Oxytocin enhanced the ability to infer mental states as conveyed by the eyes region (RMET, Baron-Cohen et al. 1995). These findings suggest a mediating role for the ability to use social cues in order to infer the other mental states. In the proposed study, we plan to examine the influence of a single dose of intranasal Oxytocin on the two primary mechanisms of empathy, namely mentalizing (Theory of Mind) and Simulation, both in healthy people and in people who suffer from schizophrenia. Mentalizing will be assessed by a variation of a validated ToM task, which requires cognitive and affective mentalizing. Simulation will be tested in two different tasks: emotion recognition via a dynamic paradigm of facial expressions, and recognition of biological motion, which necessitates the identification of the emotion conveyed in a video clips of point light walkers. Both of these latter tasks have been associated with simulation processing.



Through the process of being heard empathically, the troubled individual will control the direction, pace, and final destiny of the exploratory expedition. She will be required to do most of the hard work. Yet, she will not be left alone during this difficult voyage. Empathic listening permits those who own the challenge to begin to hear themselves. As a result, they become better equipped to solve their own difficulties. The empathic listening approach helps the person being heard to sufficiently distance himself from the challenge to see it with more clarity. There is great therapeutic value in being able to think aloud and share a problem with someone who will listen.

The good listener has enough confidence in himself to be able to listen to others without fear.

Part of being a good listener may require consciously fighting to keep an open mind and avoid preconceived conclusions. A helper may want to continually assess her listening style in a given situation. For instance, she may ask herself: Am I ...

  • Allowing the person with the problem to do most of the talking?
  • Avoiding premature conclusions based on my life experiences?
  • Helping the individual to better understand himself?
  • Permitting the person to retain ownership of the challenge?
  • Showing the party that we are listening without judging?
Author: U.S. Department of Health and Human Services

Carl Rogers (1980) defined empathy as: “the therapist’s sensitive ability and willingness to understand the client’s thoughts, feelings and struggles from the client’s point of view. [It is] this ability to see completely through the client’s eyes, to adopt his frame of reference....It means entering the private perceptual world of the other...being sensitive, moment by moment, to the changing felt meanings which flow in this other person....It means sensing meanings of which he or she is scarcely aware”.

“Mark” is a 30-year-old man who came to psychotherapy complaining of pervasive anxiety. Five minutes into the first session, the following took place:

Client: I’m really in a panic (anxious, looking plaintively at the therapist). I feel anxious all the time. Sometimes it seems so bad I really worry that I’m completely falling apart. Nothing like this has ever happened to me before.

Therapist: So a real sense of vulnerability—kind of like, you don’t even know yourself anymore.

Client: Yes! That’s it. I don’t know myself anymore. I feel totally lost, like a big cloud that just takes me over, and I can’t even find myself in it anymore. I don’t even know what I want, what I trust….I’m lost.

Therapist: Totally lost, like, “Where did Mark go? I can’t find myself anymore.”

Client: No, I can’t (sadly, and thoughtfully).

We searched carefully for all English-language studies using a measure of therapist empathy to predict treatment outcome. We found 59 different samples of clients (from 57 studies), representing 3,599 clients and 224 separate effects.

Our meta-analysis resulted in an overall effect size of .30, a medium effect, between therapist empathy and client success. This effect size is about the same size as, or slightly larger than, previous analyses of the relationship between the alliance in individual therapy and treatment outcome.

However, there was statistically significant, nonrandom variability across the effects (Cochrane’s Q = 205.8, p < .001), meaning that the empathy-outcome relation is not consistent and is affected by other factors. To investigate these sources of variability, we looked at a range of possible moderators. We found that empathy predicted treatment outcome consistently across different theoretical orientations (e.g., CBT, humanistic), treatment formats (individual, group), and levels of client problem severity. It was strongest for client- and observer-rated empathy. Empathy also appeared to predict outcome better for less experienced therapists.

