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Pergamon Clinical Psychology Review, Vol. 14, No. 3, 183-198, 1994 pp. Copyright 0 1994 Elsevier Science Ltd Printed in the USA. All rights reserved 0272-7358/94 $6.00 + .OO 027%7358(94)E0003-S BEYOND EMPATHY: ADVANCES IN THE CLINICAL THEORY AND METHODS OF EMPATHY Alvin R. Mahrer Donald B. Boulet David R. Fairweather University of Ottawa ABSTRACT. Empathy is generally acknowledged to include two components: (a) the therapist’s seeing the patient’s world the way the patient does and (b) the therapistS grasping what the patient is undergoing, thinking, fee&, and experiencing. A review of relatively recent developments indicates some advances in the clinical theory and metho& of an external model and also of an “in-the-patient’s- shoesU model of empathy, tozether with the emerpnce of an internal model whose clinical theory and methodr may be regarded as soin. beyond the traditional theories and methods of empathy. Implications are drawn for the practitioner, clinical theorist, and researcher. In the field of psychotherapy, one component of what is generally called empathy is the therapist seeing the world the way the patient does (Havens, 1974; Mearns & Thorne, 1988; Rogers, 1951). It is “the ability to enter into and understand the world of another” (Egan, 1986, p. 95), “crawling inside of another person’s skin and seeing the world through his eyes” (Carkhuff, 1972, p. 58). A second component is for the therapist to know, to grasp, to understand what the patient is thinking, feeling, experiencing, under- going. Empathy is “the mode by which one . . . imagines their inner experience even though it is not open to direct observation” (Kohut, 1978, p. 450; cf. Jaffe, 1986; Margu- lies, 1984). This second component refers not only to what the patient is thinking, feeling, and experiencing on the conscious level, but also to what may be said to be occurring at an inner, deeper, less conscious level. It involves “more than being in touch with and sharing aspects of the patient’s surface communications . . . empathy must also involve the patient’s unconscious communications and state, which is often at a variance with con- scious expressions”(Langs, 1982, p. 74; cf. Berger, 1987; Kohut, 1984; Schafer, 1959). Correspondence should be addressed to Alvin R. Mahrer, School of Psychology, University of Ottawa, Ottawa, Canada KlN 6N5. 183

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Page 1: Beyond empathy: Advances in the clinical theory and methods of empathy

Pergamon Clinical Psychology Review, Vol. 14, No. 3, 183-198, 1994 pp.

Copyright 0 1994 Elsevier Science Ltd Printed in the USA. All rights reserved

0272-7358/94 $6.00 + .OO

027%7358(94)E0003-S

BEYOND EMPATHY: ADVANCES IN THE CLINICAL THEORY

AND METHODS OF EMPATHY

Alvin R. Mahrer Donald B. Boulet

David R. Fairweather

University of Ottawa

ABSTRACT. Empathy is generally acknowledged to include two components: (a) the therapist’s

seeing the patient’s world the way the patient does and (b) the therapistS grasping what the patient is

undergoing, thinking, fee&, and experiencing. A review of relatively recent developments indicates some advances in the clinical theory and metho& of an external model and also of an “in-the-patient’s-

shoesU model of empathy, tozether with the emerpnce of an internal model whose clinical theory and

methodr may be regarded as soin. beyond the traditional theories and methods of empathy. Implications

are drawn for the practitioner, clinical theorist, and researcher.

In the field of psychotherapy, one component of what is generally called empathy is the therapist seeing the world the way the patient does (Havens, 1974; Mearns & Thorne, 1988; Rogers, 1951). It is “the ability to enter into and understand the world of another” (Egan, 1986, p. 95), “crawling inside of another person’s skin and seeing the world through his eyes” (Carkhuff, 1972, p. 58). A second component is for the therapist to know, to grasp, to understand what the patient is thinking, feeling, experiencing, under- going. Empathy is “the mode by which one . . . imagines their inner experience even though it is not open to direct observation” (Kohut, 1978, p. 450; cf. Jaffe, 1986; Margu- lies, 1984). This second component refers not only to what the patient is thinking, feeling, and experiencing on the conscious level, but also to what may be said to be occurring at an inner, deeper, less conscious level. It involves “more than being in touch with and sharing aspects of the patient’s surface communications . . . empathy must also involve the patient’s unconscious communications and state, which is often at a variance with con- scious expressions”(Langs, 1982, p. 74; cf. Berger, 1987; Kohut, 1984; Schafer, 1959).

Correspondence should be addressed to Alvin R. Mahrer, School of Psychology, University of Ottawa, Ottawa, Canada KlN 6N5.

183

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184 A. R. Mahrer, D. B. Boulet, and D. R. Fairweather

Empathy includes both of these components. It is “seeing the world as the other person does . . feeling the same way as another person does” (Gladstein, 1983, p. 468; cf. Gladstein, 1977). It is when therapists get “within the client’s frame of reference . . . they try to make their personal framework match that of the client . . they attempt to think and feel the way the client does” (Brammer & Shostrom, 1982, p. 161). It is “this ability to see and experience the world as someone else does-to put yourself in another’s shoes” (Brenner, 1982, p. 2), “the imaginative transposing of oneself into the thinking, feeling, and acting of another and so structuring the world as he does” (Dymond, 1949, p. 127; cf. Berger, 1984; Fliess, 1942; Korchin, 1976). Putting these two components together, empathy refers to the therapist’s seeing the patient’s world the way the patient does, and the therapist’s sensing and knowing what the patient is undergoing, thinking, feeling, and experiencing both at the surface, conscious level and also at an inner, deeper level.

