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Empathic Engagement in Clinical Practice: A Deep Conversation with Dr. Douglas Flemons (00:00)
Puder:
Welcome back to the podcast. I am joined today by Dr. Douglas Flemons. He is a marriage and family therapist who later got his PhD. He taught marriage and family therapy for 30 years. He has worked actively with topics like suicide, and today we're going to be talking about a recent book he wrote, Empathic Engagement in Clinical Practice (2026). So yeah, welcome to the podcast.
Flemons:
Thanks for inviting me. Delighted to be here.
Puder:
So I understand you're in North Carolina now?
Flemons:
Yes. At the moment, I'm in south Florida because it's very cold in North Carolina. But yes, I live in Nashville.
Puder:
Okay. Where in south Florida are you?
Flemons:
In Fort Lauderdale. Oh, when I was teaching at the university, we lived here. So we're just back visiting friends and getting work.
Puder:
Wonderful. So yes, tell me some misconceptions on what empathy is and how you define it. Maybe we could start there.
Common Misconceptions About Empathy vs Sympathy in Therapy (00:56)
Flemons:
A lot of people conflate empathy and sympathy, and that's not just run of the mill lay people, but researchers, the theoreticians. They don't have any clear way of distinguishing between them and so they use them interchangeably, often. And that runs you into some trouble when it comes to trying to engage empathically with your clients. If you approach it from a sympathetic mindset, you can find yourself in a world of, I don't know about world of hurt, but a world of complication.
Puder:
I feel sorry for people that find themselves in a world of hurt.
Flemons:
“Feeling sorry for” is a sympathetic response. You feel bad and you feel bad along with them, and then you then feel bad for the fact that they feel that way. So that lands you in the world of sympathy. And it's something that comes to us naturally. As humans, we're wired in such a way that if you're demonstrating pain and I'm close with you, or I care about you, or you're important to me, then my brain's going to fire in very similar ways to what's happening to you. And that's just automatic. That's sympathy. But that's not empathy. Empathy doesn't happen to you. Empathy is something you pursue.
Why Sympathy Creates a Ricochet Effect, Victimhood, and Loss of Agency (02:24)
Puder:
Yes. I think that often when people experience sympathy from others, they're experiencing it from friends. It can feel almost weighty for me sometimes to have sympathy from friends because then I feel like, “Oh, I'm making them feel bad and sorry.” I'm then feeling bad for their experience.
Flemons:
Yes. So it can become sort of this ricochet effect. You feel bad, they feel bad for you, now you feel bad that they feel bad, now they feel bad that you feel bad about them feeling bad about you, feeling bad. So that can get pretty twisted. But it's also,... there's a quality… I don't know if this happens to you, but if somebody feels bad for me, it somehow diminishes me.
Puder:
Hmm.
Flemons:
Oh, you poor thing.
Puder:
It kind of puts me in the victim.
Flemons:
Yes.
Puder:
Exactly. I'm a victim.
Flemons:
And I think that happens kind of naturally because we have a sympathetic response for people who have had unfortunate experiences. So if you're helpless or hapless, it's easier for the person to have sympathy for you than if they think that you're responsible for whatever negative experience you're having at the moment. So the feeling of sympathy automatically imbues the person with some quality of helplessness.
Puder:
Subtly.
Flemons:
Subtly.
Puder:
Yes.
Flemons:
And so that if you're the recipient of that, you mentioned the victim, victims have no agency. So if you're the subject or the receiving end of sympathy, there's a quality that your agency has been diminished or stolen from you in that quality of emotional connection.
Puder:
Yes. But what if the person's empathic experience of themself, or the experience that they're having is one of a victim and, I feel like I am a victim. The world is all against me.
Flemons:
So, I can have a sympathetic response, “Oh, David, you poor thing for feeling like a victim.” So that's certainly possible, but an empathic understanding of that doesn't have me feeling bad for you. It has me exploring the intricacies and the complexities of how it is that you're orienting to the world with that kind of belief system.
Cognitive vs Affective Empathy Debate and Lisa Feldman Barrett’s Insights (05:03)
Puder:
Do you think it's helpful to split empathy up into cognitive empathy or affective empathy? I see these kinds of differentiations in the research, compassion and empathy being the third one.
Flemons:
Yes. It's a very common division in research, cognitive and affective. I'm a big fan of Lisa Feldman Barrett's work on constructive theory of emotion (2017). And she makes the point in a bunch of different writings that there's no such thing in the brain as an affectless cognition. You can't have pure rationality in logic. It lives there. In philosophy, there's this idea of, if we're going to champion rationality over emotionality, but at the level of brain function, she says, you can't locate a thought that doesn't have an affective connection to it. And an emotion, she says, is a category of experience. So it's feeling. It's affect. But there's a cognitive spin that is placed on that affect in order for it to be recognized and felt as an emotion. So that division between affect and cognitive empathy is an after effect, a downstream after effect, of that kind of split. But if the brain doesn't operate that way in the first place, then I think the division doesn't make as much sense. So I think of it as, instead of affect of empathy, cognitive attenuated empathy. That is, there's not a hell of a lot of cognition going on, but it's not absent. And same thing, cognitive empathy being affective attenuated empathy. There's still an affective quality in it. So I don't find it an incredibly useful distinction.
Puder:
Okay. So when you kind of subscribe to her line of thinking, do you think that there are emotions as universal experience across humans, animals, you know.
Universal Emotions, Microexpressions, and Empathic Curiosity in Practice (07:30)
Flemons:
No. So universal affective states or universal ability to get ramped up and to have a positive or negative valence to that arousal, absolutely. But the defining of an emotion is a social act. It's a psychological act. And you can have the same affect of arousal with a different contextual orientation to it. And it shows up either as fear or as excitement.
