Tag Archives: Heinz Kohut

Pathways to Empathy?

Dipping into the vast[1] literature on clinical empathy, one quickly discerns the dominant storyline.  Everyone agrees that empathy, while hard to define,  hovers around a kind of physicianly caring that incorporates emotional connection with patients.  The connection conveys sensitivity to the patient’s life circumstances and personal psychology, and gains expression in the physician’s ability to encourage the patient to express emotion, especially as it pertains to his medical condition.  Then the physician draws on her own experience of similar emotions in communicating an “accurate” empathic understanding of how the patient feels and why he should feel that way.

Almost all commentators agree that empathy, whatever it is, is a good thing indeed.  They cite empirical research linking it to more efficient and effective care, to patients who are more trusting of their doctors, more compliant in following instructions, and more satisfied with the outcome of treatment. Patients want doctors who give them not only the appointment time but the time of day, and when they feel better understood, they simply feel better.  Furthermore, doctors who are empathic doctor better.  They learn more about their patients and, as a result, are better able to fulfill  core medical tasks such as history-taking, diagnosis, and treatment.  Given this medley of benefits, commentators can’t help but lament the well-documented decline of empathy, viz., of humanistic, patient-centered care-giving, among medical students and residents, and to proffer new strategies for reviving it.  So they present readers with a host of training exercises, coding schemes, and curricular innovations to help medical students retain the empathy with which they began their medical studies, and also to help overworked, often jaded, residents refind the ability to empathize that has succumbed to medical school and the dehumanizing rigors of specialty training.[2]

It is at this point that empathy narratives fork off in different directions.  Empathy researchers typically opt for a cognitive-behavioral approach to teaching empathy, arguing that if medical educators cannot teach students and residents to feel with their patients, they can at least train them to discern what their patients feel, to encourage the expression of these feelings, and then to respond in ways that affirm and legitimize the feelings.  This interactional approach leads to the creation of various models, step-wise approaches, rating scales, language games (per Wittgenstein), and coding systems, all aimed at cultivating a cognitive skill set that, from the patient’s perspective, gives the impression of a caring and emotionally attuned provider.  Duly trained in the art of eliciting and affirming emotions, the physician becomes capable of what one theorist terms “skilled interpersonal performances” with patients.  Seen thusly, empathic connection becomes a “clinical procedure” that takes the patient’s improved psychobiological functioning as its outcome.[3]

The cognitive-behavioral approach is an exercise in what researchers term “communication skills training.”  It typically parses doctor-patient communication into micro-interactions that can be identified and coded as “empathic opportunities.”  Teaching students and residents the art of “accurate empathy” amounts to alerting them to these opportunities and showing how their responses (or nonresponses) either exploit or miss them.  One research team, in a fit of linguistic inventiveness, tagged the physician’s failure to invite the patient to elaborate an emotional state (often followed by a physician-initiated change of subject), an “empathic opportunity terminator.”  Learning to pick up on subtle, often nonverbal, clues of underlying feeling states and gently prodding patients to own up to emotions is integral to the process. Thus, when patients don’t actually express emotion but instead provide a clue that may point to an emotion, the physician’s failure to travel down the yellow brick road of masked emotion becomes, more creatively still, a “potential empathic opportunity terminator.”  Whether protocol-driven questioning about feeling states leads patients to feel truly understood or simply the object of artificial, even artifactual, behaviors has yet to be systematically addressed.  Medical researchers ignore the fact that empathy, however “accurate,” is not effective unless it is perceived as such by patients.[4]

Medical educators of a humanistic bent take a different fork in the road to empathic care giving.  Shying away from protocols, models, scales, and coding schemes, they embrace a more holistic vision of empathy as growing out of medical training leavened by character-broadening exposure to the humanities. The foremost early proponent of this viewpoint was Howard Spiro, whose article of 1992, “What is Empathy and Can It Be Taught?” set the tone and tenor for an emerging literature on the role of the humanities in medical training.  William Zinn echoed his message a year later: “The humanities deserve to be a part of medical education because they not only provide ethical guidance and improve cognitive skills, but also enrich life experiences in the otherwise cloistered environment of medical school.”  The epitome of this viewpoint, also published in 1993, was the volume edited by Spiro and his colleagues, Empathy and the Practice of Medicine.  Over the past 15 years, writers in this tradition have added to the list of nonmedical activities conducive to clinical empathy.  According to Halpern, they include “meditation, sharing stories with colleagues, writing about doctoring, reading books, and watching films conveying emotional complexity.”  Shapiro and her colleagues single out courses in medicine and literature, attendance at theatrical performances, and assignments in “reflective writing” as specific empathy-enhancers.[5]