Therapeutic Practices

  • It is important for psychotherapists to make efforts to understand their clients’ experiences and to demonstrate this understanding through responses that address the client needs as the client perceives them.
  • Empathic therapists do not parrot clients’ words back or reflect only the content of those words; instead, they understand overall goals and moment-to-moment experiences.
  • Empathic responses can take many forms, including straightforward responses that convey understanding of client experience, but also responses that validate the client’s perspective, that try to bring the client’s experience to life using evocative language, or that aim at what is implicit but not yet expressed in words.
  • Therapists should neither assume that they are mind readers nor that their experience of understanding the client will be matched by clients feeling understood.
  • Finally, because research has shown empathy to be inseparable from the other relational conditions, therapists should seek to offer empathy in a context of authentic caring for the client.

 At the beginning of treatment, psychotherapists and clients outline the conditions of their work together. Agreement about the nature of the problem for which the client is seeking help, goals for treatment, and the way that the two parties will work together to achieve these goals are the essence of goal consensus. To help clients fulfill mutually agreed-upon treatment goals, mental health service providers and consumers must function as a team. Collaboration represents the active process of their cooperation in this endeavor (Orlinsky, Ronnestad, & Willutzki, 2004).

“Hope” is a 21-year-old college senior and honors student who has recently returned to college after a leave of absence due to hospitalization in a mental health crisis center. Elements of goal consensus and collaboration with her therapist are indicated in brackets.

Therapist: It sounds to me like some of the people you are close to have disappointed you. You’d like to reconnect with them but aren’t sure how to do this. This makes it hard to relax around them and focus on your schoolwork. You also mentioned being quite isolated.

Hope: Yes, I am quite uncomfortable around other people now, almost all of the time. Since I don’t know what to say or how to act, I’ve started to avoid people. [goal consensus: agreement on patient problem].

Therapist: I was thinking that over the next few sessions, we could work together to come up with ideas about how to talk about your hospitalization and recovery with your friends and family [collaboration: mutual involvement of patient and therapist in a helping relationship].

Hope: I like the sound of that. And I’d also like you to help me experiment with gradually coming out of my shell as I work on getting healthy again [goal consensus: discussion and specification of goals; collaboration: patient role involvement].

We conducted two meta-analyses to address the question of how patient-therapist goal consensus and collaboration relate to psychotherapy outcome. The analyzed studies were published in English in refereed journals from 2000 through 2009. Each study included in the meta-analyses investigated the effectiveness of treatment among adult clients in individual psychotherapy.

The goal consensus-outcome meta-analysis—based on 15 studies with a total sample size of 1,302—yielded an overall effect size of .34 (SD = .19). This substantial result reflects the meaningful positive outcomes that are associated with improved agreement between therapists and clients about the aims of treatment and how to accomplish such aims.

The collaboration-outcome meta-analysis—based on 19 studies with a total sample of 2,260 patients—yielded an overall effect size of .33 (SD = .17). As with goal consensus, this result suggests that patient well-being is considerably enhanced with a better collaborative relationship. Both meta-analytic results are particularly relevant to the provision of effective mental health services, given that each analysis was based on studies measuring important outcomes, such as client retention in treatment, symptom reduction, and adaptive functioning.

Therapists and clients should begin problem-solving only when they agree on treatment goals and the ways they will go about reaching them together.

  • Psychotherapists should rarely push their own agenda. Listen to what patients say and formulate interventions with their input and understanding.
  • Good treatment entails clients’ contributions throughout psychotherapy by respectfully requesting their feedback, insights, reflections, and elaborations.
  • Clients need to recognize the importance they play in achieving goal consensus and collaboration with mental health professionals.

