Empathy and Understanding in Mental Health Conversations

Lately, I’ve received numerous emails asking, in essence, "how can I help my loved one who has this or that problem?" I would say that I get several emails like that every week.

For example, here's one from a man we’ll call “Karl.”

Love you podcasts. Listen as often as I can. keep reading your books.

Our son is in an unhappy marriage. Last night we talked and he mentioned that there is no love in their marriage. Just coldness. The children "feel" the chasm. There is a lack of trust in the home.

Our son feels he did not protect the children in defense of their mom, even though he disagreed with her. Now the children feel their father does not have their best interests. Our daughter-in-law feels that everything is fine. She uses the passive-aggressive "silent treatment" to punish others.

Our son says she is controlling and manipulative, and that the children have become that way also. There's no truth in the home. Years ago, she wanted them to go to counseling, but our son refused; now the tables are turned.

Sad. We want to help but don't know how to approach it.

What podcasts would be helpful to us? And to our son and daughter-in-law? We visit our grandchildren often, sometimes one-on-one. Communications are open with them and with our son.

Daughter-in-law feels, and tells others, we are conspiring against her

Karl

Thank you Karl, for that moving email. It can be really sad and frustrating to see a couple in conflict who are at odds with each, especially when your son and grandchildren are involved. And I can imagine you might also be feeling anxious and a bit helpless, and deeply concerned!

When I wrote Feeling Good forty years ago, I tried to make it clear that the cognitive therapy tools I described in that book are for people to use to help themselves. It is okay to correct your own distorted negative thoughts in order to break out of a bad mood. But it is generally NOT a good idea to try to correct someone else’s distorted thoughts, because they’ll just get ticked off at you!

This is a very understandable error, because you may get really excited by the things I’m teaching, and how helpful they can be when you’re feeling depressed, anxious, or insecure. So it just makes sense that you would want to share these tools with others.

But those are generally NOT the tools to use when you’re talking to your son, daughter, spouse, or friend who’s feeling down in the dumps. There is a way to help someone you love who’s hurting—but you’ll have to use an entirely different set of tools and skills—the Five Secrets of Effective Communication—WITHOUT trying to “help.”

So, the short answer to your question is—skillful listening is all that’s called for. Anything more runs the risk of getting you into trouble. But this may require a radical change in the way you communicate, as well as your personal philosophy.

Let’s talk about what TO do, and what NOT to do when patients, friends or people you care about express angst, or seem troubled, or describe problems in their lives, and they seem to be hurting a lot.

DO NOT

1. Give advice
2. Try to help
3. Try to cheer the person up
4. Try to solve the problem s/he is struggling with
5. Try to get the other person to think or act more positively
6. Try to minimize the problem by saying it’s not that bad, or things will get better.
7. Point out ways the other person may be thinking or acting in a self-defeating manner.

Before we tell you what does work, let me focus on just one of these errors, to bring it to life for you. Recently, Rhonda and I recorded a live therapy session with a man named who was upset because his mother had lost the use of her legs to due a rare neurological disorder, and needed much greater care in an assisted living facility. This required selling the house his mother was living so they could afford the assisted living facility, and it was a great loss for everyone, since Kevin was raised in that house, and his parents and grandparents had lived there, too.

After Rhonda and I empathized with him for about thirty minutes, we asked the other therapists to offer empathy as well, as part of their practice and training that evening. We stressed the importance of simply summarizing what Kevin had told us (Thought Empathy) and how he was feeling (Feeling Empathy), without trying to “help.” One of the therapists, who was new to the group, kind of missed the mark, She did what we call “cheerleading,” telling Kevin what a wonderful and heroic person he was without acknowledging what he’d be saying and how painful it was for him.

You’ll hear this brief excerpt from the session in the podcast. When we asked Kevin how he felt about her comment, he had to tell her that he was embarrassed, and not helped, by what she’d said.

Here’s why. When you don’t acknowledge someone’s profound negative feelings of loss, anxiety, sadness, anger, and more, you might unintentionally convey the message that you don’t want to hear about how they really feel inside. And when you cheerlead, it also conveys the message that the person is not very intelligent, and simply has to be cheered up, and then everything will be okay!

We cannot be too hard on this therapist, because her efforts came from the heart, and I'm sure she felt sad for this man. And most of us have made the same mistake at times, or even often. I frequently hear parents trying to cheer their children up, or trying to tell their children what to do, or how to change, without really listening.

But, most of the time, it just doesn’t work like that!

Now that you know what NOT to do, what can you do that WILL help?

DO

Use the Five Secrets of Effective Communication, with an emphasis on the listening skills. One of the most important skills is called Feeling Empathy—simply acknowledging how the other person is feeling, and asking them to tell you more, and if you got it right.

For example, let’s say a friend or family member is procrastinating on something important, like a research report or college application, and is feeling pretty upset and self-critical. You could say something like this: “It sounds like you’re beating up on yourself for procrastinating, I’m wondering if you’re feeling

1. down, sad or depressed?
2. anxious, worried, pressured, or nervous?
3. guilty or ashamed?
4. inadequate, worthless, defective, or inferior?
5. alone or lonely?
6. humiliated or self-conscious?
7. discouraged or hopeless?
8. stuck or defeated?
9. angry, annoyed, hurt, or upset?”

