Perception

Empathy requires accurate perception of the immediate emotional state of the patient. An example of one of these emotional states might be fear, so in this case the patient feels afraid. Well of course this patient might be afraid, you say to yourself. He hurt his hand moving a large landscape stone at work, and he is afraid he might lose his job because he’s had anxiety for years; he thinks of the worst possibility first, and he’s afraid of change in general. Still, this lifestyle fear, if you will, is one of this man’s long-term traits, and it is not exactly immediate to the problem at hand. Let the psychologist use specialized empathy techniques to work on this long-term trait problem.

In your treatment setting, however, this man’s immediate emotional state has more to do with fear of the environment, fearful skepticism concerning the rehabilitation process, fear of more pain right now, and even fear of you, the practitioner. So attempt to perceive the emotional state at the moment the patient is in front of you.

Now these emotional-state, or affective-condition, words can be harder to think of than you might suspect. (“Affect,” pronounced similarly to “adjunct,” is another word for emotion.) It takes effort to build a collection of these words into your professional, working vocabulary. Would it come to mind that, in addition to feeling fear, this injured worker is also feeling pride? After all, he was the only man on the work crew strong enough to move the landscape stone. But then, as this worker tells his story, can we stack embarrassment on top of pride and fear? Why yes we can. The man is embarrassed that he hurt himself. Can accurate empathic perception become complicated? Indeed we can perceive layers of state emotions, which is one of the reasons why empathy requires more skill than sympathy.

Yet to keep this empathy process reasonable, it’s a good idea to focus on one of the patient’s affective conditions at a time. So let’s pick fear. At this point you perceived fear, along with a couple other immediate state emotions, and you picked fear.

Delivery

Now for the delivery. For empathy to occur, it’s not enough that you know what this stone mover is experiencing emotionally; you must prove to him that you know. You must somehow deliver your perception to him.

But wait. Even though your perception of his very real fear is accurate, is the word “fear,” or the word “afraid,” going to be tolerated by the strongest man on the landscape-construction crew? Probably not. So even though, before your eyes, fear is exactly this man’s emotional phenomenology, for you to reflect out loud that he feels afraid may not match his attempted opinion of himself. He may even take your comment as an insult. Now what?

In your mind, try to reduce the intensity of this word, “afraid.” Let’s see. “Anxious” is a bit clinical. “Nervous” may work. “Uncomfortable” could turn out to be too vague. Maybe “nervous” then—not just even though it undershoots the target of “afraid,” but because it undershoots this target emotion. “Nervous” comes close, while allowing this fellow to save face. Okay, then, “nervous.” Somehow you are going to deliver the word “nervous,” as an aspect of your perception of his fear.

Delivery options at this juncture are endless. Most practitioners initially move toward asking questions. Now as simple as this sounds, questions end in question marks. Keep this in mind, because soon I will discriminate between delivery sentences that end in question marks and delivery sentences that end in periods. The difference between these two forms of delivery is significant. For now, though, let’s ask this man a question. “Do you feel nervous?”

“No,” he says.

Oops. What happened? What happened was that this question is a closed-ended, yes-or-no question. The patient not only decided on “no,” but he also decided on denial. Let’s open the question up a little and give the man some less-specific wiggle room. “Have you noticed that you’ve felt a little nervous around medical practitioners before?”

“A little,” he says. Then he looks at you to see who you are again, because you just made emotional contact with this fellow. The intellectual contact was made when you heard about the three-dimensional physics of his injury story. Yet suddenly you used a different language to communicate with the emotional experience of his physical body at that moment in time. Initially it was information that passed between the two of you. Now it is almost as though something else, something invisible and something very important just passed between the two of you. Regardless, he now knows that you know about his affective condition in the present moment, because you just got done creating empathy.

During social and colloquial conversation, we usually assume that a question is a good way to start a conversation and a good way to keep a conversation going. However it is often a question that stops the conversation, which then requires another question to start the conversation up again, but which has the effect of bringing the conversation to a new halt. Person A asks person B a question, “How do you feel about hurting your hand?” Person B answers the question, and the conversation stops. “I feel stupid.”

“Why do you feel stupid?”

“Because I hurt my hand.”

The conversation has stopped twice now, each time that a question got answered. The question, a sentence that ends in a question mark, can be a somewhat difficult method to deliver empathy, or to create exploratory conversation. People who ask questions for a living typically hope for the conversation to stop after the question gets answered so that the answer can get noted and a new question can be quickly asked. In these scenarios, empathy communication is purposely shunned in favor of rapid information transfer. The comfort level of person B is not a concern, and tactics such as intimidation may be employed to push the information flow along. Communication situations such as these are commonly seen around medical emergencies, disaster-control efforts, interrogations, or cross-examinations.