According to Schroeder (1925) and Schilder (1953), Theodore Lipps is to be credited with the introduction of “einfiihlunp” into psychology and psychiatry in 1897. This concept was translated and elaborated as “empathy” by E. B. Titchener, and first used in the diagnosis of mental disease by Southard in 1918. Since its introduction, empathy has assumed a central place in many psychotherapies. For Freud (1921/1955) empathy “plays the largest part in our understanding of what is inherently foreign to our ego” (p. 108). “Empathy is believed to play a crucial role in psychotherapy by enabling the therapist to understand what the patient is experiencing from moment to moment in the psychothera- peutic process” (Fox & Goldin, 1964, p. 323). Empathy is “a sine qua non of counselling and psychotherapy” (Cox, 1988, p. 137), “the heart and definition of therapy” (Brenner, 1982, p. 2); it “constitutes what can perhaps be described as the ‘work’ of the therapist” (Rogers & Truax, 1967, p. 104), the essential core and prerequisite of psychotherapeutic and psychoanalytic observation (Greenson, 1960; Kohut, 1959; Kramer, 1989).

From its introduction into the field of psychotherapy until approximately the 1960s and 1970s the predominance of clinical theory and methods of empathy may be credited to psychoanalytic and client-centered theorists. However, since that time there have been significant advances in both the theory and methods of empathy. The purpose is to provide a review of these advances and to flag those which may be regarded as going beyond the traditional meanings and methods of empathy. The review is organized under three models, each with its own advances in the clinical theory and methods of empathy. One is an external model, a second is the “in-the-patient’s shoes” model, and the third is the internal model. It is the recently emerging third model which will be proposed as going beyond empathy as generally understood in the other two models.

The emphasis will be on approaches for which empathy is a central therapeutic feature and which are represented predominantly in recent advances in both the clinical theory and methods of empathy. Accordingly, the review will emphasize advances in psychoana- lytic and psychodynamic therapies and client-centered, humanistic, Gestalt, experiential, and existential therapies, with a lesser emphasis on behavioral, cognitive, and systemic therapies. In addition, the review will focus on recent developments in empathy theory and methods rather than on research. While there has been considerable study of empa- thy, especially as used in client-centered therapy, this line of study has leveled off, and there is comparatively little research on the more recent advances in either the clinical theory or methods of empathy.

THE EXTERNAL MODEL OF EMPATHY

In this model, the therapist is to accomplish the aims of empathy without trying to get in the patient’s shoes or to be inside the patient. More specifically, the therapist is to accom- plish the two aims of empathy while (a) retaining his/her own identity and sense of self,

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Beyond Empathy 18.5

not entering too far into the person of the client; (b) not entering too far into the patient’s world; and (c) knowing and grasping what the patient is thinking, feeling, and experienc- ing without necessarily having or sharing whatever the client is thinking, feeling, or experiencing. As an external, relating therapist, you are “to sense the client’s private world as if it were your own, but without ever losing the ‘as if quality” (Rogers, 1959, p. 99). “The state of empathy, or being empathic, is to perceive the internal frame of reference of another with accuracy, and with the emotional components and meanings which pertain thereto, as if one were the other person, but without ever losing the ‘as if condition” (Rogers, 1959, p. 210). The therapist is cautioned against having the client’s feeling. “It is not necessary- indeed it would seem undesirable-for the therapist to share

the client’s feelings in any sense that would require the therapist to feel the same emotions that the client feels” (Truax, 1967, p. 555). “It is a sensing of the client’s inner world of private personal meanings, ‘as if it were the therapist’s own, but without ever losing the ‘as if quality. . . To sense the patient’s confusion, his fear, his anger or rage as if it were a feeling you might have (but which you are not currently having) is the essence” (Rogers &Truax, 1967, p. 104).

This same “as if’ quality was earlier highlighted by Schroeder (1925) in his method of “empathic duplication,” in which the therapist finds a similar incident or situation from his own memory and uses this to grasp what the patient is feeling and experiencing: “It is as if one sees his or her thoughts and feels their affective tones and valuations . . . us ;f from within, and as if one with the psychic process that has been thus empathically observed” (p. 162).

In the psychoanalytic approach the external therapist is likewise not to merge into the patient, not to live in the patient’s world, not to have the patient’s feelings or experienc- ings. “Freud wanted to understand, to penetrate the most hidden reaches of the patient’s motivation, but he did not want to experience those motivations, himself feeling them, the two, doctor and patient, living in the patient’s world” (Havens, 1973, p. 162). The analyst is to grasp and recognize the feeling or emotion, but not to have it. “My own view is that one does not need to experience the emotions that grip the patient at that particular moment. What is necessary is to recognize a feeling, a thought, or a psychological configuration” (Szalita, 1976, p. 150; cf. Beres & Arlow, 1974); “placing oneself in anoth- er’s experience does not mean becoming that person- that is, ‘taking over’ or ‘being flooded by,’ the patient’s feelings” (Rowe & Isaac, 1991, p. 20).

Instead, the therapist is to remain external, if only to be able to subject the material to logical, intellectual scrutiny and analysis (Fenichel, 1941); “obviously we can neither at any time renounce the use, without the slightest restriction, of our faculty of reality testing, nor can we ever allow any impairment of the keen operation of any of our own intellectual functions” (Fliess, 1942, p. 220). The question is how to know what is occur- ring inside the patient while remaining external: “I cannot theorize from my experience of the encounter anything about what goes on ‘inside’ the woman. All this would tell us is how Z constitute the object and what the experience would meanfor me, but it throws no light on the intrapsychic ‘essence’ of the woman; jumping to that becomes only a projec- tion of our theories” (Chessick, 1992, p. 69).

