Accentuate the Positive: Reflections on Empathic Interpersonal Interactions

I address you today with joyful gratitude for this fantastic honor. Thank you! For almost half a century, I have practiced occupational therapy with a focus on brain injury. During the past year, I have reflected on my career and the defining characteristics that have shaped my practice and my life. Upon reflection, I have concluded that positive, empathic interpersonal interactions have been one of the most important factors in my personal and professional development. Empathy is one of the basic ingredients responsible for changes that occur during intervention. There is evidence in the occupational therapy literature that supports the need for further training in and understanding of this important process. In this lecture, I will provide a brief review of empathic interactions as they relate to occupational therapy, discuss interdisciplinary knowledge from positive psychology and social neuroscience that can enhance our understanding and use of these interactions, and offer my reflections on positive empathic interactions in my practice.I identify six positive interactions that are guided by six corresponding questions, implicitly generated by the client. The six positive interactions were, to a large degree, determined during my clinical practice. They were also shaped by many other factors, such as my Hispanic culture with its Puerto Rican roots and my roles as mentor, educator, and researcher. I trust that this lecture will heighten awareness of the importance of empathy and foster a clearer and broader perspective on this elusive process as applied to the brain-injured population. I believe that focused reflections on empathic care can illuminate the art and science of occupational therapy and promote our development as well as that of the people we serve.One of the guiding beliefs of occupational therapy is that, through positive empathic interactions, we reach out in a caring manner, trusting that the people we work with will find their own strength (Baum, 1980). However, a national survey conducted by Taylor, Lee, Kielhofner, and Ketkar (2009) of 568 practicing occupational therapists in the United States found that although more than 80% of the participants reported a high value for the therapeutic relationship and use of self, they felt that they were inadequately trained and that the field lacked sufficient knowledge in these areas. Only 4% of these therapists reported that they took courses specifically on the therapeutic use of self. Taylor (2008) has conceptualized empathy as a means for practitioners to establish the therapeutic use of self, and in another survey, Taylor, Lee, and Kielhofner (2011) found that empathy was the least used mode during the therapeutic relationship. These surveys’ results highlight the fact that training in the empathic process needs to be expanded.For this lecture, empathy is defined as a multidimensional, complex, emotional, cognitive, and movement process that emerges from an objective and subjective impression of another person’s emotional state or perspective (Davis, 1983; Decety & Batson, 2007). People engaging in the empathic process use their abilities to feel, detect, imitate, and express emotions and to communicate verbal and nonverbal signals to understand each other. Empathy is an imaginative, creative, and imitative process that depends on four factors: (1) willingness to enter the other person’s emotional state, (2) desire to use the self as a motivational agent of change, (3) competencies for language expression, and (4) readability of social communications (Watt, 2005).Following in Carl Rogers’ (1951) tradition, many occupational therapists believe that empathy is the basic ingredient for promoting change during the intervention process. Empathy promotes humanistic or person-centered practice and may foster a positive and improved understanding of social interactions (Rogers, 1951).Affirmations of empathic care and humanistic practice with a focus on emotion, optimism, and clients’ strengths are present in the occupational therapy literature and in numerous Slagle Lectures (J. C. Rogers & Holm, 1991; Rosa & Hasselkus, 2005; Yuen, 1997). Many scholars agree that empathic interactions and accentuating a positive perspective are critical for competent and compassionate health care. In her 1975 Slagle Lecture, Josephine Moore proposed a focus on the emotional component of behavior as a guiding principle for neuroscientific-based practice (Moore, 1976). She suggested that practitioners perfect their ability to relate to others on an emotional or limbic level instead of functioning entirely in an intellectual manner.Carolyn Baum, in her 1980 Slagle Lecture, called us to recommit to empathic care in the health system. She stated, “Through our professional relationships we reach out and with empathy show that we care hoping that from this caring that the person will find his or her own strength” (Baum, 1980, p. 515).In a similar fashion, Winnie Dunn, in her 2001 Slagle Lecture, advocated an accentuation