The International Journal of Psychosocial Rehabilitation

The role of empathy in quality therapeutic engagement
for increasing motivation for change in schizophrenia

Oudi Singer, M.Ed.
Kent State University

Singer, O.  (2001)  The role of empathy in quality therapeutic engagement for increasing motivation
for change in schizophrenia.  International Journal of Psychosocial Rehabilitation. 6, 45-50

The traditional scientific paradigm in the helping professions of counseling, psychology and medicine emphasized the importance of therapeutic neutrality. Significant proportion of graduate training programs in psychology and counseling are founded on the scientist-practitioner model. Science has enriched our lives as practitioners but has also created an evident side effect in the form of a moral paradox. In that educational process analytical and cognitive skills have relegated the human aspects behind the delivery of care to a secondary role. The current article will explore the core condition of empathy as manifested in client- helper dialogue in the case of schizophrenia. Contemporary trends in health delivery for individuals with borderline personality disorder and schizophrenia will be explored for clarifying unfortunate therapeutic trend. The article will demonstrate therapeutic change as related to deep empathic engagements, which will provide evidence on the vitality of empathy in change, healing, and recovery.

Science is a way of understanding the world around us. Scientific processes are done through the establishment of knowledge regarding phenomena’s (Kazdin, 1998). A significant proportion of graduate training programs in psychology and counseling are founded on the scientist-practitioner model, known as the Boulder Model (Dellario, 1996).  Practitioners from the disciplines of psychology, counseling and medicine are often being taught the scientific epistemology as a major part of their curriculum (Spiro, McCrea Curnen, Peschel, & James, 1993; Dellario, 1996). This process itself gives much attention to scientific reasoning, and to analytical skills (Bolton, 1986 as cited in Bellini & Rumrill, 1999; Jordan, 2000).
As the process of learning scientific methods to health care goes on, our students also learn with neutrality and objectivity also detachment and equanimity (Spiro et al., 1993; Jordan, 2000). Our infatuation with knowledge and science has prioritized the delivery of a compassionate care over values such as neutrality and objectivity (Spiro et al., 1993; Jordan, 2000).
The promise of instrumental control given by scientific knowledge serves as a paradox to the etiquette of care and can become a blind passion (Lewin, 1996). In others a words, Western knowledge lays it’s foundations on Baconian notions of mastery over nature, objectification of the known, instrumentally; ironically these notions stands in contrast with other epistemologies that rely more on knowing through joining, through a compassionate unity of empathic care (Keller, 1985 cited in Jordan, 2000).
Psychology as a field demonstrated its scientific rigor by modeling itself on Newtonian physics. Ironically physics scientific emphasis was on objectification and distance from the known (Jordan, 2000). As scientific psychology was developed there was much attention to the separate self in the form of diagnostic manuals that use a medical / disease model to locate pathology in the individual (Jordan, 2000).
Seventeenth century science had attracted the brilliant minds in the industrialized age up to this day. Today however, centuries later, we have found ourselves in the need for a new science, the need for a humanistic science of man as a foundation for the applied science and art of social reconstruction (Fromm, 1976; Krishnamurti, 2000).

The current essay is an attempt to explore, clarify and demonstrate the significance of mutual empathy as a new knowledge applied in relationship enhancement and therapeutic change. The main aim of the current attempt is to increase awareness to current trends in health care education and the clinical practice that follows.

The art of care and the crisis

Hippocrates counseled: “ for where there is the love of man, there is also love of the art. For some patients, though conscious that their position is perilous, recover their health simply through their contentment with the physician” (Hippocrates cited in Lown, 1996, pp. 3). The patient, the client, as a recipient of our care can grow immensely by being able to see, know and feel that the counselor/ therapist is being touched by him/ her (Jordan, 2000).
However there is an enormous discrepancy between the ideal and the real. There is a growing literature of consumers as well as practitioners who report a failure in the caring –empathic dimension (Laing, 1965; Green, 1964; Sheehan, 1983; Lewin, 1996; Lown, 1996 & Michener, 1998).
Relational therapy as well as social phenomenology has dedicated their efforts to understand the nature of therapeutic connection/disconnection (Laing, 1967; Miller & Stiver, 1997 as cited in Jordan, 2000). Disconnections are ubiquitous; people misunderstand one another, fail one another empathetically. However, if mutual empathy is not met in relationship the disconnection from acute will become chronic, and the therapeutic relationship will loose their authenticity, vitality and eventually effectiveness (Jordan, 2000).


