What Is Empathy, and Can Empathy Be Taught? Carol M Davis PHYS THER. 1990; 70:707-711.

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Empathy is a commonly used, but poorly understood, concept. It is often confused Carol M Davis with related concepts such as sympathy, pity, identijication, and self-transposal. The putposes of this article are to clearfv distinguish empathy from related terms and to suggest that the act of empathizing cannot be taught. According to Edith Stein, a German phenomenologist, empathy can be facilitated. It also can be in- terrupted and blocked, but it cannot be forced to occur. What makes empatby unique, according to Stein, is that it happens to us; it is indirectly given to us, "nonpn'rnordially." E%en empathy occurs, we3nd ourselves experiencing it, rather than directly causing it to happen. This is the charactetistic that makes the act of empatby unteachable. Instead, promoting attitudes and behaviors such as self-awareness, nonjudgmental positive regard for others, good listening skills, and self-confidence are suggested as important in the development of clinicians who will demonstrate an empathic willingness. [Davis CM. What is empathy, and can empathy be taught? Phys Ther. 1990;70: 707-715. ]

Key Words: Attitude of health personnel; Education: physical therapist, teaching methods; Empatby; Professional-patient relations; Therapeutic presence.

Distinguishing between empathy and are important to achieving a high actively listen to clients, feeding back similar interpersonal actions such as quality of health care. thoughts and feelings with sensitivity sympathy, pity, identification, and self- and accuracy. Healing in a psychologi- transposal is a difficult task. To further The Nature of Empathy cal sense would then result. add to the confusion, these terms are often used interchangeably, both in Counseling psychologists have at- Rogers's3 early work described empa- the literature and in common conver- tempted to operationally define the thy as a skill that can be taught. In his sation. In considering whether empa- "skill" of empathy in order to recog- later work? he conceded that empa- thy can be taught, a clear definition is nize it in the counseling interaction thy was not so much a skill, as a way in order. This article utilizes the phe- and to teach counselors how to empa- of being. One person who strongly nomenological description developed thize with clients.2 Carl Rogers: a influenced this shift in understanding by German philosopher Edith Stein in well-known humanistic psychologist of the process of empathy was Jewish her work On the Problem of and founder of client-centered ther- theologian Martin Buber. Buber5 de- Empathy1 to support the premise that apy, described empathy as central to scribed the importance of the "I- the skill or behavior of empathy can- the success of his therapy. Rogers Thou" relationship to the health of not be taught. Rather, the process of claimed that empathy occurs when human beings and described a proc- empathy can be facilitated by develop- therapists view clients with "uncondi- ess he termed "dialogue" as central to ing other attitudes and behaviors that tional positive regard" and when they this relationship. In dialogue, two people embark on an unfolding con- versation, the outcome of which is

not known. When the 1Drocess of CM Davis, EdD, PT, is Associate Professor and Associate Director for Curriculum, Division of Physi- "crossing over" occurs, a person finds cal Theraov. Deoanment of Orthooaedics and Rehabiliration. School of Medicine. Universitv of Mi- herself Or himself very closely con- ami, 591i~oncide Leon ~lvd,coial Gables, EL 33146 (USA). nected to or aligned with the. other %is research was supported in pan by the Dudley Allen Sargent Fund. person in a moment of shared meaning.5 Buber5 wrote of the them- This article was submilled October 19, 1989, and was accepted July 17, 1990.

32 / 707 Physical TherapyNolume 70, Number 1lmovember 1990 Downloaded from http://ptjournal.apta.org/ by guest on November 18, 2011 peutic value of this process, and a country club) with a resulting Rogers6 claimed that dialogue was strong emotional tie. When I identify identical to empathy. Buber disagreed with a person or a group, I may adopt by claiming that the moment of cross- identical values, mannerisms, prior- ing over could not be made to hap- ities, and dress. Identification is made pen; it had to be allowed to happen.6 more possible when one is not aware