What follows are six empathic models used by and available for the therapist who is external to the patient, methods by which the external therapist can know how the patient sees his world and what the patient is undergoing, thinking, feeling, and experiencing.

Observe Objective Empathic Cues

Perhaps the most common method relies on the therapist’s careful observation of cues to what the patient is feeling and experiencing. A rich source of cues is simply what the

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patient says he is feeling right now, together with cues suggesting that the patient’s self-described feeling is to be accepted or not accepted. If the patient says, “I feel really sad,” this direct self-description may be said in a way that the therapist can conclude the patient is sad, or in a way that allows the therapist to doubt if the patient is feeling sad. “We deduce somebody’s sadness on the basis of signals, relayed by that person and which we experience within ourselves as utterances of sadness, like weeping, a sad look or expression, etc.” (Vanaerschot, 1990, p. 273).

There are many cues that the therapist can use to draw inferences about the patient’s feeling. Observe the tone of voice, feeling-related material that the patient avoids, sponta- neous denials of feeling, indirect coded hints, changes in speech rate and cadence, and the use of feeling-related words, gestures, and postures. “Empathy works by judgements being made by the empathizer about the feeling state of the other person or object on the basis of associations the empathizer makes to various postural similarities” (Cooper, 1970, p. 172).

Set Aside Knowledge and Inferences About the Patient

The next three methods involve the therapist’s setting aside clinical knowledge and infer- ences about the patient, together with the intent to pursue a clinical understanding of what the patient is like. Instead, the therapist is with the patient as if the therapist has little or no knowledge or understanding or inferences about the patient, a letting-go of everything you think you know about this person (Buie, 1981; Margulies, 1984; Vanaer- schot, 1990). This means “the setting aside of expectations or presuppositions, the avoid- ance of concluding about the patient” (Margulies & Havens, 1981, p. 423). “The function of first suspending the self is to clear the perceptual field of those psychic elements in the observer that might impose an a priori structure” (Margulies, 1984, p. 1031). The thera- pist actively works to achieve this state. The therapist “puts aside all his feelings” (Freud, 1912/1953, p. 115). Furthermore, the therapist “is asked not to organize his experience immediately . . to make fluid what is fixed, to undo existing structures . avoiding immediate conclusions and suspending knowledge. . It means that he puts his theoret- ical knowledge aside while listening to his client and that he avoids drawing conclusions prematurely” (Vanaerschot, 1990, p. 281). It is a matter of “setting aside all expectations, prejudgements, and objectification of the patient and attempting to meet the patient where he is” (Margulies & Havens, 1981, p. 422).

Then you are ready to use empathic methods. “The ability to suspend judgement even to the point of gullibility makes it possible to empathize with the patient” (Greenson, 1967, p. 381). This state of bracketing knowledge and inferences about the patient is described by Margulies (1984) as common to both psychoanalysis and phenomenology. That is, he suggests this is precisely what Husserl tried to obtain by his method of phenomenological reduction and what Freud tried to achieve by free association and having the therapist in a state of naive receptivity, free of preconceptions. “This negation of the self by the therapist involves a kind of self-aggression: to submerge oneself, to submit to not-knowing, and to put oneself aside” (Margulies, 1984, p. 1043). But merely by itself, this is not enough. It is a precondition for each of the following three methods.

A State of Stimulated Free Association and Fantasy. The therapist sets aside knowledge and inferences about the patient and enters into a state of free association and fantasy so that the patient’s flow of free associations stimulates the flow of free associations in the therapist (Fliess, 1942; Freud, 1904/1953). In this posture “the patient’s free association may induce a complementary array of relatively uninhibited associations in the analyst”

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(Levy, 1985, p. 355). By listening in this way, the analyst is receptive to inner, deeper, unconscious material (Ferenczi, 1960). That is, the analyst is able to “turn his own unconscious like a receptive organ towards the transmitting unconscious of the patient” (Freud, 1912/1953, p. 115).

Once the analyst receives this inner, deeper, unconscious material from the transmit- ting patient, the external state of receptive free association is replaced by an external state of logical scrutiny and the drawing of clinical inferences from the material (Deutsch, 1926/1953; Fenichel, 1941; Ferenzci, 1960; Fliess, 1942; Jaffe, 1986; Kohut, 1959; Greenson, 1960; Reich, 1960/1973, 1966/1973; Spencer & Balter, 1984; Sterba, 1943).

A State of Naive Observation of the Patient. The therapist sets aside knowledge and inferences about the patient and enters into a state of utterly naive observation of what- ever manifests itself from the patient. “In the presence of a phenomenon . . . the phenom- enologist uses an absolutely unbiased approach; he observes phenomena as they manifest themselves and only as they manifest themselves” (Ellenberger, 1958, p. 96). The thera- pist is to be a self-less, identity-less, naive observer who does not focus attention on any particular aspect or content of what may be present. The therapist “puts himself ‘in brackets.’ . . . The therapist as a structured and organized entity is almost non-existent” (Vanaerschot, 1990, p. 282). There is mere naive observation, without any removed executive scrutiny, and therefore the therapist observes the patient’s situation wholly on the patient’s terms. “He must abandon all objectivity or surveillance of the patient’s situation and accept the patient’s experience of his situation on his, the patient’s terms” (Havens, 1972a, p. 15).

There is to be no focused searching for inner, hidden, deeper material. “The therapist must continue to observe and listen, staying with the patient’s material and directly experiencing the patient rather than searching for hidden processes” (Chessick, 1992, p. 63). By abandoning explicit efforts to get at inner, deeper material, at hidden processes, the payoff is the naive observation of what is hidden, inner, deeper. This method high- lights and requires “the shedding of all expectations, all efforts to reach behind appear- ances, in order to reach that inner experience as fully as possible” (Havens, 1973, p. 157).

