EMPATHIC RELATIONAL BONDS AND PERSONAL AGENCY IN PSYCHOTHERAPY: IMPLICATIONS FOR PSYCHOTHERAPY SUPERVISION, PRACTICE, AND RESEARCH

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1 Psychotherapy: Theory, Research, Practice, Training Copyright 2007 by the American Psychological Association 2007, Vol. 44, No. 4, /07/$12.00 DOI: / EMPATHIC RELATIONAL BONDS AND PERSONAL AGENCY IN PSYCHOTHERAPY: IMPLICATIONS FOR PSYCHOTHERAPY SUPERVISION, PRACTICE, AND RESEARCH Although psychotherapy researchers have become increasingly interested in identifying common factors that contribute to effective therapeutic practices, across psycho-diagnostic categories and treatment approaches, relatively little attention to date has been focused on the impact of these research findings for psychotherapy supervision and training programs. To address this gap, in this article we describe key components of an integrative psychotherapy supervision and training program that focuses on the development of a strong therapeutic alliance as an empirically supported, common principle of change in psychotherapy. We review empirical research evidence that addresses the contributions of therapist empathic engagement for the development of secure, relational bonds, heightened client agency, and the development of strong therapeutic alliances, and we discuss the implications of these findings for therapy practice and supervision training. We conclude with specific recommendations for future research. Lynne Angus, Ph.D., and Fern Kagan, M.A., Clinical Psychology Graduate Program, York University. Correspondence regarding this article should be addressed to Lynne Angus, Clinical Psychology Graduate Program, York University, Toronto, Ontario, Canada. langus@yorku.ca LYNNE ANGUS AND FERN KAGAN York University Keywords: therapist empathy, empathy and psychotherapy training, enhancing client agency, principles of change, psychotherapy supervision Although psychotherapy researchers have become increasingly interested in identifying common factors that contribute to effective therapeutic practices, across psycho-diagnostic categories and treatment approaches, relatively little attention to date has been focused on the impact of these research findings for psychotherapy supervision and training programs (Castonguay, 2005). The purpose of this paper is to describe key components of an integrative psychotherapy supervision and training program at York University that focuses on the development of a strong therapeutic alliance as a common principle of change in psychotherapy (Pachankis & Goldfried, 2007). In particular, the contributions of therapist empathic engagement for the development of secure, relational bonds and heightened client agency will be highlighted and the implications for therapy practice and supervision training discussed. We conclude with specific recommendations for future research. The Therapeutic Alliance as a Core Principle of Change in Psychotherapy Castonguay & Beutler (2006) recently reported findings from a Principles of Change Task Force that reviewed the extant psychotherapy research literature addressing the treatment of dysphoric, anxiety, personality, and substance abuse disorders, in relation to participant characteristics, technique factors, and the therapeutic relationship. The development and maintenance of a strong working alliance was the only common relationship principle of change that received empirical support across all four psycho-diagnostic 371

2 Angus and Kagan categories. As defined by Horvath and Bedi (2002), the term therapeutic alliance refers to the quality and strength of the collaborative relationship between client and therapist in therapy. This conceptualization of the alliance addresses the importance of positive affective bonds between client and therapist as well as more cognitive aspects of the therapy relationship such as consensus about and active commitment to therapy goals and the identification and implementation of specific tasks and interventions. Based on the empirical evidence that a strong therapeutic alliance is essential for effective psychotherapy, alliance building skills have become an important focus of psychotherapy supervision and training in the Adult Clinical program at York University. In particular, we view therapist empathic engagement and the development of a secure, relational bond as a key precondition for the subsequent identification of shared goals and introduction of tasks that taken together constitute a strong therapeutic alliance. Empathic Relational Bonds and the Development of the Therapeutic Alliance General recognition of the importance of a warm, nurturing relationship and the establishment of a secure emotional bond with a caregiver, for adaptive psychological development, dates back to the Harlow monkey experiments (Harlow, 1958). The pivotal role played by attachment patterns formed in childhood particularly the experience of a safe, secure bond with an empathic caregiver for the establishment of satisfying interpersonal relationships in adulthood has also been noted by many theorists (Ainsworth, 1979, 1989; Bartholomew & Horowitz, 1991; Bowlby, 1969, 1988). Psychotherapy researchers have established correlations between clients recollections of caregiver relationships and their capacity to form an early working alliance in therapy (Mallinckrodt, 1991) and identified the specific contributions of therapist empathy for the development of secure therapeutic bonds and productive outcomes in psychotherapy (Orlinsky, Grawe, & Parks, 1994). As defined by Rogers (1975), therapeutic empathy entails the ability to (a) accurately attune