In sum, Rogers3 emphasized that em- SYMPATHY = "FELLOW FEELING." of one's unique identity and is search- pathy occurred willfully, when one SlDE BY SlDE ing for a way to be in the world. At cognitivc:ly made it happen through the extreme of identification, one's careful listening and mirroring of ego is replaced by the mores of the words and feelings. Bubers main- group or person. In this situation, cult tained that psychological healing did behavior can develop (Fig. 1). not occur as a result of a cognitive process that one could control, but % Self-transposal is the phenomenon PITY = SYMPATHY WITH SUPERIOR resulted as a part of a special align- FEELINGS most commonly thought of as empa- ment that took place spontaneously in thy. It is the process whereby I certain kinds of conversation. "think" myself into the place (or "shoes") of another person.9 Rogers3 Edith Stein,' a phenomenologist and a actually defined empathy this way in student of German philosopher Ed- @ his early work. Psychologist Robert mund Husserl, described empathy as IDENTIFICATION = CLOSE ORIENTATION CarkhuP developed a training pro- a far more complex process. Stein TO THE OTHER; ADOPTING VALUES. gram wherein skill development em- MANNERISMS, PRIORITIES claimed that empathy is absolutely phasized this primarily cognitive be- unique and distinct from related in- Figure 1. Graphic representation of havior of accurately mirroring words tersubjective processes in that it oc- three intersubjective processes. and feelings of the client. Empathy, curs in three overlapping stages and however, is far more complex than is given to us "nonprimordially," or tions of the central process. thinking and feeling oneself into the after the fact, somewhat like a Wyschogrod* describes sympathy as place of another, as Stein1 suggests. postevent realization. A common ex- "fellow feeling." You and I are "at ample of a nonprimordially given one" with our feelings and ideas Sympathy, pity, identification, and self- experience, something that catches about something outside of us, for transposal, therefore, are not precisely most of us unaware, is "falling in example, the results of a football understood and are thus often con- love." We can want to fall in love, game or the weather. When you feel fused with empathy. All are similar to want to be in love with someone we joyfbl with me over my success, you each other in that each can be de- know wlell, but when the moment of are in sympathy with me. In a sense, scribed as a one-stage, intersubjective enrapture hits us, often it catches us we s~ndside by side sharing a com- process that one can cause to occur at unaware:. We find ourselves experi- mon feeling related to something that will. Empathy, on the other hand, is encing it, rather than causing it to happened in the past or that is hap- more complex in that it is a three- happen directly. Finally, Stein1 main- pening outside of us now (Fig. 1). No stage process, the second stage of tained that empathy is not so much a feeling of crossing over is identified, which cannot be made to occur at behavior as it is a "happening" that but the experience of sympathy is will, but happens to us when we we can either facilitate or block. This stronger than simply being in agree- allow it. description of empathy will be exam- ment with another. ined in more detail, but first it would An Example of an Experience be usefill to examine the four interac- Pity is described as a form of sympa- of Empathy tive processes that are most often thy, a kind of sympathetic sorrow, but confused with empathy. the side-by-side, shared nature of In a phenomenological research study sympathy is replaced with a superior- conducted for my doctoral Processes Most Often inferior relationship (Fig. When I dissertation,lo 10 physical therapists Confused wRh Empathy pity someone, I Feel sorry for that per- recounted their experiences with pa- son and thus I feel (perhaps subcon- tients wherein they believed empathy Four interactions most often mistaken sciously) more fortunate or superior. (including the unique crossing-over for empathy are sympathy, pity, identi- phenomenon) took place. A summary fication, and self-transposal. Each will Identification is an interpersonal proc- of one of the many experiences be described according to the phe- ess wherein the self aligns or orients follows: nomenological literature. itself closely to another person (eg, a mentor) or a group (eg, members of My patient, David, just ready for dis- Max Schleler7 described sympathy in a certain religion, a political party, or charge within the next week, wheeled great detail, identifying several varia- himself into view in the rehab gym