Puder:
Yes. I think I differ from her. I think that microexpression is a real thing. I kind of think that, especially with the congenitally blind studies, where they look at congenitally blind individuals that are flashing very similar emotions to people that were born sighted. I think there's a universal expression of emotion [see episodes 15, 16, 17, and 118]. Now, we may not be very accurate at reading the emotion, and the person who has the flash of emotion may not be very accurate in describing their emotion. For example, people with psychosomatic illness or alexithymia (Willis et al., 2025). But, I kind of differ from her in that perspective. And I would look also to John Gottman's work, where they looked at microexpression in newly married couples, and then were able to predict months of separation later. They predict physical illness in the couples just by looking at microexpression and recording how much different couples flash on their face (Gottman et al., 2001). I don't know if you've seen that study, but I think that validates this idea that there is universal expression of emotion. And I tend to differ from her in that perspective. But that we may be getting into semantics too much here.
Flemons:
Maybe. And, I would be wading into an area that I don't have expertise, because I'm benefiting from her research. I certainly didn't participate in creating it. But there is a point maybe, just one point, the idea that microexpression of an inner emotion. So you've got this, shows up on the face or in, in some kind of gesture of an emotion that's inside. So there's this coordinated communication between the two that implies that the emotion is there and then it's expressed, but so much about human experience has this recursive fold back quality to it. So the identification of what it is that you're feeling contributes to the feeling itself. And I see this a lot, working with people with panic disorder. They start to feel and they go, “Oh, I'm starting to panic.” Which then contributes to a greater release of the hormones that they're recognizing in the first place, that have them concerned. And so there's this spiraling that happens. And a lot of it has to do with the way that they're making sense of their experience. Because of that fold back recursive quality to all experience, I think it's unhelpful to distinguish, to try to distinguish between, here you have the pure, as you're talking about, here's the pure emotion, and then here's the expression of it there. Everything is so intertwined, it becomes very difficult to talk about it and make any kind of coherent sense.
Puder:
So the way that I understand what you…. I don't know if you've heard of this idea of ‘the second arrow’. It's like the first arrow is the person with panic [who] has an initial discomfort, maybe in their abdomen. The second arrow is the adding of meaning to that. Right? Like, “Oh, I'm having this discomfort in my abdomen. I may have a panic attack.” And then they start to get more, and then maybe they feel guilt, that they're having this fear. You know? So then they have the secondary type of things. Right?
Flemons:
Secondary, tertiary. Yep.
Puder:
Which, I think that's not necessarily how I understand the usefulness of microexpression. It's kind of a separate category. If you're interested, and I know we're kind of having a back and forth discussion here, trying to learn how we each think, and where we're starting from. Here, I'll show you a video. So I videotaped people watching YouTube videos, and this guy is watching a YouTube video. And so this is the flash on his face. And this is the classic flash of the microexpression of anger. Right? Now, if I was to pause him right here and to ask him what he was thinking or feeling, he may not be able to tell me that he was feeling anger. He may say, “Oh man, it's awful what I was seeing.”
Puder:
Right? And if I was thinking about being empathic towards him, I wouldn't say, “Well, you're feeling anger.” Of course. Right? But the anger is a signal to me that something is there. An emotion. Right? And so what I've seen is that since getting trained in microexpression, you'll see the flash and then they'll tell the story that proceeds, and some of that feeling in that story could be frustration. It could be anger. It could... it's complex. Right? Why are they feeling that? Why do they flash that? It could be a multiplicity of reasons. I may not have access to that. Right? They may be frustrated that I said something. They may be frustrated that their stomach is upset, or they're hungry. You know? So I think that the flash of emotion, it is a universal, in my mind, expression of an emotion. What the meaning of that is described in different cultures, by different people, with different levels of psychological awareness. People with alexithymia have a lower understanding (Willis et al., 2025). So this is my contention with her research.
Flemons:
Well, I love how you said, “I see something that shows up and I don't yet know what it means,” but you're confident that it means anger. But as far as how that plays out in his experience and the story that's attached to it, and so on, you hold back from presuming.
Puder:
I would have a level of confidence, like I would if someone said a word. That word is trying to describe something internally inside of them. What it's describing, or why it's describing that, is a puzzle. And I'd have to be curious about it. Right? And this is where I think we might have some agreement—for you, empathy as an active, imaginative, relational process. Right? And so I would never, if I said something and they're like, “No, that's not what I'm feeling.” I'd be like, “Okay, wow. Thanks. Help me understand what's going on.” You know? So I'm not necessarily the authority on it, but it's helping me see a picture. It's part of the picture.
Flemons:
We do meet there, for you not to impose your authority and to argue with them. “No. I saw the microaggression on your face. You're definitely angry. You just haven't gotten in touch with it yet.” For you to take that kind of position to try to help them get in touch with something that you're confident is there, and they're not yet aware of, would be an interaction, probably disaster. They would then back away from you, be concerned about how pushy you were, et cetera, et cetera. For you to find it interesting, for you to hold it as a point of curiosity, and perhaps to come back to it later? Terrific. Including the possibility that you're seeing whether with their words or what's showing up on their face, some quality of experience that they don't seem to be in touch with. And you don't get ahead of them. But over a period of time, through conversation, they come to arrive at a recognition of some level of anger or something that would be fine. So you get organized by what you're noticing, your expertise comes in, being able to recognize patterns and so on, but you don't impose it. And I agree completely with that.
Puder:
I think with my background, I worked 10 years, I ran this IOP partial program for people with psychosomatic illness. So a lot of these patients come in and they're medicalized. They don't have depression or anxiety. They experience all of their feeling in their body. And so, the curiosity that I've always had is how do I get it out of their body and into emotional language? They have a lot of emotion when they talk about the frustration of the medical system because it hasn't helped them. And inevitably, they have a lot of disavowed emotion, disavowed experiences of emotion. They're not allowed to, maybe early on, they weren't allowed to experience anger. They weren't allowed to experience, maybe, a positive emotion. So just to give you some context for why I'm interested in this.
Flemons:
Yeah and have expertise [on the subject]. So I would describe it a little bit differently. They have something going on with their body. They don't yet have a way of naming it. And the expression, the way it expresses with somatic issues distresses them. And that if they can bring it into language in conversation with you, it has a way of creating meaning that they didn't have access to at the beginning. And shifting the meaning is shifting the possibility of doing something different about it.
Puder:
Yes. I would agree with that. Yes. It's a fascinating field to think through. Okay. So how did you get interested in empathy? Maybe let's rewind here. What was the impetus to think about this for as long as it took to write this out?