You think you just asked a supportive, open-ended question, yet person B may feel interrogated and then respond in kind with a short, conversation-stopping answer. Interrogation and empathy may be on opposite poles of one aspect of communication. We’ll look closer at similar conversational polarities later.

So what empathy-delivery form might we use besides a sentence that ends in a question mark?

“Hey, you’re probably feeling a little bit nervous about being here.” Believe it or not, these empathy-delivery statements that do not end in a question mark, but that do end in a period, cause people to talk and talk and talk. I use the phrase “believe it or not,” because most people, professional or otherwise, to whom I introduce this concept do not believe it. Regardless, empathy efforts via question can cause people to miss the empathy event and to reject the conversation. Empathy attempts via statement can cause people to self-disclose their phenomenological affective conditions concerning the immediacy of those agitating, distracting, and otherwise undesirable nemeses known clinically as Psychosocial Stressors. To put it another way, a non-question helper empathy statement causes a patient to talk about his or her immediate feelings regarding recent bad luck.

But we might back up a step in order to confirm the value of properly used questions. It is essential when performing a diagnostic or a history-taking interview that you ask specific questions, usually a protocol of pointed questions, and that you get answers to those questions. Please understand the difference between a question designed to obtain information, versus a question or a statement designed to enhance communication or, perhaps, healing. At the same time, however, while it is important to know the difference between practitioner verbalizations that either (1) serve to glean information or (2) serve to cause affective communication, keep in mind that it is not necessary to divide these two verbal methods into two separate events. The second category (affective communication) can be mixed among the first category (information gathering) to enhance the very act of gathering information. A patient who becomes guarded about your questions concerning the details that produced an impaired hand for example, may open up instantly if you make a statement that targets the emotional condition at the moment. “You feel unhappy about getting into the details.”

Even if the patient agrees with you about this discomfort, then quits talking, you have proven your perception, and you have begun to build an emotional bridge across the divide in the direction of this patient, which may connect with the patient later. Often the information you seek will come out spontaneously after you render a couple more strategically spaced empathy reflections.

The historical healing use of empathy is lost in the shrouds of history, and probably dates back to shamans and to the wiser of our elders. The professional use of empathy was emphasized by psychologist Carl Rogers. If there was ever a stereotype picturing what Carl Rogers did for a living, it was that he rendered reflective empathy responses. Carl Rogers led the Client-Centered psychotherapy movement that, beyond empathy, called for a therapeutic relationship, practitioner genuineness, and unconditional positive regard for the patient. Rogers championed a form of psychotherapy in which empathy was a central component, and it became an uncanny yet undeniable fact that the heavy use of psychotherapist empathy is a powerful factor that can facilitate patient healing.

Rogers wrote that for healing to happen, the patient must perceive, “… to a minimal degree, the acceptance and empathy which the therapist experiences for him. Unless some communication of these attitudes has been achieved, then such attitudes do not exist in the relationship so far as the client is concerned…”²

“Since attitudes cannot be directly perceived, it might be somewhat more accurate to state that therapist behaviors and words are perceived by the client as meaning that to some degree the therapist accepts and understands him.”²

Empathy is neither the territorial possession of Carl Rogers nor of psychotherapists. Empathy has never had a patent number or a copyright or a purchase price, and there are almost no warnings or restrictions when it comes to its use. You don’t need to talk to your doctor before you attempt it. Empathy requires no specialized equipment. You can even try it at home. Some people, without any training whatsoever, become, simply by inclination and by experience, potent natural empathizers. Empathy is observed at picnics, at grocery stores, and on work crews. A few people are so good at empathy that they deliver their perceptions nonverbally with facial expressions alone. Empathy can be a natural act and, as such, is a simple human behavior that preceded the much more complicated professional behaviors required during the performance of psychotherapy. Once colloquial empathy became recognized for its power, however, it became incorporated into communication skills as a tactic, and it became included in psychotherapy as a core component, among others.

In 1969, Robert R. Carkhuff published the classic, Helping and Human Relations, which is still one of the most quoted works ever written on the components of psychotherapy. In this two-volume set, Carkhuff attempted to quantify some of these core psychotherapy components.³ The art of using these components in a coordinated fashion during psychotherapy is complicated. Still, like empathy, these components did not come into existence for psychotherapy. They were in existence as part of language and communication well prior to psychotherapy, and they are available to hand therapists as techniques to improve contact with patients, and to thereby improve the overall potential for healing. Actually we have already casually looked at a few of these components, so I will introduce them formally here.