Spiro practiced and taught gastroenterology in New Haven, home of Yale University School of Medicine and the prestigious Western New England Psychoanalytic Institute. One quickly discerns the psychoanalytic influence on his approach.  The humanistic grounding he sought for students and residents partakes of this influence, whether in the kind of literature he wanted students to read (i.e., “the new genus of pathography”) or in his approach to history taking (“The clues that make the physician aware at the first meeting that a patient is depressed require free-floating attention, as psychoanalysts call it.”).

A variant of the “humanist” approach accepts the cognitivist assumption that empathy is a teachable skill but veers away from communications theory and cognitive psychology to delineate it.  Instead, it looks to the world of psychotherapy, especially the psychoanalytic self psychology of Heinz Kohut.  These articles, most of which were published in the 90s, are replete with psychoanalytic conceptualizations and phraseology; they occasionally reference Kohut himself but more frequently cite work by psychoanalytic self psychologists  Michael Basch and Dan Buie, the psychiatrist Leston Havens, and the psychiatrist-anthropologist Arthur Kleinman.

Authors following a psychoanalytic path to empathy assign specific tasks to students, residents, and clinicians, but the tasks are more typically associated with the opening phase of long-term psychotherapy.  Clinicians are enjoined to begin in a patiently receptive mode, avoiding the “pitfalls of premature empathy” and realizing that patients “seldom verbalize their emotions directly and spontaneously,” instead offering up clues that must be probed and unraveled.  Empathic receptiveness helps render more understandable and tolerable “the motivation behind patient behavior that would otherwise seem alien or inappropriate.”  Through “self-monitoring and self-analyzing,” the empathic clinician learns to rule out endogenous causes for heightened emotional states and can “begin to understand its source in the patient.”  In difficult confrontations with angry or upset patients, physicians, no less than psychoanalysts, must cultivate “an ongoing practice of engaged curiosity” that includes systematic self-reflection.  Like analysts, that is, they must learn to analyze the countertransference for clues about their patients’ feelings.[6]

There is a mildly overwrought quality to the medical appropriation of psychoanalysis, as if an analytic sensibility per se – absent lengthy analytic training – can be superadded to the mindset of task-oriented, often harried, clinicians and thereupon imbue them with heightened “empathic accuracy.” Given the tensions among the gently analytic vision of empathic care, the claims of patient autonomy, and the managerial, data-oriented, and evidence-based structure of contemporary practice, one welcomes as a breath of fresh air the recent demurrer of Anna Smajdor and her colleagues.  Patients, they suggest, really don’t want empathic doctors who enter their worlds and feel their pain, only doctors who communicate clearly and treat them with courtesy and a modicum of respect.[7]

And so the empathy narratives move on.  Over the past decade, neuroscientists have invoked empathy as an example of what they term “interpersonal neurobiology,” i.e., a neurobiological response to social interaction that activates specific neural networks, probably those involving the mirror neuronal system.  It may be that empathy derives from an “embodied simulation mechanism” that is neurally grounded and operates outside of consciousness.[8]  In all, this growing body of research may alter the framework within which empathy training exercises are understood. Rather than pressing forward, however, I want to pause and look backward.  Long before the term “empathy” was used, much less operationalized for educational purposes, there were deeply caring, patient-centered physicians.  Was there anything in their training that pushed them in the direction of empathic caregiving?   I propose that nineteenth-century medicine had its own pathway to empathy, and I will turn to it in the next posting.


[1] R. Pedersen’s review article, “Empirical research on empathy in medicine – a critical review,” Pat. Educ Counseling, 76:307-322, 2009 covers 237 research articles.

