1. Improving Clinician’s empathy skills with ACT
Matthieu VILLATTE, PhD, Jean-Louis MONESTES, & Roger VILARDAGA
ACBS WORLD Con VIII
RENO

2. Some clients puzzle us
Clients that are difficult to help, that confront us with failure
who seem to judge us
who present opposite values comparing to ours
who made actions that are shocking to us, that seem unforgivable to us
who we think they don’t really need help; (we don't think they have serious issues)
who try to involve us in a kind of relationship we don’t want (try to be our friends…) …
We don’t become empathic  the day we graduate. We think that empathy is a skill than can (and must) be improved and trained.

3. Exercise n°1
Play your most difficult client

4. A few words about language and ACT
1- ACT is based on Behavior Analysis
Focus on learning mecanisms (functional approach)
Focus on the role of context in learning and maintaining behaviors (contextual approach)
2- Built on the behavioral model of language proposed by RFT
Relational properties of language lead to:
Cognitive fusion (verbal events evoke emotions + insensitivity to environment),
Loss of contact with present moment (fear of future and rumination of past),
Difficulty to durably suppress psychological events without deleterious consequences on values.

5. A few words about language and ACT
2- Built on the behavioral model of language proposed by RFT
Relational properties of language lead also to:
Building new directions of life (in terms of values and not only of goals)
Commiting in behaviors which consequences can be distant or absent, in presence of difficult psychological events.

6. In interactions with others, language has also problematic effects
The Conceptualized Self
(clinicians' and clients'…).
Verbal definition of the self.
Effects of fusion and insensitivity.
I behave according to this definition
I perceive others through my verbal conceptualization of them (ex. « He’s old, he can’t understand »; « She did long studies, she must look down at others »; « He has written books, he must be right »…)

7. In interactions with others, language has also problematic effects
The Conceptulized Self (one’s and others’…).
An effect also present in therapy
What therapist am I? (« I am a man/a woman »; « I am xx years old »; « I practice therapy x »
Who is my client? (frequently perceived through their « symptoms »)

8. These effects constitute barriers to empathy and compassion (acceptance of others’ emotions)
Partial perception of the client
He’s a schizophrenic, he can’t be autonomous
She’s a depressive person, she can't value anything
He’s been an alcoholic for 15 years, he can't change.
Difficulty to identify and accept emotions of the client
Interferes with pratice

9. Therapeutic relationship in ACT
We don’t need to be empathic  because it’s our job or just because it is how a therapist must be.
We need to be empathic because a main part of therapy is to shake client’s behavioral repertoire. This change comes with difficulties for the client (creative hopelessness)
Client’s life is not hopeless, experiential avoidance strategy is. Therapist’s empathy helps the client to perceive the difference.

10. Therapeutic relationship in ACT
When introducing creative hopelessness to clients, it’s essential that:
They feel they are not judged
On the opposite, that they perceive their suffering is received and accepted unconditionally
They know that it’s normal to feel what they currently feel, to think what they currently think, because of their past and because of language properties
They perceive that the therapist is on the same boat as they are: we have to be acceptant (empathic) to shape acceptance

11. Definition of the therapeutic relationship
BORDIN (1979) described the therapeutic alliance as a composite of three different aspects:
the relational bond between therapist and client
the tasks of psychotherapy
the goals of psychotherapy (or the outcomes that are sought)

12. An empathic tour of the hexaflex for therapists
Contact with the present moment
Values
Acceptance
Psychological
flexibility
Defusion
Commitment
Acceptance : acceptance and empathy are of course very bounded. Adopting other’s perspective allow a better understanding and acceptance of what he does or is, and also increases acceptance of my feelings in front of him.
Defusion : understanding language processes and how our mind produces automatic interpretations helps to detect barriers to empathy. Conversely, managing to consider lightly our judgments and thoughts about clients helps being empathic.
Contact with the present moment : allow to observe any obstacles to empathy and to its expression to the client. Focusing on client in present moment limits the influence of our thoughts and judgments about him/her, and the influence of previous experiences with others people that the client remind us. Focusing on present moment helps being deeply in the relationship, here and now.
Self as context : travelling on the road to consider self as the context of each psychological event also helps the therapist against barriers to empathy, by defusing from the therapist self as concept. The client does not threaten my self-image, my conceptualisation of myself as a “good therapist”, “someone patient”, and even my judgment about the fact that I must be empathic to be the “ideal therapist”.
Values/commitment : on can suppose that one of the main therapist’s value is to help and understand others/clients. Might be why you’re in this room right now (or maybe there was nothing else interesting at the time. Thank my mind!)
Self as context