The nature of empathy

The word empathy entered the English vocabulary as a translation, after the Greek ematheia, of the German Einfuhlung, a word brought into being by Lipps’ as he discusses aesthetic experience (Spiro et al., 1993). Empathy is phenomenological state that stands in contrast to other “scientific” observational knowledge.
Empathy has two faces: the esthetic and the personal (Gauss, 1973 as cited in Spiro et al., 1993). On the esthetic dimension empathy is visual. The physician visually observes the symptoms, and the pain of the consumer. The personal dimension is however more than just knowing what we see. Empathy is a vicarious experience in which the empathizer ‘tastes’ the recipients’ experience (Zderad, 1969 as cited in Spiro et al., 1993). As the empathy process occurs the person who empathizes, abandons himself temporarily; he relives in himself the emotions of another person (Ehmann, 1971). Empathy is a bridge from the objective to the subjective (Katz, 1963). Empathy requires living as well as knowing. If sympathy requires compassion, empathy adds to the formula also passion.
In the therapeutic arena empathy becomes a crucial elements behind the wheel of self-growth, recovery and change (Rogers, 1951, 1961; Miller & Rollnick, 1991).
Client -centered therapy research indicates that therapist’s attitude rather than their knowledge, theories, or techniques facilitate and personality change in the client (Rogers, 1951, 1961 as cited in Corey, 1996). Empathy as a vital component of the Rogerian approach is an active, synchronized and continuous process (Rogers, 1951).
Compassion, more than just a thing
Empathy is a living virtue that embraces both compassion and passion (Spiro et al., 1993). Compassion however becomes a ‘thing’ in our materialistic and quantitatively oriented culture. The common belief that if something cannot be subjected into quantitative accounting practice than its validity fades away, simply endangers the quality of compassion (Lewin, 1996).

Lewin (Lewin, 1996) expand his discussion in demonstrating a common phenomenon in our practices. Many times the psychotherapist is asked to send a treatment plan to insurance companies for review, so that benefits can be paid. The form asks short-term objectives in behavioral and measurable terms. The nature of the demand is an actual attack on the whole notion of helping a patient by listening and understanding.

However, empathy and compassion will not admit of management by objectives. It is much more a question of management by subjectives. The more appreciation to the subjective will occur the more we as clinicians will move away from the realm of the concrete, into the realm of humanity (Spiro et al., 1993; Lewin, 1996; Lown, 1996).

Pathways to therapeutic change

The major most responsible ingredient in determining whether therapeutic change has occurred is the quality of Helper-Client relationship (Frank, 1961 as cited in Kanfer & Goldstein, 1983). Even psychotropic interventions have been shown to serve their purpose efficiently, as better rapport has been established (Kanfer & Goldstein, 1983; Torrey, 1995).
On the other end of the paradigm of change stands resistance to change, or non-compliance (Miller & Rollnick, 1991). Resistance to change often occurs when the clients feels, or perceive the caregiver as a formal, ‘cold’, unconnected agent (Laing, 1965; Adams, 1993; Carling, 1995).
Non-compliance is an evident phenomenon in Schizophrenia for example. Many Individuals who live with the diagnosis of Schizophrenia neither recover nor improve (Modrow, 1996).  Studies show that 70% of the clients who live with the diagnosis of Schizophrenia are noncompliant with medication treatment. Torreys’ last explanation of the therapeutic noncompliance was doctor-patient relationships (Torrey, 1995).
Borderline personality disorder and Schizophrenia offer health professionals great deal of challenge due to their unusual or even disruptive behavioral pattern (Laing, 1965; Spiro et al., 1993; Nehls, 1999).


Contemporary trends in the treatment of BPD

The major characteristic of BPD is unstable self, major mood swings, and impulsivity. Many that hold that diagnosis are engaging in self- mutilation and suicide (Margo & Newman, 1989 as cited in Comer, 1998). The combination of these symptoms makes relationship unstable (Barrat & Stanford, 1996 as cited in Comer, 1998)

Individuals with borderline personality disorder are often viewed not only as challenging but also as a burden (Nehls, 1999). Nurses have expressed less empathy to ward people with BPD than towards persons with schizophrenia (Gallop, Lancee, & Garfinkel, 1989 as cited in Nehls, 1999). The emotional expression of pain was aggravating health providers causing a misperception of self-mutilation as a way of the consumer to seek control or attention (Nehls, 1999).