I find that people really like it when I ask these questions, and I let them answer each one. Then I ask them about their negative thoughts. What are they telling themselves? What are the upsetting messages?

When you use this approach, you are literally doing nothing to “help” the other person, but if you listen skillfully, she or he will probably really appreciate your listening, and you may end up feeling really close. In fact, I (David), had this exact experience just a couple days ago with a student who was struggling and feeling down.

Often, the person who’s depressed will be someone you love, like a family member, so your concerns for him or her, and your desire to “help,” are an expression of your love. But listening skillfully will likely be a whole lot more effective. And you can express your own feelings, too, with "I Feel" Statements, like "I feel sad to hear how down you've been feeling, because I love you a lot."

Example

A woman named Clarissa was concerned because her son, Billy, who is in his early 20s, had been severely depressed for several years, and had not responded to treatment with antidepressants and even lithium. Clarissa had read my book, Feeling Good, and listened to almost all of the Feeling Good Podcasts. She described herself as a true “TEAM-CBT convert because she’d worked with a therapist trained in TEAM-CBT and no longer suffered from the depression and anxiety she’d struggled with most of her adult life. She agreed with a lot of what I’d said on the podcasts about the chemical imbalance theory (there’s no convincing evidence for it) and antidepressants (recent research suggests they do not outperform placebos to a clinically significant degree).

But Billy was saying things like this:

“Mom, I KNOW I have a chemical imbalance because this cloud will suddenly come over me, and I feel TERRIBLE. It’s not about negative thoughts—I don’t have any negative thoughts. My depression is clearly the result of a chemical imbalance, and I feel doomed by my genes.”

Then Clarissa would try to cheer him up, which always failed, or would try to convince him that it’s not about a chemical imbalance and that if he really tried TEAM-CBT, he could overcome his depression, just as she had done. These are such common errors!

How could Clarissa respond more effectively? If she focuses on good listening skills, instead of trying to win an argument, she might say something like this:

“Billy, I really love you, and feel so sad to hear about your depression. You’re absolutely right, too. Sometimes a bad mood seems to come from out of the blue, with no rhyme or reason. And genes can be important. I've struggled with depression in the past, and maybe you've inherited some of my genes. Tell me more about how you’ve been feeling. Have you been feeling down, anxious, ashamed, hopeless, or angry? What you’re saying is so important, and I really want to her what's it's been like for you.”

Can you see that Billy would be more likely to open up and might even share some things that he’s been hiding, out of a sense of frustration, anger, or shame? And can you also see that providing some love and support—pure listening, with compassion—might be a lot more helpful than getting into an argument about the causes of depression? He might open up about all sorts of things that have been eating away at him—problems with girls, sex, sports, or his studies, or concerns about his looks, or even feelings of shame about his depression.

The next question is—when DO you help someone? And HOW do you help them.

The approach I use as a therapist might be the same approach you’d want to use. At the beginning of every therapy session, I empathize without trying to help, exactly as I’ve been teaching you in this podcast, and in this document, and I give the other person some time—typically about 30 minutes or so—just to vent while I use the Five Secrets of Effective Communication—listening skillfully—without trying to “help.”

Then I ask the patient to grade me on empathy. I say, “How am I doing so far in terms of understanding how you’re thinking and feeling? Would you give me an A, a B, a C, or perhaps even a D?”

Most of the time, the other person WILL give you a grade. If they give you an A, you’re in good shape. But if they give you an A-, or a B+, or worse, ask them to explain the part you’re missing, or not getting right.

When they tell you, you can use the Five Secrets again, summarizing the part you missed, and then ask what your grade is, to see if you’ve improved. Usually, your grade will improve a lot.

Do NOT try to “help” until you received an A!

So, let’s assume you’ve gotten an A. What then?

Then I do what’s called the Invitation Step in TEAM therapy—I ask if the other person wants help with any of the problems s/he has been discussing. You can ask the same question.

If the other person does NOT want help, but just wanted to talk and get support, your job is done. You can also ask if they want to talk some more. Most of the time, all people want is a little listening and support, and they’re not looking for help or advice.

But if the other person DOES want help, you can ask what kind of help they’re looking for. Then you can decide if you’re in a position to provide that type of help. Sometimes, the help they're looking for might not be something you can provide. For example, they may be angry at someone they're not getting along with, and may want you to tell the other person to change. I explain that this is not something I would know how to do, but I could possibly help them change the way they interact with that person.

This may sound really simple, but it takes a lot of practice and determination! It can be a lot harder than it looks.

Many people will NOT want to go down this road, and will insist on jumping in to help or cheerlead. You can do that if you want, but in my experience, pushing help on people who are hurting is rarely helpful. The “need” to help or rescue can result from your love and compassion, but it can also result from narcissism, codependency, or the desire to control or dominate another person. I see it as a kind of an addiction, too.

If you want to learn more about this, here are some things you can do:

• You can read my book, Feeling Good Together, and do the written exercises while reading, so you can master the Five Secrets of Effective Communication. This is a BIG assignment, but the reward, in terms of more loving and satisfying relationships with the people you love, will be equally great.
• You can try using "I Feel" Statements and Feeling Empathy with at least one person every day this week.

David D. Burns, M.D. & Rhonda Barovsky, Psy.D.