with and perceive a client s internal, implicit frame of reference, in terms of both conceptual and emotional meanings, and (b) evocatively and effectively communicate that understanding to the client, during therapy sessions. Building on the empirical research evidence, and informed by the work of Rogers (1975), therapist empathic engagement is a key focus of our integrative approach to psychotherapy supervision and training at York University. First of all, the feeling of being understood and accepted by an engaged, empathic listener enables clients to disclose their most important and emotionally salient personal experiences to a therapist (Angus & Hardtke, 2006). Once externalized as a story, clients are then able to stand back from and actively reflect on their inner world of emotions, intentions, motives, goals, expectations, and beliefs for the identification of effective problemsolving strategies and the construction of more coherent and empowering personal meanings. More important, sensing and seeing new possibilities for the resolution of problematic life concerns engages a hopeful expectancy for change and a heightened willingness to take action in the world. Bandura (2006) argued that the meta-cognitive ability to reflect on oneself and the adequacy of one s thoughts, feelings, and actions is the most distinctly human, core property of personal agency. It is a heightened sense of personal agency (Williams & Levitt, 2007), in which clients become engaged in taking action to effect change in their own therapy relationships (Bohart, 2000) and personal lives (Bandura, 2006; Frank, 1961), that we view as an key client outcome of therapist empathic engagement. Drawing on Rogers s (1975) definition of therapeutic empathy, both therapist attunement and communication skills are viewed as essential for sustained empathic engagement and the development of a secure, relational bonds in psychotherapy. Specifically, therapist empathic attunement skills are viewed as facilitating the following client outcomes: 1. A safe and trusted relational bond enables clients to disclose specific, emotionally salient personal stories to the therapist (Angus, Lewin, Bouffard, & Rotondi-Trevisan, 2004), without fear of rejection or censure, that in turn facilitates the identification of core relational (Luborsky & Crits- Christoph, 1990) and emotion themes (Greenberg, 2002) for the formulation of comprehensive case conceptualizations 372

3 Special Section: Relational Bonds and Personal Agency in Psychotherapy (Goldfried, 2003) and the articulation of shared therapeutic goals. 2. Therapist empathic attunement helps clients engage in active, self-reflection for the expression and symbolization of primary adaptive emotions (Greenberg, 2002) and core beliefs (Goldfried, 2003) leading to the construction of new, more coherent, and empowering personal meanings (Angus, Levitt, & Hardtke, 1999). 3. Therapist empathic attunement helps sustain client s active self-reflection in the therapy hour and engenders a heightened sense of personal agency (Bandura, 2006) and self-mastery (Frank, 1961) for the client. 4. The experience of an empathic relational bond and heightened personal agency positively impacts client expectancies for change and leads to enhanced motivation for engagement (Westra, 2004) in therapy tasks and goals. 5. Therapist active empathic attunement to fluctuations in the depth and affective tone of the therapeutic bond functions as an early warning system for the detection and repair of alliance ruptures (Safran & Muran, 2000). In addition, the communication of therapist empathic understanding and validation is viewed as facilitating the following client outcomes: 1. The experience of disclosing deeply personal and painful experiences to the therapist, and feeling accepted and understood, may be the basis of a new, corrective interpersonal experience (Castonguay, 2005; Pachankis & Goldfried, 2007) for the client. 2. Therapists empathic understanding is experienced as relieving and soothing by clients and enhances their capacity for emotional self-regulation (Elliott, Watson, Goldman, & Greenberg, 2004) during the therapy session. 3. Therapist empathic validation of client accounts of positive change new outcome stories in their lives helps to bring saliency and meaning to those experiences (Hardtke & Angus, 2004; Kagan, 2007) and may facilitate the emergence of insight (Angus & Hardtke, 2006; Castonguay & Hill, 2006) and new, more positive views of self/self-identity (Goldfried, 2003; Kagan, 2007). Just as it is essential that beginning therapists establish a safe, secure therapeutic bond for productive therapy outcomes, supervisees also need to experience a sense of safety and security empathic attunement and understanding for optimal learning to occur in psychotherapy supervision sessions. Accordingly, the importance of an empathic bond for heightened personal agency (Bandura, 2006) and mastery (Frank, 1961) in supervisory relationships will now be addressed. Empathic Relational Bonds and the Development of the Supervisory Alliance As noted earlier, the ability to form a strong bond with others seems to be a transferable skill that is learned in the context of significant relationships and then generalized to subsequent relationships. Recent studies have consistently demonstrated a similarity between the quality of the supervisory relationship and the strength of the therapeutic alliance evidenced in supervisee training sessions (Alpher, 1991; Doehrman, 1976; Friedlander, Seigel, & Brenock, 1989; Martin, Goodyear, & Newton, 1987). Addressing these findings, Patton and Kivlighan (1997) suggested