[2] F. W. Platt & V. F. Keller, “Empathic communication: a teachable and learnable skill,” J. Gen Int. Med., 9:222-226, 1994; A. L. Suchmann, et al., “A model of empathic communication in the medical interview,” JAMA, 277:678-682, 1997; J. L. Coulehan, et al., “’Let me see if I have this right . . .’: words that help build empathy,”  Ann. Intern. Med., 136:221-227, 2001; H. M. Adler, “Toward a biopsychosocial understanding of the patient-physician relationship: an emerging dialogue,” J. Gen. Intern. Med., 22:280-285, 2007; M. Neumann et al., “Analyzing the ‘nature’ and ‘specific effectiveness’ of clinical empathy: a theoretical overview and contribution towards a theory-based research agenda,” Pat. Educ. Counseling, 74:339-346, 2009; K. Treadway & N. Chatterjee, “Into the water – the clinical clerkships,” NEJM, 364:1190-1193, 2011.

[3] Adler, “Biopsychosocial understanding,” p. 282.

[4] Suchmann, et al., “Model of empathic communication”; Neumann, “Analyzing ‘nature’ and ‘specific effectiveness’,” 343; K. A. Stepien & A. Baernstein, “Educating for empathy: a review,” J. Gen. Int. Med., 21:524-530, 2006; R. W. Squier, “A Model of empathic understanding and adherence to treatment regimens in practitioner-patient relationships,” Soc. Sci. Med., 30:325-339, 1990.

[5] H. Spiro, “What is empathy and can it be taught?”, Ann. Int. Med., 116:843-846, 1992; W. Zinn, “The empathic physician,” Arch. Int. Med., 153:306-312, 1993; H. Spiro, et al., Empathy and the Practice of Medicine (New Haven: Yale University Press, 1993); J. Shapiro & L. Hunt, “All the world’s a stage: the use of theatrical performance in medical education,” Med. Educ., 37:922-927, 2003; J. Shapiro, et al., “Teaching empathy to first year medical students: evaluation of an elective literature and medicine course,” Educ. Health, 17:73-84, 2004; S. DasGupta & R. Charon, “Personal illness narratives: using reflective writing to teach empathy,” Acad. Med., 79:351-356, 2004; J. Shapiro, et al., “Words and wards: a model of reflective writing and its uses in medical education,” J. Med. Humanities, 27:231-244, 2006; J. Halpern, Empathy and patient-physician conflicts,” J. Gen. Int. Med., 22:696-700, 2007.

[6] Suchmann et al., “Model of empathic communication,” 681; Zinn, “Empathic physician,” 308; Halpern, “Empathy and conflicts,” 697.

[7] Halpern, “Empathy and conflicts,” 697; A. Smajdor, et al., “The limits of empathy: problems in medical education and practice,” J. Med. Ethics., 37:380-383, 2011.

[8] V. Gallese, “The roots of empathy: the shared manifold hypothesis and the neural basis of intersubjectivity,” Psychopathology, 36:171-180, 2003; L. Carr, et al., “Neural mechanisms of empathy in humans: a relay from neural systems for imitation to limbic area,” Proc. Natl. Acad. Sci., 100:5497-5502, 2003; G. Rizzolatti & L. Craighero, “The mirror-neuron system,” Ann. Rev. Neurosci., 27:169-192, 2004; V. Gallese, et al., “Intentional attunement: mirror neurons and the neural underpinnings of interpersonal relations,” J. Amer. Psychoanal. Assn., 55:131-176, 2007.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.

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Empathy, Psychotherapy, Medicine

What passes for psychoanalysis in America these days is a far cry from the psychoanalysis Freud devised in the early years of the last century.  A sea change began in the 1970s, when Heinz Kohut, a Vienna-born and Chicago-based psychoanalyst, developed what he termed “psychoanalytic self psychology.”  At the core of Kohut’s theorizing was the replacement of one kind of psychoanalytic method with another.   Freud’s method – which Freud himself employed imperfectly at best – revolved around the coolly self-possessed analyst, who, with surgeon-like detachment, processed the patient’s free associations with “evenly hovering attention” and offered back pearls of interpretive wisdom.  The analyst’s neutrality – his unwillingness to become a “real” person who related to the patient in conventionally sympathetic and supportive ways – rendered him a “blank screen” that elicited the same feelings of love and desire – and also of fear, envy, resentment, and hatred – as the mother and father of the patient’s early life.  These feelings clustered into what Freud termed the positive and negative transferences.

