The important role of empathy in a therapeutic alliance is seldom emphasized in training, particularly as the treatment focus has moved toward pharmaceutical intervention. Perhaps some teachers of psychotherapy feel it is self-evident and therefore there is no need to elaborate. However, in practice, this deficiency is often evident. It shows up immediately when there is the mistaken view that information can be gathered without paying attention to the unconscious currents displayed in how the patient presents during the initial interview, the initial contact where the therapist is gathering background data. This continues if there is the further mistaken view that therapy can be conducted in a detached, apparently scientific way, as if that appearance is, in itself, sufficient.
Novice therapists, particularly those whose training has focused on psycho-pharmaceuticals, sometimes are under the false impression that merely following a checklist will result in competent therapeutic intervention and guidance. This is foolish. To think that one can expect genuine healing of depression from merely a prescription of a drug, without awareness of the patient’s personal milieu and social background, the past and present contexts of their life, is both ludicrous and dangerous.
In the case of a cold or “too busy to listen” attitude of the therapist, relevant information is often not communicated or, if it is communicated, it fails to be identified as important. Results of intake assessment interviews can be biased if they follow a pattern of questions and answers according to what is solely the interviewer’s definition of essential data. A checklist style of interview presumes that one will end up with a complete and accurate sheet of information if only one asks the right questions.
Nothing is farther than the truth. That mode of interrogation may yield many false positive answers as well as many false negative answers. When there is a lack in empathy, communication often becomes meaningless. Novice therapist may miss the critical context of a response by becoming diverted over some minor detail. A simple and unfortunately accurate example is that missing a clue to early childhood sexual abuse is a mistake of vital significance in an assessment.
Empathy directs the therapist in the how, when and what to say in the history taking. The sensitive therapist will know when to keep silent, when to ask follow-up questions, and what to ask while remaining always tuned in to the emotional tone of the communication. This means that each and every intake assessment will be different, based on the presentation of the patient.
In other words, the therapist becomes sensitive to the voice of the individual’s unconscious. Conscious data and words are seen as only part of the picture. True reliable and meaningful data of the interview are obtained only in a positive therapeutic relationship. The foundation of that lies in the therapist’s empathic understanding. This highlights the fact that there is no clear line of demarcation between when an assessment ends and therapy begins.
Never forget that the patient is assessing the therapist during the entire assessment event. A patient that doesn’t see empathy from the therapist is not going to trust that therapist enough to make the assessment accurate. Further, without empathy, there is a very real risk that the interviewee will not return to become a patient due to that lack of trust. In other words, an improperly conducted assessment, without empathy, is already heading to a therapeutic failure.
Personally, I suspect empathy can be turned nurtured and developed in most individuals. But, there is a prevailing tendency to denigrate the importance of empathy, because it is not seen as true science. According to Carl Rogers (1977), three attributes of the therapist form the core part of the therapeutic relationship – congruence, unconditional positive regard and accurate empathic understanding. These are the only tools the therapist possesses, just as indispensable to the therapist as scalpels, anesthesia and the asepsis are to the surgeon.
Today, the individuals who are overly focused on psycho-pharmaceutical approaches may forget these critical attributes. In practice, some professionals are exclusively focused on accurate record-keeping Accurate record-keeping is extremely important for therapy, but is not so helpful if it is focused on primarily for the sake of practicing defensive psychiatry, the fear of litigation. A therapist with perfect record-keeping may have done everything in a legally impeccable way – always prescribing in accord with the manufacturers’ recommendations – but without empathy may be unable to successfully treat their patients.
In the absence of a warm “ready to listen” clinical approach, case after case can easily get misdiagnosed. How can that happen to good therapists? It can happen quite easily when therapists are exhausted and overwhelmed by their caseload. When the caseload becomes too much, those who only pay lip service to genuine psychotherapy will limit their success in helping to those who will respond to antidepressants. The very real problem with this then is that the carpenter whose only tool is a hammer will see everything like a nail to strike.
How often do psychiatrists go home to their double martini to relieve the distress caused by vicarious trauma? The burned-out therapist often unwittingly chooses turning off empathy as a way of protecting themselves from the emotional cost of providing therapy. The fact is that everyone wants to avoid pain, even if the pain belongs to the other person. However, therapist do not have that choice if they wish to truly benefit their patients.
Empathy requires the ability to handle psychological conflicts, including that of the therapist. It is much easier to turn off empathy and do one’s work mechanically, than to listen with empathy and feel the pain of the other person. But, the penalty for that is doing bad or useless psychiatry. Therapists need to protect themselves by caring for their own state of mind. In that way, they can expand their ability to care for their patients.