A State of Being Naively Affkfed-Effected by the Patient. The therapist sets aside knowledge and inferences about the patient and enters a state of being utterly and naively affected-effected by the patient. The therapist is merely here, present, open to whatever comes from the patient and whatever this produces or provokes in the therapist. Then the therapist switches to a mode of processing the effect, of knowing how the patient affected or effected the therapist, and reasoning that this indicates what there is in the patient that led to this impact on the therapist. This method was perhaps first described by Murray (1938), who gave the term “recipathy” to the therapist’s “becoming as open and sensitive as possible, [feeling] how the subject’s attitude is affecting him [or asking] what drive is the S evoking in me?” (p. 248). This method surfaces again in therapies such as psycho- analysis: “The affect which the therapist experiences may correspond precisely to the mood which the patient has sought to stimulate in him as, for example, the masochist who tries to evoke criticism and attack. Empathy in such instances consists of recognizing that this is precisely what the patient wishes to provoke in the analyst” (Beres & Arlow, 1974, p. 35).

Insert Yourself Info a Similar Situation From Your Own Life

The external therapist identifies the situation the patient is talking about and searches for a similar situation or incident from his/her own life. By remembering or inserting oneself

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into that remembered incident you can understand what the patient is feeling and experi- encing. “An openness on the part of the empathizer to earlier developmental experiences of his own can be used to compare . . . the patient’s current state with remembered, corresponding affective states of his own . . . this comparison helps the empathizer to understand the other person’s immediate experience” (Cooper, 1970, p. 174; cf. Fliess, 1942; Kohut, 1959; Levy, 1985). D escribed as the empathic method of “reduplicative memory experience” (Schroeder, 1925), it enables the therapist to know what it is like for the patient to be in that situation and to grasp what the patient is feeling and experienc- ing; “empathy implies a conscious effort toward an approximately accurate memory duplication of, or emotional identity with, something in the psychological experience of another which is under investigation. In so far as we achieve accuracy in such empathic duplication we can then read another’s mind by studying its memory-duplicate in many of its relations within ourselves” (Schroeder, 1925, p. 162). This method enables the therapist to make guesses about the feelings occurring in the patient. “The shared experi- ence is based to a great extent on remembered, corresponding affective states of one’s own. Observing a patient’s life at any one point, we tentatively project onto him the feelings we once felt under similar circumstances” (Schafer, 1959, p. 347). The method also enables the therapist to understand what it is like to have the patient’s feeling or experiencing. “As an example, consider the borderline patient who is frantic with a sense of abandonment. When the analyst induces in himself a somewhat similar affect by imaginative imitation, he may remember moments in his past when he lived through similar experiences” (Buie, 1981, p. 297).

Insert Clinical Model of Patient Into the Situation

Over the course of the sessions the therapist gradually builds a cumulative picture or model of the patient. When the patient talks about some scene or situation, the therapist imagines how that working model of the patient would respond, react, feel, and experi- ence in that scene or situation. “I had slowly built up within me a working model of the patient. . . . This working model was a counterpart or replica of the patient that I had built up and added to from my new observations and insights. . . I listened through this model” (Greenson, 1960, p. 421). By using this clinical model of the patient, the therapist can grasp how this patient sees this situation and how this patient thinks, feels, and experiences in this situation. “I listened to the patient’s words and transformed her words into pictures and feelings from her memories and her experiences and in accord with her ways” (Greenson, 1960, p. 421). Variations on this method have been described by others such as Kohut (1971) and Schafer (1959), yet “they all postulate the building up of an inner image of another person of ever-growing depth and complexity to which the analyst refers in understanding what the analysand is experiencing” (Levy, 1985, p. 365).

Here, then, are six methods that the external therapist uses to gain an idea of how the patient sees and perceives his world, and an idea of what the patient is thinking, feeling, and experiencing. Using these methods requires that the therapist be outside of, external to the patient; symmetrically, when the therapist is external to the patient, the therapist is able to use these six methods.

THE “IN-THE-PATIENTS-SHOES” MODEL OF EMPATHY

In this model, the therapist strives to get “inside the patient’s shoes” to see the world from that perspective and to grasp what the patient may be thinking, feeling, and experiencing when seeing the world from that perspective.

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The phrase “being in the patient’s shoes” is commonly used to give the picture of the therapist who looks out on the world from the vantage point of the patient, yet retains his/ her own identity and sense of self (Airing, 1958; Blackman, Smith, Brokman, & Stern, 1958; Lichtenberg, 1984; Stewart, 1956). The therapist senses what it is like to be where the patient is, yet always maintains one’s own individuality. The therapist “temporarily feels at one with the object while maintaining his individuality” (Cooper, 1970, p. 173; cf. Beres & Arlow, 1974). Empathy is the “process of stepping into another person’s shoes and seeing the world through his or her eyes without, however, losing touch with one’s own reality” (Mearns & Thorne, 1988, pp. 26-27). While the therapist “feels he is one with the object . . . above all, out of self-interest as well as interest in the object, he maintains his individuality and perspective at the same time” (Schafer, 1968, p. 153). It is an “empathic sharing of the experience of the patient, without merging with him” (Cooper, 1970, p. 73).