Contemporary trends of care in the treatment of Schizophrenia
Schizophrenia is another condition challenging current health providers due to the variety of non-normative nature of its symptoms (Laing, 1965, 1967; Provencher & Mueser, 1997). Selective empathy was recognized as one of the misfortunes some physicians possess (Spiro et al., 1993). Selective empathy for example could be easily recognized when the same physician gives empathic care to a person with physical condition and less of it to the person with Schizophrenia, Anxiety disorders or Obsessive-compulsive disorders (Spiro et al., 1993).

Learning how to listen to issues involved in psychotic states have been perhaps the most difficult challenges psychoanalysts have ever had (Hedges, 1996). In that challenging condition only few therapists with unique amount of patience and skills would show success in the therapeutic process. Many clinicians state that building close relationship with the individual, that had Schizophrenia, is essential to psychotherapy (Fromm-Reichmann, 1950; Sullivan, 1962).

When change occurs
Joan’s case as presented by Laing offers valuable information regarding therapeutic engagement with the client (Laing, 1965). Laing view of the therapeutic engagement is that the therapist must allow the pieces to come together. In that process of engagement the therapist’s love for the wholeness of the client, an acceptance of the client’s being is vital to the therapeutic process (Laing, 1965)
In the initial encounter with the psychiatrist Joan reported that his attempt to focus mainly on the schizophrenic symptoms (Hallucinations and delusions) simply caused her to continue with the mixed speech. When meeting a person that really cared, Joan’s feelings of alienation, and being lost slowly disappeared (Laing, 1965).
At one point Joan revealed the mere essence in which empathy operates, this time through the eyes of a patient that yearns for care: “ Meeting you made me feel like a traveler who’s been lost in a land where no one speaks his language. Worst of all, the traveler doesn’t even know where he is going. He feels completely lost and helpless and alone. Then suddenly, he meets a stranger who can speak English. Even if the stranger doesn’t know the way to go, it feels so much better to be able to share the problem with someone, to have him understand how badly you feel. If you are not alone, you don’t feel hopeless anymore” (Laing, 1965, pp. 165).
Empathy is the antidote to loneliness and alienation. Joan stopped feeling alone, there was somebody there, feeling her pain as both walk the path toward healing. Even though she regarded the helper as a ‘stranger’ she still allowed a room for ‘the traveler’, the therapist, in her home; And as Harris puts it, empathy is “a feeling of being at home with the object contemplated”, as a friend (Harris cited in Hogenson, 1981, pp. 69). At that point the therapist have succeeded to enter Joan’s realm of illness, her home, with the golden key of empathy.

Jung has gone further in describing the power that lies behind empathic therapeutic engagement. Jung’s statement that the schizophrenic ceases to be schizophrenic when he meets somebody by whom he feels understood best describes the quality effect of truthful empathic relationship (Jung as cited in Laing, 1965).


Hannah Greens’ portrayal of Deborah whom was diagnosed with schizophrenia describes ‘schizophrenia’ as an agent that provided release and relief from normality. At the onset of her psychosis Deborah was sent to the child psychiatrist, but her condition got worse. After her third session Deborah said:” am I not what you wanted? Do you have to correct my brain too?” (Green, 1964, pp.39).
Deborah’s feelings reflect on a condition treated behaviorally with disregard to experience. There is an obvious division between the psychiatrist and Deborah. This division is a product of an exhibited sympathy of ‘I want to help you’ versus a needed empathy of ‘I am you’. Therapeutic communication that is based on behavior alone without a regard to the client inner-experiences may perpetuate the illness in which it supposes to treat (Laing, 1967).
When conditions of deep empathetic and compassionate care are authentically embraced and applied by health practitioners, a climate of change and self-actualization will be created (Laing, 1965, 1967; Rogers, 1951, 1961). But empathy must remain an authentic state of symbiosis between the professional and his client, when it’s becoming a technique for rapport building, when empathy becomes as Jordan’s says a way of knowing, the component of love evaporates from it (Jordan, 2000).
Dr. Frankl, the father of logotherapy, announced in the conclusion for ‘Man’s search for meaning’:” love is the only way to grasp another human being in the innermost core of his personality. No one can become fully aware of the very essence of another human being unless he loves him. By his love he is enabled to see the essential traits and features in the beloved person; and even more, he sees that which is a potential in him, which is not yet actualized but yet ought to be actualized. Furthermore, by his love, the loving person enables the beloved person to actualize these potentialities (Frankl, 1984, pp. 116).
A brief summary could easily identify that neither science nor the thirst for knowledge or curiosity are basis for the health professional care, but rather compassion, and deep empathy (Spiro et al., 1993; Lewin, 1996). Science could be best applied when it relies on empathic communication with the recipient of care rather than relying simply on analyses and scientific reasoning.


