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“Some Thoughts on Empathy” Revisited Forty Years Later Russell Carr To cite this article: Russell Carr (2015) “Some Thoughts on Empathy” Revisited Forty Years Later, Psychiatry, 78:2, 130-133 To link to this article:

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Date: 29 September 2015, At: 21:38

Psychiatry, 78:130–133, 2015 ISSN: 0033-2747 print / 1943-281X online DOI: 10.1080/00332747.2015.1051438


“Some Thoughts on Empathy” Revisited Forty Years Later

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Russell Carr In May 1976, Psychiatry published the article “Some Thoughts on Empathy” by Alberta B. Szalita. The text had been presented in 1975 as the 18th annual Frieda FrommReichmann memorial lecture at the Clinical Center of the National Institute of Mental Health under the support of the Washington School of Psychiatry. In 40 years, our use of the term empathy and our perspectives on it have evolved considerably. By perspectives, I mean the perceived roles of empathy in treatment. There is a perception of its diminished need in today’s mental health care, which I think is a shame. As evidence, Dr. Szalita’s presentation was an annual lecture in memory of Dr. Fromm-Reichmann given at the National Institute of Mental Health (NIMH). Today, there are no lectures on empathy at NIMH, to my knowledge. If they occur, they are most likely on the biology of empathy, not how to be empathic or how to use empathy therapeutically. They do not explore, as Dr. Szalita (1976) so eloquently stated, how “empathy, like life itself, is perpetual discovery” (p. 144). Those sorts of discussions are relegated to a few professional societies with far less reach and prominence today than NIMH, such as the American Psychoanalytic Association or the International Association of Psychoanalytic Self Psychology. Although in those groups our understanding of empathy has continued to evolve, empathy might be slipping from the

centerpiece of mental health care it has held for more than a century. The Decade of the Brain has perhaps, for many, erased the need for therapeutic alliance and the special skills in listening that traditionally separate psychiatrists from other medical specialists. In our current culture and complex system of medical care, where patients can more easily feel lost in overburdened systems, the ability to connect with our patients and dwell in their suffering is all the more important. Today, empathy is discussed the most among self psychologists and others affiliated with self psychology. Incidentally, Szalita does not mention Heinz Kohut, who is often associated with empathy in psychoanalytic literature and whose first major writings would have just been recognized a few years before her presentation (Kohut, 1971). Even within self psychology, ideas on empathy have evolved considerably since Kohut’s time (Fosshage, 1992; Lichtenberg, 1989; Bacal, 1985), and other forms of psychoanalysis focus on empathy and describe it just as extensively. One of those is intersubjective systems theory, founded through the collaboration of several writers, including Robert Stolorow, George Atwood, Bernard Brandchaft, and Donna Orange (Stolorow & Atwood, 1992; Stolorow, Atwood, & Orange, 2002; Stolorow, Brandchaft, & Atwood, 1987). Kohut, while revolutionary, was still describing physic

This article is not subject to U.S. copyright law. Russell Carr, MD, is chief of the Psychiatry Department at Walter Reed National Medical Center in Bethesda. Address correspondence to Russell Carr, Psychiatry Department, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889. E-mail: [email protected]

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phenomena as solely intrapsychic processes (Strozier, 2004). This approach of focusing solely on the patient’s inner mind and only slightly alluding to the analyst’s feelings was pervasive in American ego psychology at that time. Szalita’s thoughts were also embedded in a one-person, intrapsychic understanding of the mind. Her descriptions of the sources or causes of empathy rely almost completely on intrapsychic explanations, principally ego defenses, such as projection. She does allude to Sullivan, who is frequently referenced in contemporary interpersonal and American relational psychoanalysis (Mitchell, 1988; Skolnick & Warshaw, 1992), but she describes his view of empathy as it being more like a contagion, something done to an observer. Again, the focus is on the mind of the patient doing something to others, not a reciprocal process going on between two people. In intersubjectivity theory, there is a completely different understanding of the mind that influences how empathy is understood. There is no isolated mind, which is the basis of intrapsychic approaches to empathy (Stolorow & Atwood, 1992). For intersubjectivity theory, a person’s experience of the world is embedded in context and cannot be understood separate from it. This context consists of place, time, and, most importantly, other people, and both the patient and the people around him or her exert mutual influence on each other. A person does have intrapsychic phenomena in intersubjectivity theory, but they are not the mechanistic, reified structures and drives found in traditional intrapsychic theories. There is an unconscious, but it consists of, among other things, the patterns, called organizing principles, that our minds create to make sense of the world. Our minds work through pattern recognition. Some innate drives have also evolved over the millennia of human existence, with attachment being one of the most prominent. Attachment theory, to which I return later, has become extremely influential in contemporary psychoanalytic thought and influences our views on empathy today. Unfortunately,