Kohut, however, found this traditional psychoanalytic method fraught with peril for patients burdened less with Freudian-type neurotic conflicts than with psychological deficits of a preoedipal nature.  These deficits gained expression in more primitive types of psychopathology, especially in what he famously termed  “narcissistic personality disorder.”  For these patients – and eventually, in Kohut’s mind, for all patients – the detached, emotionally unresponsive analyst simply compounded the feelings of rejection and lack of self-worth that brought the patient to treatment.  He proffered in its place a kinder, gentler psychoanalytic method in which the analyst was content to listen to the patient for extended periods of time, to affirm and mirror back what the patient was saying and feeling, and over time to forge an empathic bond from which interpretations would arise.

Following Kohut, empathy has been widely construed as an aspect, or at least  a precondition, of talking therapy.  For self psychologists and others who draw on Kohut’s insights, the ability to sympathize with the patient has given way to a higher-order ability to feel what the patient is feeling, to “feel with” the patient from the inside out.  And this process of empathic immersion, in turn, permits the therapist to “observe” the patient’s psychological interior and to comprehend the patient’s “complex mental states.”  For Kohut, the core of psychoanalysis, indeed of depth-psychology in general, was employment of this “empathic mode of observation,” an evocative but semantically questionable turn of phrase, given the visual referent of “observe,” which comes from the Latin observare (to watch over, to guard).   More counterintuitively still, he sought to cloak the empathic listening posture in scientific objectivism.  His writings refer over and over to the “data” that analysts acquire through their deployment of “scientific” empathy, i.e., through their empathic listening instrument.

I was Heinz Kohut’s personal editor from 1978 until his death in the fall of 1981.  Shortly after his death, I was given a dictated transcript from which I prepared his final book, How Does Analysis Cure?, for posthumous publication.  Throughout the 80s and into the 90s, I served as editor to many senior self psychologists, helping them frame their arguments about empathy and psychoanalytic method  and write their papers and books.  I grasped then, as I do now, the heuristic value of a stress on therapeutic empathy as a counterpoise to traditional notions of analytic neutrality, which gained expression, especially in the decades following World War II, in popular stereotypes of the tranquilly “analytic” analyst whose caring instincts were no match for his or her devotion to Freud’s rigid method.

The comparative perspective tempers bemusement at what would otherwise be a colossal conceit:  that psychoanalytic psychotherapists alone, by virtue of their training and work, acquire the ability to empathize with their patients.  I have yet to read an article or book that persuaded me that  empathy can be taught, or that the yield of therapeutic empathy is the apprehension of “complex psychological states” that are analogous to the “data” gathered and analyzed by bench scientists (Kohut’s own analogy).

I do believe that empathy can be cultivated, but only in those who are adequately empathic to begin with.  In medical, psychiatric, and psychotherapy training, one can present students with instances of patients clinically misunderstood and then suggest how one might have understood them better, i.e., more empathically.  Being exhorted by teachers to bracket one’s personal biases and predispositions in order to “hear” the patient with less adulterated ears is no doubt a good thing.  But it  assumes trainees can develop a psychological sensibility through force of injunction, which runs something like:  “Stop listening through the filter of your personal biases and theoretical preconceptions!  Listen to what the patient herself  is saying in her voice!  Utilize what you understand of yourself, viz., the hard-won fruits of your own psychotherapy (or training analysis), to put yourself in her place!  Make trial identifications so that her story and her predicament resonate with aspects of your story and your predicament; this will help you feel your way into her inner world.”

At a less hortatory level, one can provide trainees with teachers and supervisors who are sensitive, receptive listeners themselves and thus “skilled” at what self psychologists like to refer to as “empathic attunement.”  When students listen to such instructors and perhaps observe them working with patients, they may learn to appreciate the importance of empathic listening and then, in their own work, reflect more ongoingly on what their patients are saying and on how they are hearing them say it.  They acquire the ability for “reflection-in-action,” which Donald Schön, in two underappreciated books of the 1980s, made central to the work of “reflective professionals” in a number of fields, psychotherapy among them.[1]  To a certain extent, systematic reflection in the service of empathy may help therapists be more empathic in general.

But then the same may be said of any person who undergoes a transformative life experience (even, say, a successful therapy) in which he learns to understand differently – and less tendentiously – parents, siblings, spouses, children, friends, colleagues, and the like.  Life-changing events  — fighting in  wars, losing loved ones, being victimized by natural disasters, living in third-world countries, providing aid to trauma victims – cause some people to recalibrate values and priorities and adopt new goals.  Such decentering can mobilize an empathic sensibility, so that individuals return to their everyday worlds with less self-centered ways of perceiving and being with others.