Positive Regard

 Carl Rogers (1951), the founder of client-centered therapy, did not believe that a therapist’s neutrality, dispassionate stance, or intellectual understanding could facilitate a client’s growth, no matter how astute the interpretations. Instead, he believed that treating clients in a consistently warm, supportive, highly regarding manner would enable them to grow psychologically and to reduce their suffering. Rogers’ notion of positive regard is embodied in two questions he posed: “Do we tend to treat individuals as persons of worth, or do we subtly devaluate them by our attitudes and behavior? Is our philosophy one in which respect for the individual is uppermost?” (1951, p. 20). This caring attitude has most often been termed positive regard, but early studies and theoretical writings preferred the phrase nonpossessive warmth.

In his famous filmed work with Gloria (Shostrom, 1965), Rogers struggled to find a single phrase to illuminate this concept. It is, he said, “Real spontaneous praising; you can call that quality acceptance, you can call it caring, you can call it a non-possessive love. Any of those terms tend to describe it.”

You’re reading me entirely wrong. I don’t have any of those feelings. I’ve been pleased with our work. You’ve shown a lot of courage, you work hard, you’ve never missed a session, you’ve never been late, you’ve taken chances by sharing so many intimate things with me. In every way here, you do your job. But I do notice that whenever you venture a guess about how I feel about you, it often does not jibe with my inner experience, and the error is always in the same direction: You read me as caring for you much less than I do (Yalom, 2002, p. 24).

In this example, Yalom, an existential therapist, not only offers assumedly accurate feedback to his patient on her interpersonal tendencies, but in doing so, explicitly conveys the fact that he cares for this patient far more than she imagines to be the case.

To investigate the association between the therapists’ positive regard and treatment outcome, we performed a meta-analysis of 18 studies that met our criteria for inclusion (e.g., the treatment was individual psychotherapy, clients were either adolescents or adults). The overall effect size among these studies was r = .27, indicating that positive regard has a moderate association with therapeutic outcomes. Only 2 of the 18 studies had negative effect sizes. Thus, like many other relational factors, positive regard appears to be a significant but not exhaustive part of the process-outcome equation.

The only significant moderator found was the percentage of patients from racial/ethnic minority groups. The results indicated that as the percentage of racial/ethnic minorities increases in a study, the overall effect size also increases.

Psychotherapists’ provision of positive regard is strongly indicated in practice. At a minimum, it “sets the stage” for other beneficial treatment methods.

  • Positive regard may be especially useful in situations wherein a nonminority psychotherapist is working with a racial/ethnic minority client.
  • Therapists should ensure that their positive feelings toward their clients are communicated to them. For many, if not most clients, the conviction that “my therapist really cares about me” likely serves a critical function, especially in times of stress.
  • Therapists can monitor their expressed level of positive regard and adjust it as a function of the needs of particular patients and specific clinical situations. Clients vary greatly in the extent to which they need, elicit, and/or benefit from a therapist’s positive regard; indeed, clients should strive to make explicit their need for their therapist’s support and affirmation.


 Congruence or genuineness refers to a relational quality of the psychotherapy relationship. There are two facets of congruence. The first reflects a mindful genuineness on the part of the therapist, underscoring present personal awareness as well as authenticity. The second facet of congruence refers to the therapist’s capacity to conscientiously communicate his or her experience with the client to the client. Congruence is thus both a personal characteristic (intrapersonal) of the therapist, as well as an experiential quality of the therapy relationship (interpersonal).

Consider how congruence appears in everyday interactions. Insurance agent Jones is quite formal and proper, appearing to play a prescribed role, rarely saying what he/she truly feels. Mr./Ms. Jones interacts in an incongruent manner. Coffee barista Brian, however, warmly greets you by your first name, attentively asks after your family, and openly shares his opinion about a movie he recently took in. Brian engages you, makes contact, and sincerely expresses himself in the brief time it takes to pour and pay for a cup of coffee. Brian interacts in a congruent fashion.