How 30 Years of Family Therapy Supervision Led to Empathic Engagement (18:06)
Flemons:
Yes. It took a long time. Well, I originally encountered it in my master's program. I was trained in counseling psychology and got the kind of typical entry into microprocesses that would add up to empathy, active listening, and so on. But it really showed up in my supervising over 30 years as a family therapist. Family therapists don't generally talk about empathy at all. They talk about joining with clients, but very little thinking about researching, theorizing about empathy. And so I was kind of an outlier, I guess, paying attention to it. And what I noticed is, my students could have a very clear theoretical understanding of what it was that they were supposed to be doing with their clients, but if they couldn't figure out a way of connecting with them, then their theory was for naught. And so I ended up with this, and I did live supervision.
Flemons:
So I'm behind a one way mirror, six people on a team, six hours. And you see a bunch of clients, and a wonderful supervision process. I started focusing more on helping them have conversations with the clients where the clients weren't having to protect themselves from the therapist either taking issue with the way the question is being asked, or being shut down, or whatever. And so I ended up starting to talk a lot to my students about how to empathically connect and figure out, how do you do that so it doesn't backfire in your attempts to do it.
Puder:
Yes, I had a similar experience with the residents. We watched video, and I was one of the main educators at the university for a number of years, with a mentor who's now passed. But he was 90 years old at the time, and very experienced. And we'd watch videos of the residents interacting with patients, and it was the micro moments of connection and empathy [that] were probably the things we talked about the most.
Flemons:
Wow, that's wonderful.
Puder:
Yeah. Like, “Here, the patient says this, and then what's the accurate, empathic thing that you can say afterwards?” You know.
Flemons:
And in a medical setting, there's often an encouragement at least—well, I don't know this directly, so you would be a better authority—but from what I've read, Jodi Halpern’s book on empathy [From Detached Concern to Empathy (2001)], the training of doctors is “how do you make sure that you don't get too emotionally caught up with your clients so you have a friendly bedside manner, but slightly removed.” So looking at empathy as a goal, is, from what I've read at least, rather unique in medical education.
Carl Rogers on Empathy: What to Embrace and Where We Part Ways (21:01)
Puder:
Yes. I think that it's incredibly valuable. And where I would be curious is with Carl Rogers, where do you align versus where do you part ways.
Flemons:
Definitely aligned with a lot. He was so inspired to recognize the importance of, for example, letting go of judgment. And he didn't talk about it this way, but I think a lot about the boundary between therapists and clients, and judgment is one of those boundaries. So if you're my client, I hold you in judgment. I think what you're doing is wrong, for example, then that judgment gets in the way of me being able to be curious about you. I already know something about you and I disagree with it. And so I'm back from you. So Carl Rogers is saying, non-judgment is the way to go. Because when I'm not using that as a dividing technique, I can get inside of the logic of your world. And once I'm there, cool stuff happens. And if I can communicate my growing understanding of what it's like to be in your world, in your story of your life, you end up recognizing in me someone that gets you and you no longer feel alone.
Flemons:
And so he had that statement, “If you're understood, you're not alone.” And that's such an incredibly important grounding for therapeutic change. He also looked at, okay, so how do you actually unfold this in conversation, and recognizing empathy as something that you do, it's a skill that can be developed. He regretted later having focused so much on the skills because then it became robotic in the way that people tried to train students in how to do it and people trying to do it in a way that didn't feel human. But the commitment to learning, the capacity to empathize, totally on board. A place that I disagree with him, and I think it comes out of his respect for clients, is he saw a therapeutic encounter as being ideal if both the therapist and the client are open for change. And that the most meaningful therapeutic moments were places where he was vulnerable along with the client and he was open to changing himself. And he saw therapeutic changes changing or altering personality, which I think is another thing that I won't go there. But anyway, this idea of mutual vulnerability, I disagree with completely.
Puder:
What do you believe?
Flemons:
That what our job is, is to be available to clients and that there's a necessary asymmetry to that. It's not mutual. That if I think that my way to be able to help you embrace your vulnerability is for me to show you my vulnerability, that's the shape of a friendship. That's how you and I build confidence and trust in each other. You tell me something that happened to you that brought shame, and I say, “Well, I can tell you something similar. Here's something that happened to me.” We, as friends, terrific. But as therapists, if we try to use our own vulnerability as an adjoining mechanism, it creates a style of relationship that puts our well-being at risk and puts the relationship at risk. Carl Rogers, for example, ended up at some point working with a schizophrenic patient for a couple of years, very intensely. And working empathically felt like he was losing his mind. And he came very close too. He had to… get outta dodge, because he was losing it. And I think that comes from him attempting and honoring humanity and his commitment to equality meant for him that he was then in this position where he was at risk of himself having a loss of sanity in order to be able to connect with this person.
Puder:
I've been very curious about that story. He was seeing her five times a week towards the end. And he's said in autobiographies, I was gonna bring this up actually, he said things like, “I got to the point where I could not separate myself from hers. I was on the edge of a complete breakdown myself. I had to escape.”
Flemons:
Right. So, if you think of empathy as the loss of the boundary between you and the other person, to my mind, that's the shape of sympathy. That's when you and I resonate with the same emotional valence. And we don't even really bother distinguishing whose emotion it is. And this is emotional contagion that shows up a lot in situations like suicidal clusters, and so on. But that idea, that in an effort to make the connection we're erasing the differences between us, becomes, I think, incredibly dangerous. The other version is the one that I would offer instead, is the more vulnerable you are, if you're my client, the more available I am. So I'm not meeting you with vulnerability, I'm meeting you with curiosity, with warmth, with exploration with nonjudgmental acceptance. But I'm not positioning myself to demonstrate to you that I can be as vulnerable as you.
Puder:
Okay, so how does one keep a stance of empathic curiosity rather than presumption? And when do you notice, maybe, that it goes into more of that? It's going into kind of less curiosity?