By being in the patient’s shoes, the therapist can get a sense of what the patient is thinking, feeling, and experiencing, can gain “the inner experience of sharing in and comprehending the momentary psychological state of another person” (Schafer, 1959, p. 345). The therapist can attain “a state of mind which seems qualitatively to match and be held in common with the patient . . . the analyst feels he simply is ‘identified with’ or is ‘sharing’ the patient’s inner experiencing” (B uie, 1981, p. 283). Yet the therapist is always to retain his/her sense of identity and self, if only to draw clinical inferences. “The empathizer maintains the integrity of the self intact (Katz, 1963) and does so by placing the self into the other’s intrapsychic reality without being threatened by the other’s experi- ence; thus the empathizer is able to use cognitive functions effectively (Schwaber, 1979)” (Gaffe, 1986, p. 231).

Indeed, there are clear cautions against merging into the patient, rather than merely being in the patient’s shoes. The therapist’s “identification remains segregated within the ego as an object of actual or potential contemplation. It does not to any great extent unconsciously merge into the analyst’s own ego and superego” (Schafer, 1959, p. 357). Always be aware that the therapist and the patient are different persons. “The danger, however, that the therapist would forget that client and therapist are two different per- sons, and that as such, he cannot make a clear distinction any more between the client’s phenomenological world and his own, is not unreal” (Vanaerschot, 1990, p. 276). And if that happens, the therapist cannot function; “he may become engulfed in the patient’s emotional struggle and be unable to appreciate, even if the patient makes progress, what is going on therapeutically” (Knight, 1946, p. 324). A ccordingly, the therapist must be %ecure enough in himself that he knows he will not get lost in what may turn out to be the strange or bizarre world of the other, and can comfortably return to his own world when he wishes” (Rogers, 1975, p. 4).

By being in the patient’s shoes, the therapist can safely alternate between sensing what it is like to be in this world and intellectually processing the clinical material. There is “only a temporary sense of oneness with the object, followed by a sense of separateness in order to appreciate that one has felt not only with the patient but about him” (Beres & Arlow, 1974, p. 34; cf. Beres, 1968). Empathy involves going back and forth between sensing what it is like to be in the patient’s shoes and processing the material that is thereby disclosed. “It seems that it is essential for the development of the optimum capacity for empathy that the therapist be able to become both detached and involved- the observer and the participant- objective and subjective-in regard to his patient. Above all, the therapist must be able to permit transitions and oscillations between these two sets of positions” (Greenson, 1960, p. 420).

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190 A. R. Mahrer, D. B. Boulet, and D. R. Fairweathn

How does the therapist accomplish this? What are the methods that go with the in-the- patient’s_shoes model of empathy?

Seeing and Being in the World From the Patient’s Perspective

The therapist actively and deliberately tries to see and to be in the patient’s world from the vantage point of being in the patient’s shoes and perceiving the world from this perspective. It is a matter of “entering the private perceptual world of the other and becoming thoroughly at home in it” (Rogers, 1975, p. 4). The therapist stands where the patient stands and observes the world from that shared perspective. “Listening from within the frame of reference of the patient’s feelings and thoughts enables the analyst to observe and interpret in a manner that permits him to construct an ‘observation platform’ on which both can stand” (Lichtenberg, 1984, p. 127). From this position, the therapist “is able to sense what it is like to be the client in the situation” (Greenberg & Goldman, 1988, p. 697). Not only is the therapist able to perceive the world that the patient perceives, but the therapist is thereby able to have the thoughts, the feelings, and the experiencings that accompany seeing the world in this way. “In one’s imagination, one puts oneself into the world of the other. Through this imagining and imitating in phan- tasy, the knowledge of human emotional experiencing can be extended” (Vanaerschot, 1990, p. 276). The therapist can feel what the patient feels, being in this scene or situation; “the analyst builds up a temporarlly articulated internal image of the patient’s world. In building this image, in establishing the patient’s world in his own inner world, the analyst approaches a position where he is often able to fantasy and feel (in affect and body) as the patient does” (Schafer, 1959, pp. 356-357).

Duplicate the Patient’s Posture, Gesture, Expression, and Movement

This method consists of literally or imaginatively duplicating the patient’s posture, ges- ture, expression, or movement. By doing this, especially within the context of whatever situation the patient is talking about, the therapist is in a good position to grasp the patient’s thoughts, feelings, and experiencings. The therapist duplicates the patient’s sitting bolt upright, with a wide-eyed look of amazement, or the patient’s slouched pos- ture, or the repeated slamming of the right list into the open left hand, or the upward stretching of both arms above the head. The therapist “assumes facial and bodily attitudes of the other and thereby generates within the self the other’s affective state (Basch, 1983)” (Gaffe, 1986, p. 235; cf. Davis, 1985; Fromm-Reichmann, 1958). Therapists can know what is occurring in the patient “by repeating certain gestures or hand movements which they have observed in the patient. In this way, they feel that they can enter into his mood more easily and better understand the nature of his conflicts” (Beres & Arlow, 1974, p. 42).

These are two methods that go with the in-the-patient’s_shoes model of empathy. Similar to the external model, the therapist is enjoined to retain his/her own identity, sense of self, and individuality, to maintain the ability to distinguish one’s self from that of the patient. There is a reliance on the therapist’s private stream of clinical thoughts and inferences and a sharp caution against becoming merged, fused, caught, or lost in the self of the patient. As in the external model, the therapist is not to be inside the patient, not to be the person who is the patient, not to become fused or merged with the patient. The therapist is to see the world that the patient sees, but just as in the external mod- el, the therapist is not to enter into that world, not to be in the world to the extent or in the way that the patient is. Finally, the therapist is to be able to know the thoughts,

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feelings, and experiencings of the patient, but is not to undergo them very much, if at all.