Physical Therapyllrolume 70, Number 11/November 1990 708 / 33 Downloaded from http://ptjournal.apta.org/ by guest on November 18, 2011 where I was finishing up a treatment nonprimordially given; we realize it with another patient on the mat. I had only after it has occurred. In one gotten to know David and his whole sense, this characteristic of empathy family quite well over the previous 4 can be compared not only to falling months that he had been my patient. in love, but also to what happens in He was excited and scared about going home, but was quite hopeful for a 00 forgiveness. We can want to forgive good life, especially since he was en- someone, but often when forgiveness gaged to be married. I smiled to him STAGE 1 SELF-TRANSPOSAL. ACTIVE LISTENING is actually felt, only then do we real- and said, "Hi, David. Go ahead and ize it was given to us. Essentially, we transfer to the mat and I'll be with you help forgiveness to happen, but the in a moment." I continued with my final letting go of bad feelings comes patient. David didn't move. I repeated as a gift of a sort. my suggestion that he transfer, but he 0 "I looked at me and said, don't need STAGE 2 IDENTIFICATION, "CROSSING OVER" Second, empathy takes place in three therapy; I need a drink!" OF SELF overlapping stages (Fig. 2). The first stage-self-transposal-takes place I knew this was strange behavior, so I told him I'd be right with him. In a when we listen carefully and attempt few moments, I wheeled him to a pri- to put ourselves in the place of the vate area and closed the door. I CO other person. In the second stage, we kneeled down beside him and looked STAGE 3 SYMPATHY. GETTING SELF BACK suddenly feel a crossing over, an at him and asked, "David, what's emotional shift from thinking to feel- wrong?'He began to cry, and said that Figure 2. Three stages of empatby as ing, wherein we experience a deep- his fiancee and his brother had just described by Stein.' ening of understanding and aware- told him that they had fallen in love ness. This stage has been termed a and were getting married. process, they felt in sympathy with "shared moment of meaningnlo and is one another. often described as occurring like a At that moment, I, too, felt terribly sad and hurt and angry, and I reached out "blow to the stomach." We feel to him and felt the tears in my eyes as Each of the 10 physical therapists re- deeply connected to another person, well. I said to him, "Oh, David, I'm so counted three or more experiences, so deeply connected that a form of sony." and in each example, three stages identification occurs. For a moment, could be identified: 1) a kind of listen- we are at one with the other person At this point in the inte~ewwith the ing and cognitive attempt to under- and we may forget that we are sepa- physical therapist, I would ask that the stand, or self-transposal, followed by rate, that really there are two of us. therapist return to the moment that 2) an emotional deepening, a kind of Finally, in the third stage, we seem to he or she felt that the crossing over crossing over or merging of self with get our "self" back, and we stand side took place and describe it to me as if the other person, which is much like by side with the other person in sym- it were taking place in slow motion. identification, followed by 3) a strong pathy about the experience just feeling of "at-oneness" with the per- shared (Fig. 2). In this instance, the therapist said she son, or sympathy (Fig. 2). felt a kind of "lining up" of herself The second stage-the crossing with the patient when she kneeled The Unique Experiencing over-seems to hold the greatest sig- down to listen carefully to what was of Empathy nificance of the three stages. Certainly, bothering him. Then, when he told it is the most extraordinary of the her his bad news, she said it was as if Stein1 maintained that two characteris- three stages. Although ordinarily quite she had been punched in the stom- tics make empathy unique, that is, dis- risky, I believe that such a total shar- ach. It was such a blow. I believe that, tinct from all other interactions: 1) It is ing of lived experience is viewed as for a moment, she felt her crossing- given to us after the fact, or we realize positive and is desired by most peo- over response so deeply that she for- it after it has occurred, and 2) it takes ple. From my perspective, this is what got that this was not her problem, place in three overlapping stages. many of us are searching for in a life that it was her patient's problem. She partner, someone who will share with reached out to touch his hand to offer First, empathy happens to us; it is us the meaningful moments of life at support, and, I contend, to also re- given to us after the fact, somewhat the deepest levels. To feel totally mind herself physically that she was like falling in love happens to us after alone and unrecognized is very often separate from him. The therapist and the fact. We find ourselves experienc- an alienating and despairing feeling. I the patient then shared the feelings of ing empathy. Empathy catches us after contrast this to feeling listened to, to sadness and hurt and anger. In other it has happened. We seem to look being really understood and at one words, in the third stage of this total back on it and realize what just oc- with another person. This is a posi- curred. In philosophical terms, it is tive, powerful experience sought after by most of us throughout life.