Flemons:
Well, so that's an added difficulty, is to presume that you can have this complimentary positioning that I'm suggesting and still be presumptuous, and still get yourself into a world of hurt by doing that. So I appreciate the question. You hold back from presuming to know by embracing your ignorance. It's like what you said earlier, you can see something flashing on the person's face. You know that there's something going on and you don't yet know what it is and the way that you're going to find out is not for you to confidently determine that you're going to go find out what you already know is there, but that you start a conversation and you start exploring. So if you continue to embrace the idea that you are not the expert of the other person, that they're the expert. In your job, in order to develop an empathic understanding is to get inside the way that they make sense of their world so that you can make sense of it from inside. You get there by continuing to check any kind of confidence that you have that you know you can keep your confidence in your expertise. Sure. But not presuming that, “Okay, I'm already three steps ahead of you and I know what's going on, even though you don't.” You hold that presumptuousness back.
Empathic Engagement with Suicidal Clients – Tolerating Uncertainty and Fear (28:58)
Puder:
Yes. I tend to think it's almost like sometimes, in insecurity, people hold due to presumptions. Right? And it's out of the insecurity, I think, we get more rigid or we get more kind of caught up in our own experience. Think about some of the hardest clients it might be to enter into. And you talk about in the book, Suicide [Relational Suicide Assessment: Risks, Resources, and Possibilities for Safety (Flemons & Gralnik, 2013)], specifically, how you've noticed we almost want to jump to a solution- we can want to jump to not be empathic in contrast to showing people that we know how dire they feel internally [we might not want to give empathy because it is so scary that they might be actually in such a horrible place]. Can you talk more about that? Can you put words to that? What have you seen? I know you've done some research on suicide, as well.
Flemons:
So, the broader point that you made, I absolutely agree with. Holding to uncertainty is very, very difficult for everybody, and therapists included. So when somebody's potentially suicidal, and we're not sure, it creates… it's unnerving… creates anxiety, and there's this great desire to know so that you then know, okay, so what's the next steps? What are we gonna do to help protect the safety of this person, if that's necessary? And so hanging out in uncertainty is incredibly uncomfortable, and being able to tolerate uncertainty for a extended period of time is a terrific skill to develop in order to be able to then not jump into the presumptuousness of preemptively deciding whether this person is or isn't suicidal. That requires you to be able to hold some sensibility of their desperation and their hopelessness and to just swim around in it with them. And, then offer questions with curiosity based on what you're coming to appreciate about their circumstances. But not to rush into an early decision. I mean, there's certainly, sometimes it's a slam dunk. Somebody comes in and it's clear to them, it's clear to you that they have no intention to continue to live. So that's not what we're talking about. But the gray zone conversations, they have the idea that if they don't mention the word suicide, then you're not gonna get the machinations of the state going. And so they just won't mention it, but it's implicit in everything that they're saying. Those gray zone conversations require us to be able to hold on to our distress and our uncertainty and just hang out with them.
Puder:
I think it's very common as providers to feel fear in the midst of that. Right? Like, what if this person does end their life like…. So I think our own experience of fear can kind of come into making it harder to empathize. How do you deal with that?
Flemons:
There's lots of things that can make it hard to empathize. And you're absolutely right. Fear is one of them. The moment you're organized by your fear, and fear isn't a bad thing. If a person comes in and the hairs on the back of your neck are going up because of what they're saying or what's showing up on their face, or whatever their indicators are, that fear can help organize the curiosity. So you should pay attention to it. One of the difficulties that my students would display is they would feel that fear and then think that that was unprofessional. Just like feeling moved by someone that's desperately sad and tears welling up in their eyes and feeling, “I gotta stop that because that's unprofessional.” So they're afraid for a client, and they're trying to shut down the fear. Now their conversation is with themselves, “I gotta calm down. I gotta relax. I gotta….” If the conversation is with themselves, they're out of connection, outta conversation with the person. So it requires being able to acknowledge that the fear is there, makes sense that it would be there, and have it not get in the way of a continued conversation and exploration.
Puder:
Yes. I think what you're describing is kind of that the fear itself, if we can approach that with a lack of judgment towards ourselves. Right? Compared to if we judge ourselves and then we're caught up in our own fear and judgment of ourself, and we're then more and more in our own experience, and it's harder and harder to empathize with the other person's experience.
Flemons:
Yes. Judgment raises its head in both places. Both the other person is doing something that concerns us, that grosses us out, that upsets us, that offends us. That kind of judgment gets in the way, but then if we're looking at our own reactions and judging those, that gets in the way, and both block the empathic exploration of the person's experience.
Puder:
Good. Well, okay. So I was thinking I would role play with you. And so I'm gonna be a clinician who has just met with a patient and it stirred up a lot for them. Because, I think you know we have a lot of mental health professionals here. I imagine they feel some level of weightiness with some clients. So I was thinking, well, let me create a scenario that could resonate with some of them.
Flemons:
Sure.
Role-Play: Managing Therapist Fear, Countertransference & Safety with High-Risk Clients (35:03)
Puder:
Okay. So, after I left this session with this guy, there was something about the session and this person that I felt like I was almost in danger.
Flemons:
You felt something going on with him that worried you.
Puder:
Yes. And I don't normally feel this way necessarily, and I don't know if it's other things going on in my life right now, but I think the main thing was that I was just… I don't know, I think this guy might want to hurt me. And he didn't express anything directly towards that, but I felt that so profoundly.
Flemons:
That you started feeling like you weren't safe in the session.
Puder:
Well, I didn't feel I was safe after the session.
Flemons:
Ah, so that there was some sense that he would have it in for you?
Puder:
Yes.
Flemons:
On the way home or something?
Puder:
I remember leaving my office and I usually leave one door, but I left the other door, because I was thinking, “Okay, if this guy's been following my patterns, maybe I'll throw the patterns off.” But then I'm conscious of that awareness, but that's a very unusual awareness for me.
Flemons:
Very unnerving. How early in the session? Was this a first session?
Puder:
Yes. This was a first session.
Flemons:
So how early in the session were you getting the sense of that? That he knew something about you or that he had a particular ax to grind with you? What was going on?
Puder:
I think the way some of the content on how he was very angry, but also not very aware of the anger. Very unhappy with a lot of things in his life, a lot of prior people in his life. Very, very unhappy. But I left the session and I was just like, “I should probably leave the other door.”
