Where’s the empathy in addiction treatment?

Originally published June 4, 2020 on Recovery View

I have been fortunate enough over the past 25 years to sit in on Chemical Dependence (CD) groups and provide feedback to counselors.  Out of 23 skill areas evaluated, this item: “Counselor demonstrates empathy” is consistently one of the lowest rated.  This is due in part to most counselors having not been taught the skill in a clinical setting and because of the lack of group supervision at many treatment facilities.  Many seasoned counselors I’ve evaluated have never had a supervisor sit in on group and provide feedback.  At the risk of sounding dramatic, it may be that many treatment centers’ managers have little idea of what is really happening in their groups.  It is very important for rehabs to regularly provide such in-group supervision, and to teach the skill of empathy. 

One of the reasons it is vital to learn this skill is because of its importance in building therapeutic alliance.  Several researchers cite therapeutic alliance as being the most important determinant to success in treatment (outside of extra-therapeutic factors which we have no control over).  According to Mee-Lee, D., McLellan, A.T., and Miller, S.D. (2010): “Therapeutic Alliance between client and counselor in a planned and structured treatment plan is what creates positive outcomes.”   Furthermore, Cabaniss (2012) describes the key part of a therapeutic relationship between a counselor and a client is the empathy that the counselor provides. 

With therapeutic alliance being so important, and empathy being a key component to building it, the importance of learning empathic skills cannot be over stated.  “Clients must experience from their therapists in order to have a good therapeutic relationship: (a) acceptance, (b) trust, and (c) feeling understood” (Krause, Altimir, & Horvath, 2011, pp. 271).  This last item, “feeling understood” is the essence of what empathy provides.  When a client feels understood, they feel validated, trusting, safe, and confidence is built that the counselor can help them.

In my Long Beach private practice, clients are taught the tools of recovery and how to use them to feel and experience uncomfortable emotions – the driving force behind addiction.  In working with such clients, I’ve discovered there is one recovery tool that is clearly the most effective in coping with such emotions and preventing relapse: getting on the phone with another alcoholic or addict who can truly understand what they are going through.  What are they getting from this support person? You guessed it: empathy – the ability to put themselves in the other person’s shoes resulting in validation, understanding, and safety.  Those who have attended my trainings can attest to the fact I’ve been “screaming from the mountain tops” the importance of reaching out to sober support during difficult times. 

As people in recovery learn to do this, they are better able to handle feelings like shame, grief, anger, and fear.  You might say that they become resilient in the face of day to day difficulties.  I’ve been especially interested in teaching clients resilience in the face of shame as so many with addictions come from abusive families which breed shame.  As a result of this work, I came up with a term: “Shame Resilience.”  “Hmm” I thought to myself: “What a great term I invented!”  So, I googled it and it turns out – NOT!  The term was already published by a well-known researcher by the name of Dr. Brene’ Brown. Rats! 

Anyway, I had heard of Dr. Brown from a TED Talk I viewed on YouTube that featured her presentation: The Power of Vulnerability.  Finding out that she coined the term “Shame Resilience” re-interested me in her work.  In reviewing her research, I came upon a conclusion she came to in her work: “Empathy is the antidote for shame” (Brown 2007).  Wait, what?!!!  I have been teaching this anecdotally for years and felt it was validated by her research!

I actually believe empathy is the most important aspect in the success of self-help programs in helping people get sober, and is actually how the mothership of self-help groups, Alcoholics Anonymous, got started.  Bill W. and Dr. Bob getting together and feeling the other truly understood what they were going through when no one else could was one of the keys to them getting sober.  They then eventually found that what was keeping them sober was helping other alcoholics – and AA was born!  Regardless of the difficulty some have with the spiritual component of 12 step programs, the power of empathy that such programs provide should not be ignored.

So, how do we apply such an important principle in our treatment groups?  Well, here a few tools that can help in developing the skill of empathy:

  • The first thing to pay attention to is being present and engaged. This requires leaving our stuff at the door!  How can we be fully present for another client’s difficulties when we are engrossed in our own? 
  • We need to engage patients early with empathic listening and responding. The primary thing our clients should walk away with is feeling validated and understood.  How we do that is by trying to understand what it is like being in their shoes.  This does not mean we have to agree with their thoughts, attitudes and feelings, but we need to understand how they might feel that way and be able to exhibit such understanding. 
  • Pay attention to what they might be seeing when they look at your face. Do you have a caring affect or does it appear flat?  When they look at you, there should be no question about your caring for them.  If they look at you and wonder about that, you are not doing it right and could “lose” them.  Unfortunately, many counselors, whom I’m sure have a passion for helping others and truly care about their clients, do not naturally have a look on their face that shows they care.  For some, they just don’t seem to have it in them without being disingenuous.  In that case, they need to make up for it with their words.  They need to be able to put into words their care for, and understanding of, their clients in a way that will make them feel understood, loved, and validated.
  • Involve other group members by asking them if they have ever had such feelings or experiences and have them share such with the client. This, in effect, provides validation and makes the person feel understood.  Now, I generally teach that we should allow clients to provide feedback prior to the counselor doing so to create an environment of learning and to not hinder the maturation process of the group.  We also don’t want them to become dependent on us.  However, when sensitive feelings and issues are being brought up, it is important for the counselor to be the first one in, so the client is initially met with empathy, which results in safety and sets the stage for others to provide such.

Once our clients feel understood and validated through the empathy they receive and therapeutic alliance is built, we can then better utilize some of our other skills like CBT to help them change dysfunctional and self-defeating thoughts and, subsequently, the feelings that lead to the behaviors that get them into so much trouble.

While, there is much to learn about the skill of empathy, my hope is that by reading this article you will see the importance of empathy in recovery and have learned some of the basics of providing such.  If you would like to learn more about incorporating group supervision into your facility, please click here .  You can also find a recorded webinar on group facilitation here: (1.5 CEU’s).

Stay safe and thank you for all you do to help our clients recover!


Bob Tyler Recovery Services

(714) 981-9096


Works Cited:

Brown, Brene. (2007). I Thought it was Just (but it isn’t): Making the Journey from “What Will People Think?” to “I Am Enough”.  Penguin Random House: New York.

Cabaniss, D. L. (2012). The therapeutic alliance: The essential ingredient for psychotherapy. Huffington Post. Retrieved from http://www.huffingtonpost.com/deborah-l-cabaniss-md/therapeutic-alliance_b_1554007.html

Mee-Lee, D., McLellan, A.T., Miller, S.D.(2010): “What Works in Substance Abuse and dependence Treatment”, Chapter 13 in Section III, Special Populations in “The Heart & Soul of Change.”

“What Works in Substance Abuse and dependence Treatment”, Chapter 13 in Section III, Special Populations in “The Heart & Soul of Change” Eds Barry L. Duncan, Scott D. Miller, Bruce E. Wampold, Mark A. Hubble. Second Edition. American Psychological Association, Washington, D.C. pp 393-417.