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Point / Counter-Point 4

Posted By James B. Anderson and Jodi Polaha, Thursday, March 22, 2012




James B. Anderson (\ˈem-pə-thē\)

1:the imaginative projection of a subjective state into an object so that the object appears to be infused with it.

2:the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner;also: the capacity for this.


The importance of the relationship between therapist and client has long been recognized as a key to successful intervention. In his landmark work in developing his style of psychotherapy, Carl Rogers advocated a humanistic, client-centered approach to therapy. Central to Rogers' approach was the creation of the relationship between therapist and client. According to Rogers (1946):

If the counselor can create a relationship permeated by warmth, understanding, safety from any type of attack, no matter how trivial, and basic acceptance of the person as he is, then the client will drop his natural defensiveness and use the situation (p. 419).

Since Rogers' work, a strong therapeutic alliance has been reliably demonstrated to be associated with positive therapeutic outcome, regardless of type of therapy. Recognizing the importance of such a relationship, many clinicians have made the assumption that empathy is an essential component of effective therapy. Explicitly or implicitly, it seems that many assume that empathy serves as a mediating variable to achieve the coveted alliance so valuable to positive therapeutic outcome.

A prime example of this assumption can be found within Motivational Interviewing (MI). MI is a contemporary therapeutic approach that has been demonstrated to be efficacious when used to help patients make behavioral changes for a variety of health concerns (smoking, weight loss, diabetes, etc.). While certainly not a magic bullet approach (it's not a "panacea,” as founders William Miller and Stephen Rollnick repeatedly remind us), it is very clearly a very important approach to clinical care that has the potential to make primary care interventions more effective. Listed first amongst principles for an MI approach to talking with patients is the expression of empathy from the therapist towards the patient. While it is clear that therapeutic alliance is important to therapeutic outcome generally, and that expression of empathy may be an important path to such an alliance, I argue that it is the former component ("expression”) that is more vital than the latter ("empathy”).

What is vital to what happens in therapy is a result of what happens in therapy—that is, outcome is related to actions, not a hypothetical construct felt inside of the therapist. Certainly the relationship between the patient and the provider is important, as has been repeatedly demonstrated, but that relationship is an interaction of behaviors that have symbiotic influence on one another. When the construct of therapeutic alliance has been evaluated empirically, a number of variables that influence outcome and treatment retention have been identified, ranging from agreement between patient and clinician about treatment tasks, to level of patient arousal (energy and alertness) to the bond between clinician and patient as characterized by expressions of acceptance and confidence.

While one could argue that it is helpful for a therapist to truly have a subjective sense of what life feels like in his or her patient's shoes in order to exude behaviors typically interpreted by patients (or observers) as representative of clinician empathy, it is not necessary. In fact, a clinician might be able to effectively articulate his or her difficulty understanding a patient's motivations or circumstance to help the patient clarify values, recognize possible dissonance between actions and values, and assert and strengthen autonomy to make decisions even if they are not completely understood by another. The bottom line is that while a good working relationship is important (and perhaps vital) to successful treatment, the way that the therapist feels is not essential to creating such a relationship. It is the interplay of behaviors between individuals involved in this complex interaction is important, and ultimately the way that the patient thinks and feels as a result of the interaction is much more important to therapeutic outcome than the feelings of the therapist.

Empathy Shmempathy?

Jodi Polaha

Empathy Shmempathy?

Does the therapeutic alliance (with or without empathy included) predict positive outcomes in therapy? I called my good friend Trent Codd, III, Cognitive Behavior Therapist Extraordinaire, about the empathy issue. He pointed me to studies by DeRubeis and Feeley (1990) and Feeley, DeRubeis, & Gelfand (1999), examining early and late measurement of process variables, including factors specific to CBT as well as therapeutic alliance/facilitative conditions. The findings of these studies showed that "common factors” including alliance did not affect depression early in treatment (CBT factors did), but were, instead, the consequence of change. Since these common factors were traditionally evaluated at a point when a great deal of symptom change had already occurred they could not be considered causal. These results suggest the field needs to go back and redesign its studies, taking temporal factors into account. In the process, researchers could examine the definition of "alliance,” better operationalize "empathy,” and try to unbundle these to identify which elements have greatest impact (or, the MINC, Minimum Intervention Needed for Change) just like we are doing with multi-component evidence based interventions.

Is empathy relevant? It is an empirical question, which is the easy "out” for any academic with a full in-box. Therapists' assumption that empathy is effective or necessary might be driven by a history of real-world observations; the stuff upon which relevant science is based.