Flemons:
So you got the sense that he was relating to his world very much from this position of anger without really being able to recognize it in himself. So it makes sense that he was also relating to you somehow in this angry mode. What were you picking up on that your spidey sense was picking up on the fact that he was angry at you?
Puder:
There were some kind of challenging questions. Like, “I don't know if therapy works.” “I don't know if this is all bullshit.” He kind of like both wanted someone, but then also didn't want someone. If that makes sense. That he…
Flemons:
Was challenging you.
Puder:
There was some challenging. Yes, there was a little bit of challenging.
Flemons:
And then how did you respond?
Puder:
I tried to come back to like, what were the goals that he was coming in for and the things that he was hoping to accomplish, that he had already stated. And how I think a lot of those are helped in a relationship and not just like some self-help book. Since this happened like a week ago, I've had a nightmare of an intruder. And this is very… I mean, there is a little bit of background to this from my story, which you might have remembered, that my grandfather died by being mugged outside his office. And so I wonder if that has anything to do with it. You know, like how much of it is my own stuff versus the patient's stuff? It's kind of confusing to me.
Flemons:
Well, you're very aware that it's possible, in your effort to help people, to put yourself at risk. You got your grandfather in mind.
Puder:
Oh, there was also that therapist that was murdered in my city, actually a couple weeks ago. And so that was in the news and I've actually been doing some research on therapists and psychiatrists and social workers, mostly social workers, who have been murdered by former clients. And so I'm reading about this as well, so I don't know how much that has to do with it. So it's kind of convoluted. Is what I'm feeling an accurate depiction of my danger with this person?
Flemons:
Right. Is it accurate? And your sensitivity from what you've read in the news and in your own family history, allowing you to be exquisitely sensitive to an accurate danger. And then to what degree is that sensitivity heightening your concern about danger beyond what it actually might be? And it's really hard to figure out, how do I tell the difference?
Puder:
Yes. It's really hard to figure out. It's really hard to figure out.
Flemons:
When you were actually having the conversation with him, were these concerns on your mind at all? Were you aware of picking up on his angry countenance, his way of being?
Puder:
There was a moment where I was actually, and I've never, you know, it's interesting because like we talk about countertransference in our therapy sessions together. I've never had the thought before, that this person might want to kill me. And I was actually worried, does this person have a gun on them? That actually occurred to me in this session.
Flemons:
Impossible, I would imagine at that point, for you to be able to continue the session in any kind of productive way, you're just concerned about your safety. If you don't feel safe, it's pretty much impossible then to undertake any kind of therapeutic conversation.
Puder:
I think from our work, I try to get curious. Like, “What is it about this guy that elicits this reaction?” You know? “Am I kind of picking up something that is kind of unsaid, a level of paranoia maybe, or some of this person's own internal world?” And so that's what I was thinking in session when that happened. I was like, “This is very curious to me.” But then it comes out in my dream a lot more impactful. It comes out a lot more scary in the dream that night where it's like, “Oh, there's a person at my door with a gun.” You know?
Flemons:
It sounds like when you were in the session, you were able to keep your professional identity informing your engagement, and then in your dream at night, it's more that role of trying to figure him out gets put to the side and it's just the raw fear that he could pose a risk.
Puder:
Yes. The raw fear. Right? Yeah. Yeah. And it kind of jolted me awake too with this intensity and this, “Am I safe? Am I safe?” You know.
Flemons:
What a fabulous question. And so you saw him a week ago, did you schedule another session with him? What's the status of the appointment?
Puder:
Yes. Scheduled another session.
Flemons:
For when?
Puder:
It was going to be next week.
Flemons:
And you're wondering whether or not to cancel.
Puder:
I'm wondering whether or not…. I'm kind of wanting to flush out how much of this is just my circumstances in my life, or how much of this is a real paranoia, that I should be concerned about this person?
Flemons:
Well, you said that you had a unique reaction. So this hasn't happened to you before. You've seen lots of patients. So having this concern, this is the first time you've gone out a separate entrance. It's the first time that you've had a nightmare.
Puder:
I mean, I've had dreams and I've had some nightmares about patients, but this, there's something about this that feels different.
Flemons:
So your reaction can tell you a lot about what it must be like to be in his interpersonal network, what the people that he knows are living with.
Puder:
Yes.
Flemons:
And really appreciate the danger that he seems to bring into his relationships. But the real question is, can you help him when your life is potentially at risk?
Puder:
Yeah. And it's like, I feel guilty that I even have these internal thoughts.
Flemons:
Hence the questioning. Am I only making this up because my grandfather was mugged outside of his office?
Puder:
Yeah. Or the recent death of the therapist in town. Right?
Flemons:
Yes.
Puder:
Which I read the case on this therapist in town, and this person had a prior history of violence, rape. This person was in jail for almost 20 years before released. So this was a historically violent sexual offender. So that kind of helps me a little bit, you know, get my head around, “Okay, this client I saw didn't have a history of any of that.” Right? That he told me.
Flemons:
That he told you. Yes. And you're the first practitioner in the practice to see him. So no one else has had an eye on him?
Puder:
No, no. No one else had had an eye on him.
Flemons:
You saw him. Sounds like if you're going out a separate entrance. You saw him at the end of the day. Were you the only person in the office?
Puder:
Yes. So I think that’s the fear that I have. I don't know if this is going to be a good client for me, but I also have a lot of guilt about not seeing them. Like, I feel like I need to be able to help everyone.
Flemons:
Yes. It would be good for you to let go of that idea. You're not going to be able to help everyone, and you can't be helpful unless you feel safe, physically safe, emotionally safe.
Puder:
Wait, wait. So are we still in the role play? Is this what you would actually say to a provider in this case?
Flemons:
Yes, absolutely.
Puder:
Okay. So if you're a provider listening to this and you're a female or male, and there's a client that you're seeing and you don't feel safe, I would totally agree with you. You don't need to see this person.