Adams, P. (1993). Gesundheit!. Vermont: Healing Art Press.

Bellini, J.L., & Rumrill, P.D.R. (1999). Research in rehabilitation counseling. Springfield, Illinois: Charles C Thomas Pub.

Carling, P.J. (1995). Return to Community: Building Support Systems for People with Psychiatric Disabilities. New York: The Guilford Press.

Comer, R.J. (1998). Abnormal psychology. W.H. Freeman &
Company: New York

Corey, G. (1996). Theory and practice of counseling and
psychotherapy. Pacific Grove, California: Brooks/Cole Publishing.

Dellario, D.J. (1996). In defense of teaching master’s
level rehabilitation counselors to be scientist-practitioners. Rehabilitation Education, 10, 229-232.

Ehmann, V.E. (1971). Empathy: It’s origin, characteristic,
and process. Perspectives in Psychiatric Care, 9, pp. 72-81.

Frankl, V.E. (1984). A man’s search for meaning. New York:  Simon and Schuster Publication/ Touchstone Books.

Fromm, E. (1976). To Have or to Be?. New York: Bantam books.

Fromm-Reichmann, F. (1950). Principles of intensive psychotherapy. Chicago: University of Chicago.

Green, H. (1964). I never promised you a rose garden. New York: Signet Books.

Hedges, L. (1996). Strategic emotional involvement. Northvale, New Jersey: Jason Aronson, Inc.

Hogenson, G.B. (1981). Depth psychology, death and the hermeneutic of empathy. Journal of Medical Philosophy, 6, pp. 67-89.

Jordan, J.V. (2000). The role of mutual empathy in relational/cultural therapy. Psychotherapy in Practice, 56,
pp. 1005-1016.

Kanfer, F.H., & Goldstein, A.P. (1983). Helping people change. New York: Pergamon Press.

Katz, R.L. (1963). Empathy: Its Nature and Uses. New York: Free Press.

Kazdin, A. (1998). Research design in clinical psychology. Needham Heights, MA: Allyn & Bacon.

Krishnamurti, J. (2000). To be human. Boston & London:   Shambhala.

Laing, R.D. (1965). The divided- self. United Kingdom:Penguin Books.

Laing, R.D. (1967). The politics of experience and the bird of paradise. United Kingdom: Penguin Books.

Lewin, R.A. (1996). Compassion: The core value that animates psychotherapy. Northvale, New Jersey: Jason Aronson Inc.

Lown, B. (1996). The lost art of healing. New York: Ballantine Books.

Michener, A.J. (1998). Becoming Anna: The autobiography of a sixteen-year-Old. Chicago & London: The University of
Chicago Press.

Miller, W.R, & Rollnick, S. (1991). Motivational Interviewing: Preparing people to Change addictive behavior. London/New York: The Guilford Press.

Modrow, J. (1996). How to become a schizophrenic: A case against biological psychiatry. Everett, Washington: Apollygon Press.

Nehls, N. (1999). Borderline Personality Disorder: The voice of patients. Research in Nursing & Health, 22, pp. 285-293.

Provencher, H.L., Mueser, K.T. (1997). Positive and negative symptom Behaviors and caregiver burden in the relatives of persons with schizophrenia. Schizophrenia Research, 26, pp. 71-80.

Rogers, C. (1951). Client-centered therapy. Boston: Houghton Mifflin.

Rogers, C. (1961). On becoming a person. Boston: Houghton Mifflin.

Sheehan, S. (1982). Is there no place on earth for me?. New York: Houghton Mifflin Company Boston.

Spiro, H., McCrea Curnen, M.G., Peschel, E., & James, S.J. (Eds.). (1993). Empathy and the practice of medicine. New Haven/ London: Yale University Press.

Sullivan, H.S. (1962). Schizophrenia as a human process. New York: Norton.

Torrey, E.F. (1995). Surviving schizophrenia. NewYork: Harper Perennial.

This article is dedicated to Pedro, may our roads be crossed again.

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