BEYOND EMPATHY: THE INTERNAL MODEL

Recent advances have also led to the emergence of a third model. Rather than being essentially external to the patient, or in-the-patient’s shoes, the therapist is to be “internal” to, or “aligned” with, the patient.

The internal therapist lets go of her identity or self, and enters into an alignment with the person who is the patient. There is a deliberate disengaging from one’s ordinary, continuing self, identity, individuality; a deliberate letting-go of the stream of therapist thoughts and inferences; and a deliberate merging or fusing or alignment with the person who is the patient. “The empathizing individual is ‘infused with’ or ‘vicariously experi- ences’ the other’s state of mind. His or her personality is momentarily replaced, we can say, or gives way to this state. To that extent, he exists less as a separate person” (Havens, 1978, p. 341; cf. Sollod, 1988, 1993). The therapist fully merges with the patient; “the ego or psychic state of the counsellor had temporarily become merged with that of the counselee; he and I were one psychic unity. This is empathy” (May, 1989, p. 63). In this state, there can be very little awareness of the distinction between therapist and patient; “there is a critical point in empathy above which, when empathizing with more intensity, the emotional self-other differentiation gets lost. So, high levels of empathy would go together with a loss of emotional separation” (Vanaerschot, 1990, p. 289; cf. Corcoran, 1981, 1982). In the psychoanalytic vocabulary, the therapist gives up her ego for that of the patient (Olden, 1953). This model “treats the phenomenon of merging, or fusion, literally, as if there really were a genuine intermixing, blending of one personality with another’s” (Buie, 1981, p. 285). The therapist literally enters into the patient “by a process of empathy in which an immediate passage is made into the other” (Major & Miller, 1984, p. 246).

Being aligned with the patient, more than just being in the patient’s shoes, is taken to mean occupying the very same physical space as the patient, with the two sharing the same skin. That is, “the therapist ‘feels into’ and conceives his self representation together with the patient in the same space. . . . He may conceive of himself as actually sitting where the patient is” (Rothenberg, 1987, p. 449). Quite literally, the therapist operates out of the very same physical space occupied by the patient. “In the empathic event in therapy, the homospatial process first moves patient and therapist from their usual con- texts as totally separated objects, and brings them into an impossible configuration within the same space. . . . This was not tjust as’ the patient nor ‘as if he were the patient. This was not the therapist simply substituting himself for the patient” (Rothenberg, 1987, p. 451).

When the therapist lets go of her own identity or self and deliberately aligns with, merges with, or fuses into the person who is the patient, there is a kind of resonant reverberation or echoing of the feeling occurring in the patient. We can place ourselves emotionally close to the other person, allow the reverberations of feeling to occur. . . . The waiting, feeling posture, in which one echoes some of the patient’s statements and above all supports and echoes his feelings, is passive empathy” (Havens, 1978, pp. 340, 344). This is “an intense resonance. It is a kind of contamination, a primitive form of emotional communication, in which a strong feeling within one person evokes the same feeling within the other” (Vanaerschot, 1990, p. 276). It is acknowledged as occurring especially in strong feeling. That is, “strong affect in one individual simply stimulates the same affect in others” (Furer, 1967; cf. Buie, 1981), and the phenomenon is grasped and made clinically useful by the therapist who is merged or fused with the patient.

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The internal model enables the therapist to have sensitive access to the feelings and experiencings occurring in the patient. “He is to feel what the patient feels. This is the discipline of the existential method” (Havens, 1973, p. 157; cf. Havens, 1972a, 1972b). By being inside the patient and by being in the scene or situation in which the patient is being, the therapist will actually undergo feelings and experiencings. Together with the patient, in a scene of being beaten by his father, “I felt the pain of his father’s beatings, curious as it may seem, as though I myself were receiving the blows” (May, 1989, p. 62). When the patient has a depressed feeling of heavy inferiority, “a depression occurred in myself as though the inferiority had been my own. . . And when he concluded by stating his determination to stick it out at college if it killed him, I felt a certain excitement as though this resolution had been made by my own will” (May, 1989, pp. 62-63). The feelings are real, and really felt. “This sensing may be intense and enduring with the counsellor actually experiencing her client’s thoughts and feelings as powerfully as if they had originated in herself’ (Mearns & Thorne, 1988, p. 39). When patients weep, that occurs in the therapist too. “I noted that when patients wept, I not only felt like weeping myself, but also frequently found myself uttering brief, low cries” (Havens, 1978, p. 339). The internal therapist will typically have accompanying bodily sensations. “When he referred to the rejection by his mother, I even experienced a burning ragelike feeling on my own skin” (Havens, 1986, p. 16).

What are the clinical methods that are designed to enable the therapist to attain the internal locus and thereby to see the patient’s world the way the patient does, and also to sense and know what the patient is undergoing, thinking, feeling, and experiencing? There is a pair of interlocking methods.

Therapist’s Attention Is Directed Toward Patient’s Center of Attention

The therapist’s attention is deployed, as fully as possible, toward whatever the patient is attending to (Havens, 1986; Mahrer, 1978, 1982, 1986, 1989c; May, 1989; Rothenberg, 1987). Instead of attending to one another, both patient and therapist are attending to a third focal center. This is the framework used in psychoanalytic free association, where both patient and therapist are, to a large extent, attending to the flow of associational material rather than to one another. However, the method involves the patient’s attention being deployed explicitly toward feeling-connected images, objects, scenes, and situa- tions.

As the patient is attending predominantly to whatever is important, the therapist likewise attends to the same material. As much as possible, the therapist’s attention is directed “out there,” onto whatever the patient is attending to. Both therapist and patient are attending predominantly to the cancer, the headache, the look on the other person’s face, to being and living in whatever scene or situational context is connected with feeling and is immediate and present for both patient and therapist.