Flemons:
I had a student once who was seeing a client because, I guess, I think he was a diversion process. He'd been caught masturbating in public and he was sent to therapy instead of jail. So she's seeing him and she said in the session he was starting to indicate masturbation. And she was distinctly uncomfortable and she said, “I didn't know what to do. I didn't want to be his mother and tell him to just stop it. I didn't want to just ignore it. I didn't know what to do. And I don't know how to help him, but I just don't feel comfortable.”
Puder:
Which, by the way, I'm thinking about the audience of mental health professionals who are listening to this. This is a good thing to think about, “How am I going to handle this type of situation?” Because it could happen. Right? You could have an autistic patient, you could have, I mean, different types of patients at different levels of functioning. Right? This could potentially come your way. So, okay, so what did you recommend?
Flemons:
I said, “It seems to me you have three ways to go. One is you refer him elsewhere, entirely legitimate. You can't help him unless it feels comfortable working with them. Second is you say we're here to talk about masturbation not to demonstrate it. And so if it goes from talking about how that has impacted your life and how you want to change public masturbation into you demonstrating it, then we're gonna stop the session; and I get to decide when it's gone into that realm, not you. And the third is, you could utilize what's happening. And so when he goes and reaches for himself and you get curious about what is it that impelled him just now to reach for and start masturbating in front of me. Tell me what's going on for you right now. And you could, in the moment, explore what was happening and make that perhaps therapeutically helpful. But that could only happen if you felt safe. And that, to my mind, would be best managed by somebody else being in the room with you. So, three options, all fine, but your confidence and comfort come first.” And she said, “I picked door number one.” So she made a referral, which I thought was entirely appropriate.
Puder:
Yes. I would probably to recommend door number one, unless they had, I don't know, like what level of experience or comfort would be necessary to go through door number three, you know?
Flemons:
I think profound experience, and it would be much easier if it wasn't a male/female kind of dynamic.
Puder:
I think that for the sake of clarity with the podcast listeners, if it's a one-off countertransference of, “There's something about that that doesn't feel right,” you got to listen to that. Right? And one of the supervisees I had recently said that they went immediately to Zoom only sessions with this one person. And that was one step that she felt comfortable with because then she wasn't in the same room. But I get very sensitive to people, especially providers, that feel a high degree of guilt that they need to see everybody. Whereas, if you're feeling like there's something really off, like maybe for good reason you're feeling that.
Flemons:
Yes. In the role play that you were doing with me, the person’s nightmare. I was listening very closely to that because it's obviously, something about what happened is spinning around and, so to pay attention to that and honor it.
Flemons:
To honor any kind of emotional response, not necessarily be shut down by it. Like at the end of role play, you know, the character was worried that perhaps the person was listening into our conversation. So that level of fear is then getting in the way of being able to think resourcefully about what steps I need to take.
Puder:
Right. And, you know, there's a thin layer between insight into psychotic thoughts and actual psychotic thoughts versus if this is actually a helpful degree of paranoia. Right? And so I'm playing around with that, and I'm also thinking that the reason why I picked this specific story is that you had a story in your book that was very similar about a patient that elicited a lot of fear in you. Can you tell me about that story?
Flemons:
This guy walks into a clinic—I was a graduate student at the time. He walks in, we usually scheduled sessions, but I was around and the office manager said, “Can you see him?” “Yes.” He walks in, he has mirrored sunglasses on, never takes the sunglasses off. And he says he's there because his wife left him. “And she said a precondition for me coming back is you getting therapy.” So he says, “I'm here to get therapy so that she'll come back and however many sessions it takes, however often it takes, I just want her back.” So we start to talk, and he mentions along the way, “When she does come back, I can't take it. Her leaving me, this is not the first time she's left. I can't take it. It's not happening again.” And he made it very clear that if she came back and tried to leave again, he was gonna off her.
Flemons:
And so I then got incredibly frightened that somehow my helping him was going to lead to her death. And said that out loud. I said, “I've got a problem. I welcome the fact that you've come for therapy and I look forward to being able to help you. But I recognize that if I help you enough so that she's willing to come back, it puts her life at risk and I'm not willing to do that.” And he leaned toward me, conspiratorially, and he said, “Hey, listen, don't worry, I won't tell anyone I was here, not even the cops.”
Puder:
I feel very safe. Knowing that bit of information makes me…
Flemons:
Oh, no. Okay. Oh…
Puder:
I feel very reassured. Yes. There's almost like a projection that you are going to be just like him in that too. Sure. Like, all people think like I do, all people think as Machiavellian and psychopathically, sadistically as I do. Right? And so you're just another guy that's thinking like I am. And you're like, I don't know.
Flemons:
My job is to be able to make sense of the fact that that's how he sees the world, but not for me to adopt the same principles. So I told him I couldn't continue to see him. And, it's a long time ago, I don't think that I did an adequate job of finding him an alternative.
Flemons:
What I did do is call the woman in distress and let her know that she needed to take care.
Puder:
Okay.
Flemons:
But I could not be helpful because the stakes were too high for the possibility of this woman dying.
Puder:
Yes. I almost feel that it's reminiscent of the type of client that comes in and says, “I really need Xanax, because when I'm coming off of cocaine, it helps me relax.” And I'm like, “I can't be complicit in you using a drug that could end your life.” Right? So it's like, I can't be helpful in this, you know. Like, I can help you if you want to get off cocaine, but I'm not going to give you another controlled substance to ameliorate the suffering of coming off of an illicit substance.
Flemons:
Right.
Puder:
On an ongoing basis.
Flemons:
But the empathic way into that, I agree a hundred percent with what you said, and if you present it that way, then you're just putting up a wall and saying, “Look, I'm not going to be complicit in helping you in this way.” To deliver the same message empathically would be. “The cocaine is providing excitement for you, or it's helping you cope in various ways. I want to hear all about that. And of course, it ramps you up in a way that then you feel so frazzled and you need something to be able to come down from it. And good on you. Xanax is one way to do that. If you were going to work with me, we would look at a way where you didn't need the Xanax because you didn't need the cocaine. Would you be interested in exploring that?”