In psychotherapy, this means that the therapist is openly “being the feelings and attitudes which at the moment are flowing within him” (Rogers, Gendlin, Kiesler, & Truax, 1967, p. 100) and not hiding behind a professional role or holding back feelings that are obvious in the encounter. Congruence thus involves mindful self-awareness and self-acceptance on the part of the therapist, as well as a willingness to engage and tactfully share perceptions.

We conducted a meta-analysis on the relation between therapist congruence and treatment outcome. In order to be included in the analysis, a study had to report quantitative information adequate to calculate an effect size (ES). This resulted in 16 studies on 863 clients. The overall effect size for congruence with outcome was .24 (95% CI = .12 to .36). This is considered a small to medium-sized effect, accounting for about 6% of the variance in outcome, and providing evidence for congruence as a noteworthy facet of the therapy relationship.

  • Psychotherapists must embrace the idea of striving for congruence with their clients. This involves acceptance of and receptivity to the client as well as a willingness to use this information in conversation.
  • Congruence must be mindfully developed by therapists. As with all complex skills, this will require discipline, practice, and effort. This includes active and engaged listening on the part of the therapist.
  • An effective therapist models congruence. This may involve self-disclosure as well as sharing of thoughts and feelings, opinions, pointed questions, and feedback regarding client behavior. Congruent responses are honest; they are not disrespectful, overly intellectualized, or insincere.
  • Therapists can identify their congruence style and discern the differing needs, preferences, and expectations that clients have for congruence. Effective therapists will modify and tailor their congruence style according to client characteristics (e.g., culture, age, education).
  • A congruent therapist communicates acceptance and the possibility of engaging in a genuine relationship, something not easily expected from others in clients’ lives.

Adapting the Relationship to the Individual Patient

One of the most consequential trends in mental health concerns the movement toward evidence-based practice (EBP). The purpose of EBP is to promote effective mental health services. As applied to individual clinicians, EBP should increase the efficacy and efficiency of services provided to individual patients (or patient groups). As applied to society as a whole, EBP should enhance public health (Norcross, Hogan, & Koocher, 2008).

The Institute of Medicine (2001, p. 147) defined evidence-based medicine as “the integration of best research evidence with clinical expertise and patient values.” An American Psychological Association task force (2006, p. 273), beginning with this foundation and expanding it to mental health, defined evidence-based practice as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.”

EBP thus rests on three pillars: best available research, clinical expertise (of the practitioner), and patient characteristics. In fact, EBP resides in the intersection or overlap of these three evidentiary sources. The patient, the therapist, and the research all need to be in alignment or “on the same page.”

Psychotherapy has long concerned itself with tailoring the treatment to best match the needs of the individual patient according to the research. Every psychotherapist recognizes that what works for one person may not work for another; we embrace the maxim, “Different strokes for different folks.” This matching process has been accorded different names: adaptation, responsiveness, attunement, tailoring, matchmaking, customizing, prescriptive, and individualizing. However, the goal is identical: to increase treatment effectiveness by tailoring it to the unique individual and his/her singular situation.

The historical means of tailoring or adapting treatment to the individual patient has been to match the patient’s disorder to a particular treatment method. A patient presenting with, say, a specific anxiety disorder might be matched with cognitive-behavioral therapy, the most researched form of psychotherapy for anxiety. Another patient suffering from bipolar disorder (manic-depressive illness) might receive mood stabilizing medications, the most researched treatment for that condition.

This matching is certainly useful for select disorders; some psychotherapies make better marriages with some mental health disorders (Barlow, 2007; Nathan & Gorman, 2002). But only matching disorder to treatment in this way is incomplete and not always effective (Wampold, 2001). As Sir William Osler, father of modern medicine, is reported to have said: “It is sometimes much more important to know what sort of a patient has a disease than what sort of disease a patient has.” The research demonstrates that it is indeed frequently effective to match psychotherapy to the entire person—not only to his/her disorder (Norcross, 2011). And that match or adaptation should consider both the treatment method and the therapeutic relationship. In this way, the best available research, clinical expertise, and the patient’s characteristics are seamlessly integrated in EBP.