Physical Therapyllrolume 70, Number 11lNovember 1990 Downloaded from http://ptjournal.apta.org/ by guest on November 18, 2011 When health care students say, the second stage of empathy-ross- mature a person is, the more the "I resist feeling empathy with my pa- ing over-to occur, 1) one must allow imagination can see even the smallest tients because I fear I will lose my the experience of coming outside of of similarities. In fact, maturation can therapeutic objectivity," I contend it is oneself, a characteristic that requires a be, in part, charted by an increasing not empathy they fear but secure sense of self, and 2) cognitive feeling of at-oneness with all human identiJication.When students are development to the stage of formal beings. Those with creative imagina- taught never to sympathize because it operations or abstract thought (as in tions and a genuine interest in people is demeaning to patients, what is the experiencing of being in another's of all types will experience this real- meant is that pity often strips a person place) must be present, which Piagetll ization more. of dignil7 and self-worth, and the con- characterized as occurring around the current feelings of judgment interfere time of puberty. With puberty comes In the phenomenological research I with the healing relationship. When the ability to envision what it might conducted with other physical we hear, "I can empathize with you be like to be in another's shoes. Thus, therapists,1° I questioned a young, but on that point!" what is meant is, I can adolescents begin to make more mature, physical therapist athlete sympathize with you. Empathy catches meaningful plans for a career because about his experience of empathy for us in its process. My contention is that they can envision more clearly what it his patients. He recounted an experi- we can Facilitate it, and we can pre- would be like to be a journalist or a ence with a patient in intensive care vent it firom happening, but we can- lawyer. Likewise, adolescents begin to whom he was administering pul- not mak:e it happen. The question more fully to realize the effects of monary percussion and drainage. He then arises, "Can we teach students to their behavior on others and can feel described experiencing the crossing- empathize?" the hurt another feels as a result of over stage of empathy as his patient, their own actions, and thus are able an elderly, homeless person, rolled Can Empathy Be Taught? to be genuinely sorry for what they her eyes back into her head in sheer say and do that is hurtful. physical exhaustion. I asked him how Acknowledging the importance of he, a strong athlete, had even noticed Rogers's3 work to effective counseling, One might erroneously assume that a this frail woman's response, let alone CarkhufP developed a rather elabo- baby crawling across the floor, grasp- felt empathy for her. He smiled and rate thelory and process of training ing a blanket to offer to a crying child, said, "I run the Boston Marathon each that identified empathy as a skill, the is experiencing empathy. This is not year. I know what it's like to feel ex- accuracy of which could be evaluated possible. Instead, this might be an hausted and out of breath." In this on a co~ntinuum.The most skilled example of primitive trial-and-error way, this mature professional illus- counselor listens to the client and learning to extinguish a noxious trated that, by virtue of the fact that responcls accurately to both words stimulus. we all breathe, we have the capacity and underlying feelings. Responses to experience the breathlessness of are graded from 0 to 5 in accuracy. Intellectual and ethical development another person, no matter how dif- Elaborate counselor-training programs in the college years has been de- ferent that person appears.1° have been established to train people scribed by Perrylz as unfolding from a in the skill of empathy. However, ac- concrete, outer authority base found In my view, adolescent striving to be cording to Stein's1 description and to in first-year college students (eg, "All just like those one admires and to be the experiences recounted by the older people are rigid and resistant to accepted by others is eventually re- physical therapists in the previously the changing times. My father told me placed by the struggle for individual mentioned research study,1° CarkhuP that.") to an inner frame of reference autonomy and self-worth. This strug- is teaching self-transposal, not empa- found in those ready to graduate 4 gle, I believe, often takes place during thy. If we accept that empathy hap- years later (eg, "Resistance to change professional education for physical pens to us, we must also accept that it has less to do with age and more to therapy. cannot 'be taught. Empathy seems to do with how in control of the change be a communication process that de- the person feels."). The more aware one is of one's iden- velops as we mature. Cognitively and tity and personal values and bound- emotiorlally mature people should be The more concrete a person's intel- aries, the easier it is to retain one's capable of experiencing empathy, be- lectual and ethical development, the identity in interaction with others and cause it seems to develop along with more similar to another person he or the easier it is to not mistake patients cognition and emotions during she must be to allow empathy to oc- and teachers for parents or grandpar- puberty. cur with that person. For example, a ents. The more self-aware one is, the person with very concrete intellectual greater the ability to feel at one with The firsit and the third stages of and ethical development would say fellow persons and the greater the empathy-self-transposal and syrnpa- that it would be impossible for a likelihood of this occurring. There- thy-an be taught and developed in white person to empathize with a fore, although we cannot directly others, because we can cognitively black person because they would teach others the behavior of empathy, create them. However, in order for have so little in common. The more we can teach exercises in self-