13. Why developping empathy and compassion ?
Utility of empathy and compassion
For the client:
Favors identification and acceptance of their own psychological events
Favors change (my problems are caused by universal processes; like others, I can change)
For the therapist:
Better identification of emotions felt by the client.
Better identification of the function of behaviors (reduces the filter of language in the search of useful cues).
Reduces the tendency to change the client's psychological events

14. How does ACT develop empathy competencies?
Identifying psychological events of the client… Different possible ways:
Gathering cues + rules
Works, but still language (with its potential limits…)
Changing perspective
Uses language but more direct access to psychological events of the client

15. A word about RFT and perspective taking skills…
Language= relating events arbitrarily (or not!)
Different ways of relating events:
Frame of equivalence, opposition, hierarchy, etc.
and frames of perspective taking (=DEICTICS)

16. Deictic frames: I / You (interpersonal perspective)
Here / There (spatial perspective)
Now /Then (temporal perspective)
This particular type of relational responding is learned through multiple exemplars of questions/answers involving different perspectives (What do you see from there? Yesterday, did you know I would come today?)
(Hayes, 1984; McHugh et al., 2004)

17. 3 step model of the therapeutic relationship
Perspective-taking
Deictic framing
Empathy
Transformation of functions of deictic relations
Psychological flexibility
Contextual control over deictic and other relational functions
I/You
Excitement
Affection
Joy
I/You
Sadness
Fear
Hate
Contextual control
I/You
Here/There
Now/Then
Effective therapeutic relationship

18. Competencies in relating the self to others, time, and space are correlated to identifying others’ mental states (Villatte et al., 2008, 2009, 2010)
The more I am skilled in taking the perspective of others, the more I am able to identify what they think and feel.

19. Objective : Developing our competencies in changing perspective
Multiple exercises that employ various contexts and each time, a change of perspective.
Exercise n°2 (Finish the sentences)
Exercise n°3 (Live other's emotions)

20. How does ACT develop compassion ?
Changing perspective leads to contacting emotional states of the client
Triggers emotional states in the therapist
Can trigger avoidance of the therapist (with problematic effects of experiential avoidance…)

21. Exercise n°4 Negative judgment
Use on yourself the same techniques you employ with your clients (all the hexaflex!).
Exercise n°4 Negative judgment

22. Knowing the past to develop empathy

23. Knowing the past to develop acceptance of the other
According to behavior analysis, our next behaviors are the product of history of previous behaviors and consequences
« Past is the future of our present »
The more you know one’s past, the more you can accept it, since you understand why one behaves that way.

24. Exercise n°5 Client’s past

25. Knowing the past to develop acceptance of the other
It’s a deterministic, but also a probabilistic model: history of previous behaviors and consequences causes our futur behaviors, but …
- hazard can play an important role
- huge number of variables in interaction
- each consequence has different effects depending on history of behaviors and consequences

26. Important variables to know, but also hazardous learning
Some important variables (hence important to know to improve empathy), notably repetitive or emotionally loaded ones
Some « hazardous » learnings: superstitious behaviors reinforced randomly (ex BPD)

27. Knowing the past to develop empathy
Understanding these mechanisms allow to improve acceptance of the client, even if it’s impossible to exactly know the whole story, neither to predict exactly how the client is going to behave
Most importantly, implications of determinism are :
Absence of responsability of one’s behaviors
Anybody else with the exact same behavioral history would behave exactly the same (including the therapist)

28. Exercice n°6 Client's journey to session

29. Improving Clinician’s empathy skills with ACT
Matthieu VILLATTE, PhD, Jean-Louis MONESTES, & Roger VILARDAGA
ACBS WORLD Con VIII
RENO