In this chapter, we provide a summary of the research on effectively adapting the treatment and the relationship to the individual patient in psychotherapy. Here are six effective means of tailoring psychotherapy to the entire person beyond diagnosis alone. For each, we identify the patient characteristic (e.g., reactance, preferences, culture) and review the research that indicates matching to it enhances the success of psychotherapy. We then feature how this adaptation can be actualized in session by the psychotherapist and the patient.

This patient characteristic refers to being easily provoked and responding oppositionally to external demands. Think of this personality trait along a defiance–compliance continuum: Some people tend to respond defiantly to authority figures and power, while others tend to respond in more compliant, easygoing ways. A meta-analysis of 12 select studies (1,102 patients) revealed a medium effect size (d = .76) for matching therapist directiveness to patient reactance (Beutler, Harwood, Michelson, Song, & Holman, 2011). Specifically, high-reactance patients benefit more from self-control methods and less structured treatments. Low-reactance clients, on the other hand, benefit more from therapist directiveness, explicit guidance, and more structured treatments. Thus, psychotherapists and consumers can together decide the optimal level of directiveness and structure that will work for them.

Patients enter psychotherapy with varying readiness to change or what researchers have called stages of change. Some minimize or deny their problems (precontemplation stage), some acknowledge their problems but are not yet ready to modify them (contemplation stage), while others are ready and eager to alter their problems immediately (action stage). A patient’s stage of change reliably predicts the success of psychotherapy; in a meta-analysis of 39 studies involving 8,238 patients, those clients starting treatment in the precontemplation stage did not fare nearly as well as those starting in contemplation or action (d = .46; Norcross, Krebs, & Prochaska, 2011). Another meta-analysis of 47 different studies showed large effect sizes (d = .70–.80) for matching treatment methods to the different stages of change (Rosen, 2000). Specifically, consciousness-raising and emotion-generating methods are most effective in helping people move from contemplation, while skills training and more behavioral methods are most effective for those in the action stage. Disparate systems of psychotherapy can be effective when tailored specifically to the patient’s stage of change.

Psychotherapy can also be profitably matched in many cases to the patient’s preferences in terms of the desired therapy method (e.g., psychodynamic, cognitive-behavioral, solution-focused), treatment format (individual, family, group), relationship style (e.g., active vs. more a listener), therapist characteristic (e.g., age, gender, religion), and treatment length (brief, medium, or long). A meta-analysis of 35 studies compared the treatment success of clients matched to their preferences versus clients who were not matched. The clients receiving their preferences did significantly better (d = .31) and were a third less likely to drop out of psychotherapy prematurely (Swift, Callahan, & Vollmer, 2011). It is the wise psychotherapist and the assertive consumer who explicitly discuss accommodating the client’s strong preferences whenever practically possible.

EBP integrates the best available research with clinical expertise in the context of patient characteristics, culture, and preferences (American Psychological Association, 2006). Thus, an escalating amount of research has investigated the effectiveness of tailoring or adapting psychotherapy to the patient’s culture. A meta-analysis of 65 studies, entailing 8,620 clients, evaluated the impact of these culturally adapted therapies vs. traditional (nonadapted) therapies. The results showed a definite advantage (d = .46) in favor of clients receiving culturally adapted treatments (Smith, Rodriguez, & Bernal, 2011). Professionals and consumers can adapt psychotherapy to culture in various ways, such as incorporating cultural content values into treatment, using the client’s preferred language, and matching clients with therapists of similar ethnicity race.