Flemons:
So then…
Puder:
It's reminiscent. I've been deep in the Epstein files. And because I'm a psychiatrist, I look up things like the different drugs and see if they appear in the Epstein files. There was a very lengthy description of the effects of GHB, which is the date rape drug that a doctor was providing to Epstein. And there's some level of ick in that. Right? It’s this association that you gave of this guy trying to control his girlfriend. Right? To the point that she can't escape and “I'm gonna kill you.” This homicidal level of power. Right? “If you do try to escape, I'm going to kill you.” And I think that was kind of that sadistic vibe I got in a lot of the Epstein files.
Flemons:
Yep. There are limits to what we as therapists can offer. If I had been able to provide an empathic response to this guy, if I could rewind and redo it, I would've said something to the effect of, “Your wife obviously means the world to you. And when she left you this last time, it turned your world upside down.”
Flemons:
If you agreed with that, I would proceed with, “And so, of course, you're desperately thinking, I've gotta prevent her from ever doing this again. And the one way that you know is to do it through threat and through violence, prevent her from leaving. If you were to continue to come here I would fully endorse the idea of your wife not having to leave again. However, what we would do is we'd explore a way for you to make it safe for her to stay rather than for it to be unsafe for her to leave.”
Puder:
Yes. And I think that would be something that would get through, maybe you wouldn't get an incredibly negative reaction from him because, for the departure of, “No, I can't treat you.”
Flemons:
Yes. I was afraid to say, “I can't treat you.” I was worried that he had a gun in the session, and I was worried that if I said, “I'm sorry, I can't see you,” that he would then be violent to me.
Puder:
Yes.
Flemons:
So being able to empathically connect with him so that it makes sense that I couldn't help him so that he wouldn't then be in judgment against me. It was in part a way of keeping me safe enough to help him be safe, which would help his wife be safe.
Puder:
Yes. Yes. I think the other option with a person like that is to refer them to a higher level of care and be like, “Look, your level of care that you probably need at this point is more of a partial level of care or an inpatient, even. If you want to really overcome things, that's what I would recommend. I don't think once a week is going to be the level of care that is really going to help you accomplish your goals of developing a new psychological toolkit to deal with these huge emotions that you're dealing with.”
Flemons:
Yes. And it comes back to what you said earlier, having the wherewithal and the ability to say, “I can't help everyone, so I'm going to refer you to somebody that has expertise in an area that I don't.”
Preventing Vicarious Trauma – How Therapists Disengage After Deep Empathic Sessions (59:01)
Puder:
Moving more to this idea of vicarious trauma. Right? Empathically being immersed in people's stories every day, day in and day out, and the vicarious trauma that we kind of absorb as mental health professionals. How does empathy help us? Or how do you supervise people in the midst of that?
Flemons:
Yes, great question. So, facing vicarious trauma, it's very human to then just try to not feel as a way to cope, but that then leaves the practitioner numb and then really not caring. And that creates burnout. So that doesn't really help. The alternative is to treat empathically. If you treat it as a skill for engagement, to then learn the skill of disengaging. So, to begin a session and explore a way into the sense and sensibility of the person's experience requires you to have a felt sense of what's going on. It doesn't mean that you have to suffer in exactly the same way or to the same degree, but that you're allowing your body to register what's happening with them, and for them, and your response to them, and all of that so that you're emotionally available in the process. And then, at the end, to come out of that session and to be able to release that connection to disengage. And that can be done through mindfulness, meditation techniques, doesn't have to take a long time, but to have a kind of a ritual of entering into and entering out of, exiting from an empathic relationship. And to do that between every client, every patient throughout the day. And then at the end.
Puder:
What's your practice? What do you do?
Flemons:
At this point, it's now virtual, it's all virtual. Before, it was in person. But I do a lot of individuals, a lot of couples, some families.
Puder:
Okay. What is your practice between patients? What do you do?
Flemons:
Oh, I see what you're asking. I end the session, and before I begin case notes, I turn toward my experience and I pay attention to what it is that I'm feeling, what I'm noting, what I'm remembering, and I'm releasing it on an exhale. I'm just letting go.
Puder:
So you do some deep breathing.
Flemons:
I actually don't do it with deep breathing, but I do pay attention to the release of carbon dioxide. And I have an imagination exercise where I latch whatever it is that's going on physically for me to the carbon dioxide and gets released, binds to the carbon dioxide and gets released. So I do that in my imagination.
Puder:
Okay.
Flemons:
There's another practice that's related to the Tibetan Buddhist practice of Tonglen, of taking what I'm feeling and then transforming it into relief. So just allowing the body to, instead of releasing what you're feeling, to have it transform, and then when it gets released, it's being released as a form of relief. It's another imagination kind of exercise.
Puder:
And then, what do you do on your time off to sort of decompress or, you know, what have you found most helpful in your career?
Flemons:
So the essence of meditation is to have a focus, say, on a breath-focused meditation. And then recognizing that that focus gets lost. Something intrudes, something interrupts, recognizing what is interrupted, letting it go, coming back to the focus. The meditation practice is always coming back to some point of focus by letting go of, or transforming some kind of interruption. Something that's stolen away your attention into a distraction or a story or a memory or an anticipation or something. It's always just coming back to that. And so, that is the same with empathy. After disengaging, anything that brings me back into thinking about a client, if it's useful, like, “Oh, I didn't recognize something I didn't pick up at the time. Now something's occurred to me.” I'll write it down so that I've got it when I go back. And then when I've got that, I then let it go. And if something's eating at me, I pay attention to, “Is there something about this that I need to be paying attention to that wasn't picking up?” And then once I've got that noted, then I let it go. So I'm not ignoring intrusions, but I'm making use of them and then letting them go when I don't need them.
Flemons:
And then I do…
Puder:
And then what?
Flemons:
Well, then I do just a bunch of stuff that has got nothing to do with seeing clients.
Puder:
Yes. Yes. I think it's good to have things that are completely different. So, okay. Good. Well, hey, I think we need to…. Oh, go ahead.
Flemons:
I was just going to ask what you do.
Puder:
Well, life is full with kids right now, and so, it's a good distraction from work when I go for walks with the kids, play Minecraft together, stuff like that.
Flemons:
Wonderful.
Puder:
And I love good food sometimes. Just having a break midday and going to get some food. There's something about that that's just nice to kind of turn it off sometimes, to get angry at something else, you know, outside of like all the patient stuff. Like the Epstein files.