Still, when placing this question in the context of a field working to implement and disseminate our science in new and changing paradigms driven by a new group of consumers, I'm having a hard time empathizing with the issue as a whole. What is the place of empathy or even therapeutic alliance in integrated care? What about in mHealth or eHealth interventions, which are gaining popularity and an evidence base? Treatment in these contexts bears little resemblance to the kind of therapy upon which these concepts of empathy and alliance were originally conceived. Perhaps, for the readers engaged here, it's time to exnovate some of the research targets that made sense in days gone by and consider innovating fresh and relevant targets.




James Anderson PhD
Jodi Polaha PhD

James is a second-year UMass Fellow of Clinical Health Psychology in Primary Care. He received his BA from the University of Wisconsin- Eau Claire, research training from the Neuropsychiatric Institute of UCLA, and his PhD in Clinical Psychology at Western Michigan University.

Jodi is an Associate Professor in the Department of Psychology at East Tennessee State University where her primary professional interest is research, training, and workforce development in rural integrated practice.  

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Randall Reitz says...
Posted Thursday, March 22, 2012
Colleagues, as you both point out, the science behind therapeutic relationships is still nascent and inconclusive. As such, I will join you in abandoning empiricism to provide my gestault on this topic:

No, empathy is not essential. Yes, empathy makes everything a whole lot easier.

There have been patients who I disliked, but that I saw in therapy for more times than an integrated therapist should admit. I had scant empathy for them. I continued to see them because they wanted to continue to see me. With them, I was able to make a separation between my "therapist-as-self" and my "therapeutic offerings".

There have also been patients who continued to see me despite their antipathy for me. Most of them were coming due to a secondary gain (i.e. court-order, separating-spouse, or narcotic-prescribing-physician). In all these cases it remained clear to me (and probably the patient) that everyone would have been better served if the therapist had empathy for the patient and the patient had approval of the therapist.

Since this discussion started with Rogers, I will finish with a Rogerian question. Perhaps his most enduring contribution to our field was "unconditional positive regard". Is UPR even possible without empathy? I don't think it is. In fact, I will assert that empathy and UPR are almost exactly the same construct.
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Jackie M. Williams Reade says...
Posted Thursday, March 22, 2012
If we are looking at the pure definition of the word "empathy" then I can see how empathy alone is not enough to be helpful, but rather the expression of that empathy is needed. I have witnessed clinicians who are able to express empathy that appears helpful to the patient when, in fact, the clinician has admitted later that they did not actually feel empathy at all, rather they were just using perfunctory language. So I can see both sides... However, my primary interest regarding empathy these days is in how empathy may have just as much value for the clinician as it does for the patient. I find studies that show empathy and other "self" measures being helpful in promoting quality of life, resilience, and decreased levels of burnout and stress for clinicians to be fascinating. Empathy without the knowledge/ability to know how to express it and what to do with those feelings can be overwhelming and ultimately unhelpful so it is important to not just end the conversation at increasing empathy, but rather expressing empathy appropriately and having the ability to be mindful regarding your empathic responses are also crucial in a patient-provider relationship.
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Dan Marlowe says...
Posted Friday, March 23, 2012
I want to issue the caveat that this is more of a diatribe than a comment, but only because I think James brings up a lot of great points that we, MH professionals, tend to gloss over or give a half-interested empirical glance to….with that…here we go 

I must admit, I am in a peculiar position because I completely agree with and disagree with James’ points at the same time. I am in complete agreement with the notion of therapeutic outcomes being related to actions, as well as the fact that how the patient thinks/feels about the interaction is incredibly important. However, I think the main point of disagreement for me is how he uses the term ‘empathy,’ and how he connects it back to his two previous assertions. If we look at the 2nd definition he used to open his post- the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner- my issue is with the “-ing” endings on each of those words along with the opening word of the definition, “action.”