Physical Therapyllrolume 70, Number Downloaded from http://ptjournal.apta.org/ by guest on November 18, 2011 awareness such as values clarification effective helping relationship, active fessionals with compassion and empa- and awareness of one's strengths and listening skills, use of "I statements" thy for patients. We must create expe- weaknesses in communication. We to express one's feelings, assertiveness riences to develop these attributes, can also facilitate the shift from black training, ethical dilemma resolution, and we must take responsibility for and white, or concrete, thinking to therapeutic presence with dying pa- modeling these behaviors and leflect- more abstract, nonjudgmental tients and families, and patients who ing on them with students, to raise perspectives. have questions about the physical re- their consciousness about the nature strictions on sexual expression would of a mature healing presence. What About Empathy be examples. In sum, the teaching Can Be Taught? experience in professional socializa- Acknowledgments tion should be centered on experien- My contention is that, although empa- tial learning of self-awareness and I would like to acknowledge Ruth B thy, as a process, can be facilitated to effectiveness in communicating a ther- Purtilo, PhD, PT, FAFTA, for her assist- occur, the behavior itself cannot be apeutic or healing use of oneself with ance in the process of working directly taught as a skill. Certainly, patients and colleagues. In this way, through the complexity of thoughts teachers can help develop it in stu- empathy will be facilitated to occur, surrounding empathy over the period dents by offering experiences that along with the therapeutic presence.l3 of several years; the 10 physical thera- increase self-awareness, listening pists who so generously shared their skills, awareness of the commonalities Conclusion experiences with me in the original of all human beings, and respect and research; and Robert Gailey, who tolerance for the differences. Empathy The art of healing is, in part, made up helped create the illustrations for this can be facilitated by teaching human- of a therapeutic use of oneself or a article. istic interviewing skills, by helping therapeutic presence for patients. This students identify their prejudces and presence is more than knowledge and References fears, and by developing students' skill alone; it is also composed of a confidence in their therapeutic skills compassionate understanding of the 1 Stein E. On the Problem of Empathy. 2nd so that they can be free of anxiety and patient and a communication that the ed. The Hague, the Netherlands: Martinus thus more likely to establish a thera- therapist is worthy of the trust that the NijhoffDr W Junk Publishers; 1970. 2 Carkhuff RR. Helping and Human Relations: peutic presence for others. Empathy patient has bestowed. Empathy en- A Primer for Lay and Professional Helpers. can be facilitated by modeling these hances the therapist's therapeutic New York, NY: Holt, Rinehan and Winston Inc; behaviors and then reflecting on them presence and deepens the patient- 1969. with students so that learning practitioner interactions without fear 3 Rogers CR. Client-Centered Theram. Boston, Mass: Houghton Mifflin Co; 1951. OCCU~S.~~ of losing one's self in the process. 4 Rogers CR. Empathic: an unappreciated way This shared meaning seems to en- of being. Counseling Psychologist 1975;l:l Anxiety, self-doubt, prejudice, and low hance the patient's process of 5 Buber M. Between Man and Man. Boston, self-esteem focus one's attention in- healing.I4 Mass: Beacon Press; 1955. ward, making it difficult to establish a 6 Friedman MS. Martin Buber: The Li&e of Dia- logue. New York, NY: Harper & Row Publish- therapeutic presence for others, and Empathy is a process that eludes ers Inc; 1960. thus these behaviors can prevent em- teaching.' However, developing stu- 7 Schleler M. The Nature of Sympathy. Ham- pathy from occurring. Teachers who dents' therapeutic presence through den, Conn: Archer Books; 1970. treat their patients and their students professional-socialization experiences 8 Wyschogrod E. Empathy and sympathy as with compassion and then reflect on and through modeling compassion tactile encounter. J Med Philos. 1981;6:2543. 9 Spiegelberg H. Toward a phenomenology of that process do a great deal to de- and allowing empathy can facilitate imaginative understanding of others (Putting velop this awareness of compassion at empathy to occur. Likewise, helping ourselves in the place of others). In: Proceed- work in students.'* students identify any negative, frag- ings of The Interactional Congres of Philoso- menting behaviors such as prejudice, phy, 1953. 10 Davis CM. A Phenomenological Description The theoretical framework for the self-preoccupation, excessive nervous of Empathy as It Occurs Within Physical Thera- psychosocial development of students, talking, poor listening and poor asser- pists for Their Patients. Boston, Mass: Boston University; 1982. Doctoral dissertation. often termed professional socializa- tiveness skills, and low self-esteem 11 Piaget J. Intellectual evolution from adoles- tion, can be viewed as logically pro- will assist students in taking responsi- cence to adulthood. Human Development. gressing from experiences and theory bility to change these behaviors that 1972;15:1-12. that lead to a clearer understanding block empathy and interfere with 12 Perry WG. Forms of Intellectuat and Ethi- first of oneself alone, one's values and healing. The role of the clinical in- cal Development in the College Years. New York, NY: Holt, Rinehan and Winston Inc; needs, and the influence of one's fam- structor is paramount in helping stu- 1968. ily on the desire to be in the helping dents to become aware of behaviors 13 Davis CM. Patient/Practitioner Interaction: professions. Next, the exercises might that can block empathy. An Expetiential Manual for Developing the Ari progress to theory and experience of Health Care. Thorofare, NJ: Slack Inc; 1989. 14 Pence G. Can compassion be taught? with other people in interaction. Such We can no longer simply hope that J Med Ethics. 1983;9:189-191. topics as the characteristics of an our students will become mature pro-

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