Flemons:
Yeah. Epstein files will do that for you.
Puder:
Nice distraction. And yeah, I mean, I do a lot of the podcast stuff, so I feel like that takes a lot of the extra time, but I feel like I've gotten better at compartmentalizing that to not take over too much of my evenings.
Flemons:
Wonderful. Yeah. That's incredibly important, to protect your non-work time. Kids are great for ensuring that that happens. “Daddy, daddy.”
Puder:
Yes. So this is wonderful. Anything, as we kind of wrap up our time, anything that's still lingering, that you feel like is a big point that we didn't even really convey, but you want to make sure that you convey?
How to Demonstrate Empathy (Instead of Claiming “I Understand”) (01:05:37)
Flemons:
Yes. The demonstration of empathy is different from the claiming of it. So a lot of people, practitioners attempt to reassure their clients that they understand, “Oh, I get you. I understand. I've had something similar that happened to me so I understand what you're going through.” And it's all the cases that I've supervised, I've never seen that claim go well.
Puder:
Yes Someone with more borderline characteristics may jump on that and be like, “How dare you? You have no idea what it's like.”
Flemons:
And good on them.
Puder:
“How could you possibly understand?”
Flemons:
That's right.
Puder:
But then, you know what's funny? I find AI sometimes, the chatbots, will do that. “I completely understand what you're going through.” And my statement back to them is like, “You don't understand. You're a stack of cold, hot GPUs in some factory in the middle of....” And they'll be like, “Oh, Haha. Good one. Yes. I am a hot stack of GPUs in a factory. You're right.”
Flemons:
Yes. So even when it's a wet, warm stack of neurons that is facing the client, they're saying, “You have no idea what I'm going through,” is accurate. Because you truly don't, but you can demonstrate your understanding. And if you're doing a good job, they're agreeing with you. So you make a statement, you float an idea, they agree with you, you now know that you've got some empathic connection going on, and when you're wrong, they correct you and you stand corrected, you adapt, and you're building over the course of the conversation a tighter and tighter connection that's based on your developing through your curiosity and imagination and appreciation of what their experience is.
Puder:
I think there's one part, if I can read, since I actually did an episode on The Bear [see episode 242]. We did a full breakdown of the psychology of Carmen and his mother. So you wrote this portion where you go to season one, episode eight of The Bear, and he's talking, I think at AA, and you write what he is, what he says, but then you write what you would empathically say to him. So I think this might demonstrate what we're talking about here. So you say, “Okay, my name is Carmen. My brother's an addict. My brother was an addict.” And then you write, “Was an addict. It takes a while for the reality of his death to sink in.”
Puder:
Carmen goes on, “My brother could make you feel confident in yourself.” You said, “He could build you up.” Carmen goes on, “You know, like when I was nervous, I was scared. I wouldn't want to do something. He'd always tell me just to face it.” You would say back, “You just knew he had your back.” So it goes on. It's long. But there, my listeners will kinda get the gist of it, but a lot of good practical thinking through of how to, how you said that, “You state the empathically and you demonstrate it. You demonstrate the understanding. You don't say, ‘I understand.’”
Flemons:
You can understand and demonstrate not only in terms of the word choice, but the affect with which you say it.
Puder:
My mentor, Dr. Tar, would say something like, “You can understand it in part, you can imagine in part, but you can never understand fully.” Right? You can have a glimpse into their world. You can seek to understand. Right.
Flemons:
And yes, absolutely. And that is the best we can do. And that's a lot. It's that commitment to striving to understand. There's research that says clients feel more connected with therapists who attempt and fail to make a correct empathic statement than those that would claim that they understand. So they appreciate the fact that we're doing our best.
Puder:
And then you also talk about, we didn't really talk about the both/and empathizing, holding multiple perspectives. Can you mention that briefly?
Flemons:
Yes. So I've got this experience as a family therapist. You got two or more family members holding very different ideas/beliefs about the other and about what happened. And family therapists get caught trying to be neutral, not side with one person against the other. And often that can result in them being so bland that they don't connect with either. The alternative, both/and empathizing, is to be able to grab the essence of what one person is saying and say it back to them so that they agree and then turn to the other person and do the same thing with them. And those two versions of reality are at odds with one another. And you hold both of them going back and forth between them. So that each person feels like you get them. Even though they don't get each other. And that becomes a conduit for developing a different relationship between them.
Puder:
Some good reflectiveness there to be able to hold all parties, all the pieces of the family, all their different, you know, to empathically immerse yourself in the varying viewpoints and to see there is a both/and there often, but they can often miss each other in the midst of that. Right?
Flemons:
They're in search of some ultimate truth. If only can both agree that I'm right and you're wrong, then we can go on from here. That each of them are sort of operating from that assumption. And instead, what we're doing is saying there isn't one objective truth that we're in search of. It's, we're gonna honor the fact that you can profoundly disagree and have different versions of reality. And my job is to make sense of each of them, not to be a judge as to which one's. Right?
Puder:
So good. Well, Dr. Flemons, it's been a pleasure. I think we should probably wrap it up here. Do you have a website or are you on social media or where would you point people towards if they wanna learn more about what you have to offer?
Flemons:
Yes, I have a website, contextconsultants.com.
Puder:
Okay. And we'll put that in the show notes. Great. Well, wonderful having you on. So nice to meet you and we'll leave it there for today.
Flemons:
Lovely to meet you. And thanks for the great conversation.
References
Barrett, L. F. (2017). The theory of constructed emotion: An active inference account of interoception and categorization. Social Cognitive and Affective Neuroscience, 12(1), 1–23.https://doi.org/10.1093/scan/nsw154
Flemons, D. G., & Gralnik, L. M. (2013). Relational suicide assessment: Risks, resources, and possibilities for safety (Annotated ed.). W. W. Norton & Company. https://wwnorton.com/books/9780393706529
Flemons, D. (2026). Empathic engagement in clinical practice. American Psychological Association. https://bookshop.org/p/books/empathic-engagement-in-clinical-practice-douglas-flemons/1cea95e4ea1db87c?ean=9781433843365&next=t&next=t%2Ct
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