like her contemporaries in psychoanalysis, Szalita appears to ignore attachment theory in her presentation, even though Bowlby’s writings on attachment appeared in psychoanalytic journals in the 1950s, and the first volume of his major trilogy appeared in 1969 (Bowlby, 1969). With the concept of a mind as being embedded and inseparable from an intersubjective context, empathy looks rather different from what Szalita describes. The provider affects the patient and the patient affects the provider. A relationship with the patient, of which empathy is part, will vary depending upon the provider. Szalita gets close to this when she describes the patient getting the spinal tap, but it remains a curious example. She describes herself as sterile, distant, even disinterested in relation to the patient. She then coincidentally murmurs a phrase while looking at his chart that is in the patient’s language and is culturally acceptable. It is also from her past. He then obeys, smiling, and she does her procedure. She implies empathy in this story but no sense of connection, understanding, or relationship with the patient. Her murmuring the words seems to pull for connection with him. Although she does not describe this interaction in nearly the same way, today this could be described as both patient and provider acknowledging their human connection, and the provider, through a cultural and religious reference, empathically acknowledging the fear and lack of control the patient was feeling in the context of a spinal tap. The context of a spinal tap might have been additional stress to make this patient more reluctant to agree to treatment. He might have appeared oppositional, and if his experience of the context not taken into account, then he might be labeled as antisocial or as having some other static, even characterological, problem. As in the example of the spinal tap, what we bring as our past and our experiences of self and world influence how we empathically understanding our patients. Intersubjectivity theory emphasizes empathic attunement to the affective experiences of

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patients. But we cannot walk in the shoes of another person, a common description of empathy that Szalita references. Instead, we can only understand the experience of another as filtered through our own. There is no objective understanding or description of another person’s experience. There is no God’s-eye view. Instead, there are perspectives. Intersubjectivity theory acknowledges such perspectivalism and thus describes empathy as empathic introspection. We can understand the experience of another only by reflecting on his or her experiences in light of our own. What we bring to any interaction with a patient influences how we understand that patient. What we bring includes our professional training, what we have learned from other patients, and our own patterns (organizing principles) of experience for understanding the world. Both the patient and provider bring their own organizing principles to any interaction. The mutual influence of these organizing principles on one another and how we understand each other are the basis for transference. In addition to intersubjectivity theory, attachment theory has pervasive influence in contemporary psychoanalytic ideas. It is an essential part of understanding the experience of others, both in therapy and their developmental history. There are numerous researchers and contemporary writers in attachment theory who apply their work to psychoanalysis (Beebe & Lachman, 1988; Stern, 1985; Main, 2000). In my opinion, attachment theory gives better explanations than were found in intrapsychic, one-person psychoanalytic explanations of empathy. For instance, Szalita refers in her presentation to a mother inducing anxiety in her infant. She quotes Sullivan at length, describing this interaction as empathy and even magical or paranormal, but today we can easily describe this as attachment. It could simply be the infant’s own anxiety at seeing his caregiver anxious, possibly withdrawing from him or otherwise disrupting their normally secure attachment. Perhaps we would say today that the infant is attuned to his mother and