of a child’s positive tendencies to balance the image of children with sensory processing problems (Dunn, 2001). Wendy Coster, in her 2008 Slagle Lecture, also promoted an accentuation of the positive when she suggested that occupational therapy measures have the power to positively shape the story that others hear about the persons we assess (Coster, 2008). She advised therapists to persuade others to tap the strengths of clients to develop comprehensive interventions.The discussion of positive empathic interactions has been led by Suzanne Peloquin (1995), who has used empathy as a value and a means of reclaiming the profession’s heart. Her numerous writings on empathy serve as our profession’s inner voice that inspires us and calls us back to the art of practice. Her 2005 Slagle Lecture was an exposé of beliefs that guide our practice. Her call relies on positive empathic interactions as a critical value (Peloquin, 2005).Dr. Peloquin’s writings on empathy have helped me articulate what I believe has been my underground clinical practice. She believes that the empathic process requires being sensitive, respectful of differences, and fully present to the other person. She asserted that empathy enables the act of doing with so that it becomes an expression of being with (Peloquin, 1995). Both therapeutic actions empower and encourage each other.In general, our scholars have described empathy as a creative skill (Peloquin, 1989). Anne Mosey (1981) referred to the art of practice as the capacity to empathize with another individual. Charlotte Royeen, in her 2003 Slagle Lecture, described and promoted the habits inherent in the art of practice (Royeen, 2003). Florence Clark’s 1993 Slagle Lecture encouraged positive interpersonal interactions such as friendship, rapport, and equality to help clients define and find solutions for their problems (Clark, 1993). Janice Burke, in her 2010 Slagle Lecture, portrayed therapists as choreographers of the therapeutic encounter. She illustrated important distinctions between what is said and what is done in practice (Burke, 2010).Although abundant affirmations of empathy exist in the literature, there is limited evidence for the measurement and the development of empathy as a foundation for improved therapeutic interactions. As early as 1977, Charles Christiansen compared the empathy ratings of occupational therapy students with those of peers and faculty using the Hogan Empathy Scale. The results revealed a significant correlation between measured empathy and the perceived ability to empathize (Christiansen, 1977). More recently, Froman and Peloquin (2001) suggested rethinking the use of the Hogan Empathy Scale (Cross & Sharpley, 1982) after a critical psychometric analysis revealed poor internal and discriminant validity of this scale (Froman & Peloquin, 2001).Another empathy measure used in occupational therapy was the Kagan Empathy Scale (Campbell, Kagan, & Krathwoh, 1971) used by Bethany Wise and Marilyn Page (1980). When researchers administered the scale to students before and after completing a seminar and a group process course, they found that the course had positively affected the student’s empathy (Wise & Page, 1980).A 2010 study of Australian occupational therapy students by Brown and colleagues using the Jefferson Scale of Physician Empathy (Hojat et al., 2001) and the Medical Condition Regard Scale (Christison, Haviland, & Riggs, 2002) found that the students showed variable empathy levels depending on the diagnoses of their clients. The students held substance abuse in comparatively low regard as compared with other conditions such as stroke, traumatic brain injury, and cerebral palsy. This result provides further support for the need for more training in the area of empathy.There are few empathy studies focusing on the client’s perspective. Although phenomenological in nature and rooted in the traditions of the humanities, Peloquin’s exploration in the 1990s of the narratives of clients sought to better define their perceptions of the meaning of empathy as well as its absence, often called depersonalization (Peloquin, 1993, 1996). Peloquin proposed that stories of effective empathy could guide interventions and practitioners.A 2010 follow-up qualitative study by Sharon Myers, a counseling psychologist, and Catherine White, an occupational therapist in Canada, confirmed that empathy can act as a catalyst of personal growth. They found that 10 yr after treatment, clients continued to credit the empathic therapeutic relationship as the basis for their personal growth (Myers & White, 2010). Two predominant themes emerged: (1) Therapeutic relationships were a foundation for change, and (2) they led to affirmation and enhancement of the personal agency of clients.In another study by Cordier and colleagues (Cordier, Bundy, Hocking, & Einfeld, 2010) in Australia, researchers used the Test of Playfulness (Bundy, Nelson, Metzger, & Bingaman, 2001) to compare play in children with attention deficits with typically developing children. 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