It is somewhat natural for the patient to turn away from attending mainly to the therapist when the patient is concentrating on free association, on the empty chair in the Gestalt two-chair technique, or on a focal center used in hypnotherapy, or more com- monly whenever the patient turns away to concentrate on a memory, on selecting the right word for it, on whatever the patient momentarily is attending to. In order for the therapist to attend to whatever the patient is attending to, this method invites the therapist to do what the patient is doing, both directly looking out there, and perhaps closing the eyes to see it better, without the immediate distraction of looking at and talking to the other person (Major & Miller, 1984; Rothenberg, 1987; Sollod, 1993).

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Therapist Allows What Patient Is Saying to Come in and Through Therapist

When both patient and therapist are directing their attention out there, the therapist can allow what the patient is saying to be as if it is coming in and through the therapist (Mahrer, 1986, 1989b, 1989c; May, 1989; Sollod, 1988, 1993). Whatever the patient says and does, however it is being said and done, is as if the therapist is “talking along with the patient” (Rothenberg, 1987, p. 451). As the patient looks at the cancer and says, “I know it’s going to kill me, n it is as if the therapist is also saying these words, in the same way. Both are looking at the cancer. The words are essentially coming from both patient and therapist.

It is the patient who says these words, but it is as if the patient’s voice were inside the therapist so that the words seem to be coming from some part of the therapist. Looking at the cancer, seeing it right there, it is as if something from within the therapist is saying, “I know it’s going to kill me.” The therapist is postured so that the words are simultaneously occurring in and through the therapist. In this sense, the therapist is the vehicle through which the patient’s words are said.

The combined use of these two clinical methods allows the therapist to come quite close to seeing the patient’s world the way the patient does and to joining in on what the patient is undergoing, thinking, feeling, and experiencing. To the extent that both patient and therapist are aligned, both living and being in some situational context, the therapist may almost literally see the patient’s world the way the patient does (Havens, 1978, 1986; Mahrer, 1978, 1989c; May, 1989). To the extent that the patient’s attentional center or scene is accompanied with feeling, and the therapist enables the patient’s words to come in and through the therapist, the therapist may well share what the patient is undergoing, thinking, feeling, and experiencing, both at the surface and at deeper levels. Indeed, when feeling level is strong, when both patient and therapist are centered onto a scene of strong feeling, and when the therapist uses the two clinical methods to a full degree, the therapist may well be sensitively close to the patient’s inner, deeper feelings and experi- encings (Mahrer, 1982, 1986, 1989a, 1989b, 1989c; Major & Miller, 1984; May, 1989; Mearns & Thorne, 1988; Vanaerschot, 1990).

The specifying of these two clinical methods anchors the internal model and provides a picture that is less diffuse and vague. It is one thing to conceptualize the therapist as merging with, fusing into, entering into the patient, becoming one psychic unity. The excess metaphorical baggage is somewhat removed when the picture is of both patient and therapist being “aligned” with one another, both attending predominantly to a third center of attention or scene and the therapist allowing the patient’s words to come in and through the therapist. In other words, these two clinical methods help to remove the internal model from its loosely poetic, metaphorical image and to give it a somewhat more practical clinical status.

DISCUSSION

The external and the in-the-patient’s_shoes models of empathy have been around almost from the entrance of empathy into the field of psychotherapy. Recent advances in their clinical theory have yielded six clinical methods in the external model and two clinical methods in the in-the-patient’s_shoes model. In addition, recent advances in predomi- nantly existential clinical theory have yielded a new model, the internal model, together with its two interlocked clinical methods.

All three models enable the therapist to try to see the world the way the patient does, and also to try to know what the patient is undergoing, thinking, feeling, and experienc-

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ing both at the surface, conscious level and also at an inner, deeper level. All three models share similar aims and objectives in this regard.

However, there are at least three ways in which the internal model may be seen as going beyond the traditional meanings of empathy:

1. In the internal model, the therapist predominantly attends to the patient’s world, determinedly and explicitly seeing that world, living and being in that world. Most of the therapist’s attention is focused on what the patient is attending to. In contrast, in the other two models there are explicit cautions against attending to the patient’s world too much, going too far, losing oneself in the patient’s world (Airing, 1958; Blackman et al., 1958; Cooper, 1970; Mearns & Thorne, 1988; Rogers, 1959, 1975; Schafer, 1959; Stewart, 1956).

2. In the internal model, the therapist is situated so that what the patient is saying and doing are essentially coming in and through the therapist. In contrast, in the other two models there is a greater emphasis on the therapist’s processing what the patient says and does. The therapist listens to, observes, receives, draws inferences from what the patient says and does.

3. In the internal model, the therapist undergoes a full measure of the feelings and experiencings that are present as the therapist is being in the patient’s immediate world and is letting the patient’s words come in and through the therapist. In the other two models, there are explicit cautions against sharing in the patient’s whole- sale feelings and ongoing experiencings, actually having these feelings and experi- encings together with the patient (Beres & Arlow, 1974; Cooper, 1970; Havens, 1973; Rogers, 1959; Rowe & Isaac, 1991; Schafer, 1959; Szalita, 1976; Truax, 1967).