that trainees are taking the knowledge they are gaining in supervision about building and maintaining relationships and applying it to the relationship with their client (p.113). On the basis of a recent review of the psychotherapy supervision research literature, Ronnestad and Ladany (2006) recommended that supervisors attend to the development of a strong supervision alliance by using and generalizing therapy skills such as empathy and clarification responses. In addition, a strong working alliance in the supervisory relationship appears to foster an increased sense of self-efficacy (Lent et al., 2006) and personal agency in supervisees (Bordin, 1983; Patton & Kivlighan, 1997). The establishment of a secure, relational bond in the supervisory relationship appears to help foster a heightened sense of trust and confidence in beginning therapists wherein they are more likely to try new ways of empathically responding to clients and test out specific interventions and techniques. 373

4 Angus and Kagan At York University, Masters clinical students complete an introductory psychotherapy training practicum that focuses on the development of specific helping skills (Hill & O Brien, 2001) such as active listening, open-ended questioning, emotional validation, and evocative reflections for the development of secure, empathic bonds with clients. Through a series of in-class role plays, readings on the alliance and videos of therapy sessions, supervisees experience how empathic attunement and communication skills encourages clients to disclose core concerns and emotionally salient personal stories. During the first year of the Ph.D. program trainees complete a second, more advanced level psychotherapy practicum that adopts an integrative approach to the implementation of assessment and practice-based case formulation skills introduced in Masters-level courses. In addition to further developing empathic attunement and understanding skills for the establishment of secure relational bonds, supervisees also learn how to identify the emergence of within-session client process markers for example, disclosure of emotionally salient personal stories (Angus et al., 2004), expression of heightened emotional arousal (Greenberg, 2002), changes in therapeutic collaboration (Safran & Muran, 2000) and irrational beliefs (Goldfried, 2003) as indicators for the implementation of specific therapeutic interventions. It appears to be particularly helpful when supervisors model a process-diagnostic approach to listening to therapy sessions wherein components of the therapeutic alliance (e.g., bond, tasks, goals) and specific client process markers are identified and assessed in the context of the cut and thrust of the unfolding therapeutic dialogue. Although session outcomes measures such as the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989) are systematically reviewed in supervision sessions, supervisors also stimulate beginning therapist s reflective engagement in the moment-by-moment process of psychotherapy by replaying taped therapy sessions and empathically exploring supervisee responses and disclosures. Supervisors also foster supervisee agency by directing trainee attention to intervention choices they have made in sessions to bring new information to the trainee s awareness. In the advanced practicum, we also help supervisees to become more aware of their own therapy session skills by having them identify and transcribe a 20-minute segment from a recent therapy session and complete an intensive process analysis of the client therapist dialogue. Supervisees are required to reflect on and descriptively analyze the client therapist exchanges in terms of four basic categories: client utterances, therapist responses, alternative responses and comments, and reflections on the interaction between client and therapist. By critically assessing their own withinsession responses and using their own clinical judgment to identify possible alternate strategies for future implementation, supervisees begin to develop a heightened sense of trust in their own capacity to become effective agents of change in psychotherapy. In terms of novice therapists contributions to productive supervisory relationships, we have found the following supervisee attitudes to be important for successful new learning and skill development: 1. Openness to new learning. Skill acquisition and increased personal agency are not well served by either overly self-critical appraisals or blaming, externalizing attitudes in supervision sessions. 2. A compassionate awareness of the vulnerabilities and strengths of self and others. Empathic self-attunement (Rogers, 1975) and self-reflexive awareness is essential for enhanced personal agency (Bandura, 2006) and skill mastery (Frank, 1961) in supervision. Although it is clear that empathy and personal agency have important roles to play in the development of productive relational bonds, and new learning in both psychotherapy and clinical supervision, it is also important to address key differences that distinguish the nature and purpose of supervisory and therapeutic alliances. Empathic Relational Bonds in Psychotherapy and Supervision: Key Differences One key difference is in the focus of inquiry in supervision versus therapy. The focus of therapy is the elaboration of the client s story and the client s acquisition of new self-knowledge and skills to live a fuller, more satisfying life. In contrast, both supervisee and supervisor are focused on establishing a helping relationship with 374