There is nothing privileged about psychotherapy training in acquiring an empathic sensibility.  I once asked a senior self psychologist what exactly differentiated psychoanalytic empathy from empathy in its everyday sense.  He thought for a moment and replied that in psychoanalysis, one deploys “sustained” empathy.  What, pray tell, does this mean, beyond denoting the fact that psychoanalysts, whether or not empathic, listen to patients for a living, and the units of such listening are typically 45-minute sessions.  Maybe he simply meant that, in the nature of things, analysts must try to listen empathically for longer periods of time, and prolongation  conduces to empathic competence.

Well, anything’s possible, I suppose.  But the fact remains that some people are born empathizers and others not.  Over the course of a 27-year career in psychoanalytic and psychiatric publishing, I worked with a great many analysts and therapists who struck me as unempathic, sometimes stunningly unempathic.  And those who struck me as empathic were not aligned with any particular school of thought, certainly not one that, like self psychology, privileges empathy.

Nor is it self-evident  that the empathy-promoting circumstances of psychotherapy are greater than the circumstances faced day-in and day-out by any number of physicians. Consider adult and pediatric oncologists, transplant surgeons, and internists and gerontologists who specialize in palliative care.  These physicians deal with patients (and their parents and children) in extremis; surely their work should elicit “sustained empathy,” assuming they begin with an empathic endowment strong enough to cordon off the miasma of uncertainty, dread, and imminent loss that envelops them on daily rounds.  Consider at the other end of the medical spectrum those remaining family doctors  who, typically in rural settings, provide intergenerational, multispecialty care and continue to treat patients in their homes .  The nature of their work makes it difficult for them not to observe and comprehend their patients’ complex biopsychosocial states; there are extraordinary empathizers among them.

When it comes to techniques for heightening empathy, physicians have certain advantages over psychotherapists, since their patients present with bodily symptoms and receive bodily (often procedural) interventions, both of which have a mimetic potential beyond “listening” one’s way into another’s inner world.  There is more to say about the grounds of medical empathy, but let me close here with a concrete illustration of such empathy in the making.

William Stevenson Baer graduated from Johns Hopkins Medical College in 1898 and stayed on at Hopkins as an intern and then assistant resident in William Halsted’s dauntingly rigorous surgical training program.  In June, 1900, at the suggestion of Baer’s immediate supervisor, Harvey Cushing, Halsted asked Baer to establish an orthopedic outpatient clinic at Hopkins the following fall.  With no grounding in the specialty, Baer readied himself for his new task by spending the ensuing summer at the orthopedic services of Massachusetts General Hospital and the Boston Children’s Hospital.  At both institutions, many children in the orthopedic ward had to wear plaster casts throughout the hot summer months.  On arrival, Baer’s first order of business was to alter his life circumstances in order to promote empathy with, and win the trust of, these young patients.  To wit, he had himself fitted for a body cast that he wore the entire summer.  His sole object, according to his Hopkins colleague Samuel Crowe, was “to gain the children’s confidence by showing them that he too was enduring the same discomfort.”[2]

Psychotherapists are generally satisfied that empathy can be acquired in the manner of a thought experiment.  “Bracket your biases and assumptions,” they admonish, “empty yourself of ‘content,’ and then, through a process of imaginative identification, you will be able to hear what your patient is saying and feel what she is feeling.”  Baer’s example reminds us that illness and treatment are first and foremost bodily experiences, and that “feeling into another” – the literal meaning of the German Einfühlung, which we translate as “empathy” – does not begin and end with concordant memories amplified by psychological imagination.[3]  In medicine, there is an irremediably visceral dimension to empathy, and we shall consider it further in the next posting.


[1] Donald A. Schön, The Reflective Practitioner: How Professionals Think in Action (NY: Basic Books, 1983); Donald A. Schön, Educating the Reflective Practitioner (San Francisco: Jossey-Bass, 1987).

[2] Samuel James Crowe, Halsted of Johns Hopkins: The Man and His Men (Springfield, IL: Thomas, 1957), pp. 130-31.

[3] The imaginative  component of empathy, which is more relevant to its function in psychotherapy than in medicine, is especially stressed by Alfred Margulies, “Toward Empathy: The Uses of Wonder,” American Journal of Psychiatry, 141:1025-1033, 1984.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.