“Empathy” Revisited Forty Years Later

becomes anxious when she seems to be preoccupied. Through infant observation studies, we know infants are capable of such experiences (Beebe & Lachman, 1988). Why would he not get anxious? She is the center of his world, providing food and care. If she is suddenly in distress, shouldn’t he be worried also? Finally, there are some areas where I see Szalita’s presentation on empathy as a forerunner to many contemporary psychoanalytic ideas on understanding human experience. She describes ways for providers to improve skills in developing empathic understanding of patients. A few of these are tried and tested and remain important today: learning about the human condition from patients, from our lives, and from literature, and then also our personal analyses. I probably learned the most about listening from being listened to in my own analysis. She then gives another way that is becoming more recognized today: coming “to grips with fears of death.” This has become more important as contemporary focus on empathy has shifted toward understanding trauma (Stolorow, 2007; Carr, 2011). What she describes as coming to terms with death and deriving from that a stronger commitment to life, contemporary writers such as Robert Stolorow have described in more philosophical terms, such as authentic Beingtoward-death and authentic resoluteness (Stolorow, 2007). Both of these today are considered goals of treatment for a patient and are also essential in a therapist who wants to help someone bear, process, and integrate traumatic emotional experiences. Ideas and our understanding of empathy continue to evolve. Being able to develop an empathic understanding of the experience of another person is key to mental health care. It helps a provider treat a patient and helps keep a suffering human being, often prone to a sense of isolation and shame, engaged in treatment. In fact, many will argue that an empathic approach is the foundation of treatment for much of the pathology we treat in mental health, particularly trauma and personality



disorders. One of my mentors in psychoanalysis once said to me, “There is nothing more powerful than being understood by another human

being.” I still believe that, and I hope it is not lost in our world with ever-encroaching technology and burdensome systems of care.


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Bacal, H. (1985). Optimal responsiveness and the therapeutic process. In A. Goldberg (Ed.), Progress in self psychology (Vol. 1, pp. 202–207). Hillsdale, NJ: Analytic Press. Beebe, B., & Lachman, F. (1988). Mother–infant mutual influence and the precursors of psychic structure. In A. Goldberg (Ed.), Frontiers in self psychology (Vol. 3, pp. 3–25). Hillsdale, NJ: Analytic Press. Bowlby, J. (1969). Attachment and loss. Vol. 1: Attachment. New York, NY: Basic Books. Carr, R. B. (2011). Combat and human existence: Towards an intersubjective treatment for combatrelated PTSD. Psychoanalytic Psychology, 28, 471–496. Fosshage, J. (1992). Self psychology: The self and its vicissitudes within a relational matrix. In N. Skolnick & S. Warshaw (Eds.), Relational perspectives in psychoanalysis (pp. 21–42). Hillsdale, NJ: Analytic Press. Kohut, H. (1971). The analysis of self. New York, NY: International Universities Press. Lichtenberg, J. (1989). Psychoanalysis and motivation. Hillsdale, NJ: Analytic Press. Main, M. (2000). The organized categories of infant, child, and adult attachment: Flexible vs. inflexible attention under attachment‐related stress. Journal of the American Psychoanalytic Association, 48(4), 1055–1095.

Mitchell, S. (1988). Relational concepts in psychoanalysis. New York, NY: Basic Books. Skolnick, N., & Warshaw, S. (Eds.). (1992). Relational perspectives in psychoanalysis. Hillsdale, NJ: Analytic Press. Stern, D. (1985). The interpersonal world of the infant. New York, NY: Basic Books. Stolorow, R. B. (2007). Trauma and human existence: Autobiographical, psychoanalytic, and philosophical reflections. New York, NY: The Analytic Press. Stolorow, R. D., & Atwood, G. E. (1992). Context of being: The intersubjective foundations of psychological life. Hillsdale, NJ: Analytic Press. Stolorow, R. D., Atwood, G. E., & Orange, D. M. (2002). Worlds of experience: Interweaving philosophical and clinical dimensions in psychoanalysis. New York, NY: Basic Books. Stolorow, R. D., Brandchaft, B., & Atwood, G. E. (1987). Psychoanalytic treatment: An intersubjective approach. Hillsdale, NJ: Analytic Press. Strozier, C. (2004). Heinz Kohut: The making of a psychoanalyst. New York, NY: Other Press. Szalita, A. B. (1976). Some thoughts on empathy: The eighteenth annual Frieda Fromm-Reichmann memorial lecture. Psychiatry, 39, 142–152.

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