James essentially builds the argument that empathy is a construct located inside that of the therapist and is separate from action/outcome, which is born out in his comment that empathy is “…a hypothetical construct felt inside …the therapist.” He then goes on to draw a distinction between the internal feeling called “empathy” and the expression of that empathy, which he in turn says, “…is more vital than the later.” However, I am having a hard time drawing the connection between the definition used to describe the construct, and the issue he takes with the construct in regards to the therapeutic alliance. By definition, empathy is not a feeling since it is the “action of understanding…and vicariously experiencing the feelings, thoughts, and experience of another…” A feeling is defined as “the general state of consciousness considered independently of particular sensations, thought, etc.,” so, how can empathy then be a feeling, since, by definition, it is directly connected to another’s feelings, thoughts, and experience (i.e., interdependent)? Even if we wanted to take the position that empathy is a feeling about feelings, all we have done is create a feeling-infused Mobius strip, which if empathy is my feeling about your feelings, what about my feelings about my feelings about your feelings (empathy2 ?)…so on and so forth. In treating empathy as a feeling we create an entire cadre of upper-level abstractions that we have to find names for and fit into our models of change- great for us academics, but not so useful for the actual work of helping patients/clients…one of James’ main points and a beautiful point at that.

A second concern is the question of who determines empathy, the empathizer, or the one being empathized with? Again, I go back to the “otherness” inherent in the definition used to describe empathy. If it is truly the understanding of another’s experience, how can I, as the ‘outsider’ in fact say I empathize, that I ‘understand’ my client’s experience- who better to judge my understanding of their experience (as the client) than they? This would be akin to me debating with Rogers what he meant about his work. He is the one who wrote it, how could I understand his work better then he? In this hypothetical conversation, Rogers would ultimately determine whether or not I understood his work (i.e., his experience) through how I expressed my understanding of that work with/to him. James touches on this point when he states that the most important thing is how the patient thinks and feels about the interaction- I completely agree with him here as well, albeit for a different reason. In short, if empathy is the action of my attempt to understand another’s experience, then whether or not I have empathy can never be stated by me directly, only expressed by the person I am empathizing with. Now, if we want to get really complicated (Yay!), we can talk about a patient’s understanding of my understanding of their understanding of their experience, or their expression of empathy for my expression of empathy. Very obnoxious, I know, but important to highlight that empathy is not only what I do (do being the opportune word) as the therapist, but also what my client does with me concurrently- it is not a therapeutic technique or quality, it is a human quality, and it is recursive in every sense of the word.

Empathy is not a feeling, but an interdependent expression of my understanding of another’s understanding of their experience (i.e., an action). In that vein of thought then, how can one tease out the difference between empathy and its expression since without its expression what else would it be, based on the very definition used to classify it? Even in making the point that “a clinician might be able to effectively articulate his or her difficulty understanding…” as a means of intervention outside the use of empathy, how is this anything but the expression (not feeling) of empathy at work? If empathy is not a state, but instead a process of relating, the fact that I concede I do not know, also means that the intervention listed (i.e., clarification) is the very action of attempting to understand (i.e., empathy)…how can one help a client/patient recognize dissonance between actions and values without knowing: a) what they are, and b) how the client sees them fitting together? The intervention he listed is explicitly contingent on his ability to understand their understanding of their experience of their values/actions.

Empathy, in the most basic sense, is about the relational synchronization of experience and action, which is not the same as sympathy (i.e., I do not have to like or agree with my client to understand their experience). After writing this very long and drawn out post, it struck me to look up the definition of sympathy- “harmony of or agreement in feeling …” This term fits much better with the distinctions being draw in his post between expression and feeling, and if that is the case, then yes, I would agree that sympathy has little to do with therapeutic outcomes.
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James Anderson says...
Posted Friday, March 23, 2012
Dan, I think we are agreeing on what makes a difference in therapy and any disagreement we may have seems to be around definitions, both in that of "empathy" and that of "feeling."

I have a hard time with the definition of a feeling ("A feeling is defined as 'the general state of consciousness considered independently of particular sensations, thought, etc.,'") that you provide. I tend to think of feelings from a more Skinnerian perspective-- they are private events (or behaviors) that are influenced by the same sorts of antecedents and consequences that affect more external behaviors. Feelings rarely (if ever) happen completely independently from thoughts or circumstances. I am not sure if that is what the quote is saying or not (it says that "feelings are considered independently of particular sensations...etc.", but does not say "uninfluenced by." It seems to me that the definition of empathy at the top (taken from Mariam-Webster, BTW) does suggest some sort of internal event occurring within a person, and my point that such a sensation is not required to do effective therapy. However, I really like Jackie's point about the potential benefit of empathy for clinician performance.

I like your ideas about the implications of the articulation of a clinician's difficulty understanding a patient's actions. One result of this may be an improvement of the clinician's understanding (which I would argue is not the same as empathy), but more important to my yes is the extent that it helps the patient recognize the connection between his or her values (or lack thereof), and make a decision of how to act to deal with any discrepancies identified.
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