Last week at the chronic pain centre, I had the opportunity to see two therapists consecutively interact with the same patient, with two very different outcomes. The therapists were co-conducting a psychological assessment of a new patient who was extremely and visibly depressed. The patient walked into the office slowly and hunched over. He didn't make eye contact during the introductions, and slouched in his chair, tears falling unchecked even before the interview started.
The first therapist was shaken by the patient's appearance, and unsure that he was in a condition to answer three pages of questions about pain, mood, and functioning. She began the evaluation anyway, but the interview rapidly went nowhere. The patient spoke slowly, softly, and infrequently, and continued to cry. The therapist felt insensitive probing someone in such obvious distress, and spoke to him more and more slowly and softly. As palpable despair crept into the room, the therapist started fumbling her words, and within ten minutes, she too was slouched in her chair, feeling helpless.
The second therapist took over. She obtained the patient's consent to continue the evaluation and then, sitting up straight and speaking at a normal volume, she continued the interview. When the patient stumbled or got stuck, the therapist rephrased the question to make it easier. Her attitude and questions expressed empathy, but she maintained composure and didn't behave as though her questions were an imposition.
How did the patient react? He sat up straighter. His tears gradually stopped. He raised his voice to a normal volume and made more eye contact. He joined the conversation and the second therapist was able to obtain the information necessary to formulate a treatment plan.
What happened here?
In a fit of unhelpful overempathy, the first therapist had fallen head first into the patient's emotional world, taking on his hopelessness and helplessness. The second therapist didn't take on the patient's mood; instead, she maintained her own competent and upbeat manner, and her energy spread to the patient. Her composure conveyed a message of strength: whereas the first therapist's behaviour communicated "You (and I) are too fragile to complete this interview," the second therapist's attitude said to the patient something like "I see that you are in immense physical and emotional pain, but I believe that you have the strength to communicate your situation and participate actively in your treatment."
In the therapy room, part of the therapist's job is to be in control, to model competence and mental health, and to convey appropriate optimism to the patient. To do so effectively, the therapist needs to strike a balance between empathy and some degree of emotional separation. In this case, the first therapist's excessive emotional empathy maintained and propagated the patient's despair, and prevented the therapist from doing her job. The second therapist's appropriate empathy allowed her to maintain composure, do her job effectively, and propagate hope. The patient's reaction made it clear which attitude was more helpful!