Each of the three models may be suited to its own clinical methods, and much less fitting for the clinical methods of the other models. In other words, the therapist who uses any one model will likely forego the clinical methods of the other models. The internal therapist would be less inclined to use a private stream of cognitions in a logical scrutiny of the data and less inclined to use observed empathic cues or to insert himself or herself into similar situations from one’s own personal life. The external therapist would be less likely to live and be directly in the scene with the patient, to allow what the patient says and does to come in and through the therapist, or to share in what the patient is undergo- ing at the immediate moment. The therapist who uses the in-the-patient’s_shoes model would tend to sacrifice the therapist’s flow of associational material, to apply a cumulative clinical model of the patient, or to be sensitive to the presence of observed emphatic cues in the patient. The use of any of the three models generally inclines the therapist toward the clinical methods fitted for that model.

The “payoff’ question is whether or not the three models can provide similar or differ- ent empathic yields. To what extent may the three models be regarded as alternative routes to essentially similar pictures of how the patient sees his or her world and to what the patient may be undergoing, thinking, feeling, or experiencing? To what extent do the three models provide substantially different empathic payoffs? Does it make a difference whether the therapist uses one or another of the three models of empathy?

One consideration is whether the model relies on the therapist’s removed processing of the data. In the external model, and to some extent in the in-the-patient’s_shoes model, the therapist arrives at inferences by means of a removed stream of private thoughts. There is a deliberate intellectual processing of the data. In the internal model there is more emphasis on the immediate, shared undergoing of what the patient is seeing, saying,

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doing, feeling, and experiencing. A second consideration is that each model may well have its own favorite kinds of data. Even granting a measure of overlap, the external and the in-the-patient’s_shoes models can accommodate a relatively broad band of data, while the internal model explicitly focuses on data in which both patient and therapist are attending to objects, times, and scenes of strong feeling. A third consideration is that the substantially different locations of the therapist almost insure substantially different work- ing data. In the internal model the therapist is living and being in the scene, is saying and doing what the patient is saying and doing. The working data occurring in the internal therapist are almost assuredly different from that of the external therapist, who may be recollecting similar events from her own life, or from the therapist who is in the patient’s shoes while maintaining her own identity and avoiding getting drawn in to the patient’s scene or what the patient is actually feeling and experiencing. On the basis of these considerations, it would seem that the three empathic models may well yield different pictures of the way the patient sees the world and what the patient is undergoing, think- ing, feeling, and experiencing.

It should be acknowledged that if the three models do yield different empathic informa- tion, that may or may not be a problem. The possible differences become a problem if they are all looking for the same thing and if the empathic inferences make a difference in what the therapist then does. If, for example, the therapist infers a pronounced sense of abandonment using an external method, but not when using the internal method, that difference is important for the therapist who may be inclined to diagnose the patient as a borderline. On the other hand, differences yielded by the three models may be significant with regard to particular purposes and uses. When the patient is crying about the death of a grandmother, the external model may be more useful in identifying the stimulated affect in the therapist, whereas the internal model may be more useful in obtaining the inner, deeper experiencing in the ongoing moment of strong feeling.

With regard to research, the recent advances in the theory and clinical methods of empathy point the way toward at least two avenues of further study. One has to do with the therapist qualities and characteristics that incline the therapist toward or away from these three empathic models. Fenichel(l953) regarded empathy as a feminine quality and proclaimed that “women are more empathic than men” (p. 104). Greenson (1960) agreed that empathy “has a definite feminine cast. For men to be empathic they must have come to peace with their motherly component” (p. 423). Are there personal qualities and characteristics that enable a therapist to use any of these three models, or any one in particular? Is it easier for beginning therapists to use the external model than the internal model? Does the internal model involve greater risks than the in-the-patient’s_shoes model?

A second research avenue offers the choice of either studying ways of improving each of the three models or of comparing the three models to see which one may be better for seeing the patient’s world the way the patient sees it and for grasping what the patient is undergoing, feeling, and experiencing. Our preference is to investigate ways of improv- ing each of the three models, together with their clinical methods and the in-session conditions under which each model may be used to its greatest advantage. One of the problems in comparing the relative efficacy of the three models is accepting the assump- tion that there is a single, accurate, objective criterion of the way the patient sees the world and for what the patient is undergoing, feeling, and experiencing, especially at an inner, deeper level. What is the criterion against which the three models may be com- pared? How can one be shown to be more accurate, objective, and effective when each is carried out with reasonable competence? It is doubtful that proponents of all three models would accept such an assumption, or any proposed criterion. In general, while some

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researchers may be drawn toward such comparisons among the three models, we are more inclined toward studies designed to improve all three sets of clinical methods and their respective usefulness in the ongoing process of therapy.

1.

2.

3.

4.

5.

CONCLUSIONS

Therapists use clinical models and methods designed to enable the therapist (a) to see the patient’s world the way the patient does and (b) to know what the patient is undergoing, thinking, feeling, and experiencing, both at the surface level and at an inner, deeper level. In general, these two aims fall under what is known as empathy. On the basis of recent advances in the clinical theory and methods of empathy, it is proposed that a useful framework consists of three models of empathy: an external model, an in-the-patient’s_shoes model, and an internal model. This threefold frame- work is proposed as useful for the practitioner, the clinical theorist, and the re- searcher. It is proposed that (a) recent advances have yielded at least 10 empathic methods, (b) the external model of empathy is associated with six empathic methods, (c) the in-the-patient’s_shoes model of empathy is associated with two empathic methods, and (d) two interlocking methods are appropriate for the internal model of empathy. The internal model and its methods are relatively recent developments. A compari- son with the other two models and their methods suggests that the internal model may be regarded as a significant departure beyond the traditional meanings and methods of empathy. Adopting and using this provisional framework of models and methods of empathy may be expected to have significant implications for the practitioner, the clinical theorist, and the researcher.

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Received April 9, 1993

Accepted September 22, 1993