Another patient personality trait concerns coping style: how we characteristically respond to new or problematic situations in our lives. Some people tend to habitually withdraw or blame themselves (internalizers), some tend to regularly lash out or act out (externalizers), and of course, others are in the middle and use a balanced coping style. A meta-analysis of 12 rigorous studies (1,291 patients) found medium effect sizes (d = .55) for matching the therapist’s method to the patient coping style (Beutler, Harwood, Kimpara, Verdirame, & Blau, 2011). In practice, the research suggests that interpersonal and insight-oriented treatments tend to be more effective among internalizing patients. By contrast, the symptom-focused and skill-building treatments tend as a rule to be more effective among externalizing patients. Together, patients and their therapist can decide among several treatment methods that fit their personalities and preferences.

Some patients enter psychotherapy with a definite interest in incorporating their religious beliefs or spiritual values into the work. Many research studies have investigated whether these religious-accommodative therapies work as well as, or better than, their secular counterparts. A meta-analysis of 46 studies, involving 3,290 clients, found that patients receiving such therapies experienced equivalent if not superior progress. When examining the most rigorous studies, in which the religious-accommodative therapies and alternative therapies shared the same theoretical orientation and treatment duration, there were no significant differences in the mental health outcomes between the treatments. However, patients receiving the religious or spiritual-accommodative therapies progressed significantly better (d = .33) in their spiritual outcomes than patients receiving secular therapies (Worthington, Hook, Davis, & McDaniel, 2011).

The effectiveness of psychotherapy can be demonstrably improved by tailoring psychotherapy to one or more of these six patient characteristics: reactance level, stage of change, preferences, culture, coping style, and religion/spirituality. Two more dimensions—patient expectations (Constantino, Glass, Arnkoff, Ametrano, & Smith, 2011) and patient attachment style (Levy, Ellison, Scott, & Bernecker, 2011)—are definitely related to treatment outcome. More hopeful and more securely attached patients benefit more from psychotherapy, but we do not yet have as much or as compelling research on how to adapt psychotherapy specifically to them.

Decades of research now scientifically support what psychotherapists have long known: Different clients require different treatments and relationships. But the research has now identified specific patient characteristics and optimal matches by which to tailor or adapt treatment. In the tradition of EBP, psychotherapists can create a new, responsive psychotherapy for each distinctive patient and singular situation—in addition to his/her disorder.



Gregorio Billikopf Encina, Author, University of California, 2006 by The Regents of the University of California

1. Rogers, Carl R. (1951). Client-centered therapy: Its current practice, implications, and theory. Houghton Mifflin Company, Boston.

2. Nichols, M. P. (1995). The Lost Art of Listening: How Learning to Listen Can Improve Relationships (p. 111). New York: The Guilford Press.

3. Benjamin, A. (1974). The Helping Interview (2nd Edition) (p. 21). Boston: Houghton Mifflin Company.

4. Nichols, M. P. (1995). The Lost Art of Listening: How Learning to Listen Can Improve Relationships. New York: The Guilford Press.

5. Winslade, J., and Monk, G. (2000). Narrative Mediation: A New Approach to Conflict Resolution (pp. 126-128). San Francisco: Jossey-Bass Publishers.

6. Gayle M. Clegg, “The Finished Story,” Ensign, May 2004, 14, 174th Annual General Conference, The Church of Jesus Christ of Latter-day Saints, Saturday Morning Session, 3 April 2004.

7. Benjamin, A. (1974). The Helping Interview (2nd Edition) (p. 44). Boston: Houghton Mifflin Company. Empathy ceus continuing education, lcsw, counselors, mft, nursing, nurses

8. Egan, Gerard. (1986). The Skilled Helper:  A Systematic Approach to Effective Helping (3rd Edition), Brooks/Cole Publishing Company:  Monterey, California, pages 199-200

9. Rogers, Carl R. (1951). Client-centered therapy: Its current practice, implications, and theory. Houghton Mifflin Company, Boston.

10. Egan, Gerard. (1986). The Skilled Helper:  A Systematic Approach to Effective Helping (3rd Edition), Brooks/Cole Publishing Company:  Monterey, California.




|Home |CEUs FAQs | Course Approvals |Contact Us |Login |