5 Special Section: Relational Bonds and Personal Agency in Psychotherapy the client. The supervisee s personal development is in the service of providing a better outcome for the client, not an end in itself. In addition, there is evidence to suggest that the interpersonal basis of the alliance is different in supervision than therapy. Specifically, clients initial disclosures of personal information and emotionally-salient stories seem to contribute to the rapid development of a shared affective bond between therapist and client in good outcome therapy dyads (Angus et al., 2004). In contrast, the discussion of supervisee personal issues, during initial therapy supervision sessions, has been found to occur more often in low alliance dyads and may be linked to weaker supervisory alliances (Chen & Bernstein, 2000). Supervisory relationships, by definition, include an evaluative component and an early focus on supervisee personal issues, before a sense of safety has been established, may undermine the development of a sense of shared trust and the development of a robust supervisory alliance. The specific intentions and goals that guide the focus of inquiry in supervision and psychotherapy are also different. It seems likely that supervisees are primarily seeking assurances of their competence as clinicians from their supervisors and this differs from the understanding and new meaning construction that clients often seek from their therapists. Clients seek understanding first and only once this has been achieved do they feel safe enough to make changes. Supervisees seek understanding and require the empathy of their supervisors, but they do so in the context of their efforts to achieve competence as psychotherapists. It is only when a sense of confidence as a beginning therapist has been securely achieved that it is safe to disclose personal issues and not have them undermine the supervisory working alliance. In summary, we foster the development of trusting, empathic relational bonds in therapy and supervision for heightened personal agency, identification of shared goals, and the effective acquisition and implementation of specific therapeutic interventions. It is clear however that more research is needed to empirically validate the unique contributions of empathic bonds for the development of heightened mastery and personal agency in the context of psychotherapy practice and therapist training programs. Future Research Directions Given that supervision continues to occupy a central role in the transmission of therapeutic skills, future research would be well advised to explore the nature of the supervisory relationship from different role perspectives, using a multimethodological approach. In particular, we believe that it will be important to more fully investigate the relationship between empathic engagement and heightened agency for productive outcomes in both psychotherapy supervision and practice. Previous research studies, representing a range of therapeutic approaches, have consistently established that the impact of therapist empathy for treatment outcomes is most accurately assessed from the client s perspective (Burns & Nolen- Hoeksema, 1991; Lafferty, Beutler & Crago, 1991; Lorr, 1965). Accordingly, it may be important to acquire novice therapists first person accounts of productive and unproductive supervisor relationships using qualitative research methods (Hardtke & Angus, 2004) to gain a fuller understanding of the relationship between supervisor empathy and the development of supervisee self-efficacy (R. L. Lent et al., 2006; R. W. Lent, Hill, & Hoffman, 2003) and personal agency as novice therapists (Lehrman-Waterman & Ladany, 2001; Ronnestad & Ladany, 2006). The role of agency in psychotherapy and supervision is another important direction for future research. In a recent qualitative study, Williams and Levitt (2007) interviewed 13 expert therapists and identified a set of core principles that are commonly used to encourage agency in clients. Delineating the ways in which expert therapists encourage client agency has important implications for psychotherapy practice and training. Future investigations could also use qualitative methodologies to assess how supervisee agency is enhanced in supervisory relationships and assess the impact of those findings in terms of supervisee therapy outcomes. In addition, the link between a focus on alliance building skills in supervision and therapy outcomes remains cloudy. Although several researchers have put forth evidence that the alliance is a measurable skill that can be taught (Bambling, King, Raue, Schweitzer, & Lambert, 2006; Crits- Cristoph et al., 2006; Hess, Knox, & Hill, 2006; Summers & Barber, 2003), there remains a need for more research into how specific supervisory 375

6 Angus and Kagan interventions such as the use of empathic attunement and communication skills, impacts on client satisfaction with treatment goals and tasks, supervisee self-efficacy and the overall strength of the alliance. The concept of parallel processes (Ekstein & Wallerstein,1972) and the exploration of the different ways in which the supervisory relationship is reflected in the therapy process may also be an illuminating approach to studying the nature of the supervisory relationship and the contribution of supervision to therapy outcomes. Using the WAI (Horvath & Greenberg, 1986) to measure the client therapist alliance and the training version of the WAI, which assesses the strength of the supervisory alliance (WAI T; Ladany, Ellis, & Friedlander, 1999) to measure the interrelationship between the supervisory and training alliance is also a promising direction for future research. 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