Unhelpful empathy

Well-trained therapists fail even while doing all the “right” things

“I know exactly what you are going through!”

When the doors close in the therapy room only the patient and therapist are privy to what’s happening inside. There are a few exceptions where this black box is opened: when a therapist is training, doing court-mandated work, or conducting research. That’s where I come in — my specialty is listening to therapists perform therapy. I’ve had the unique privilege to listen to thousands of hours of therapy sessions over the past ten years to assess the quality of the therapeutic interaction.

One of the surprising insights I have gained from this work is that my global impression of the therapist’s ability to be empathic was sometimes unrelated to the specific skills they performed. In other words, they could be well-trained therapists using skills that are supposed to be empathic, and yet somehow fail to demonstrate empathy. Here’s an example:

Patient: So I’m just really struggling here to cut back on my drinking and it seems like the rest of my life is getting harder.

Therapist: Seize the day! You can do it!

Patient: I wish it was that easy.

Therapist: You are really working hard to quit right now!

Patient: Not exactly, I am not quite sure even where to start.

Therapist: You started by showing up today. You’re on your way there!

Patient: Yeah, okay. [Thinks: She doesn’t get it.]

When listening to a session like this, it becomes obvious in the patient’s reaction that they are not feeling understood. On a technical level, this therapist is doing things they were trained to do. For example, they are providing affirmations of the patient’s strengths and reflections of their willingness to change; however, these empathic skills are applied incorrectly or at the wrong time. I started to call these strange therapy interactions of almost good but somehow bad therapy, examples of “unhelpful empathy.”

Unhelpful empathy involves the therapist performing the listening skills that scientists have defined as good and empathic; however, the sum of the parts is a total empathic failure.

The primary difference between a therapist demonstrating unhelpful empathy versus incompetence is that unhelpful empathy includes all the good parts of therapy but they are simply misapplied. In short, these therapists lack the special sauce. Or as one of my least favorite principle investigators used to say, they didn’t have the listening “protoplasm.” They may actually understand their client very well but can’t express it, leaving their client alone in their struggle.

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Sauce and protoplasm aside, there are several unhelpful empathy archetypes that I and other scholars have identified:

The Robot

Accurate understanding without emotion

Patient: So I’m just really struggling here to cut back on my drinking.

Robot: You are facing a number of different obstacles related to drinking reduction.

The Robot can fully understand what the speaker is saying and may even understand what they are feeling. They demonstrate a “theory of mind” which is the ability to grasp the perspective of the other person; yet, they somehow fail to demonstrate empathy because they prioritize accurate and logical understanding over emotional connection and warmth. The patient expects emotional synchrony to occur and even though the therapist’s words are correct, the result is feeling misunderstood.

The Bleeding Heart

Emotion without understanding

Patient: So I’m just really struggling here to cut back on my drinking

Bleeding Heart: You are really working hard to quit right now!

The Bleeding Heart is the opposite of The Robot — the trappings of a supportive empathic listener are present like, warm tone and use of cheerleading, but they demonstrate inaccurate reflective listening. The example at the beginning of the article is an example of this type of listening. Bleeding Hearts often misread and misinterpret what the speaker is saying. They may have problems with theory of mind or force their understanding of the patient into a type of false synchrony. There is something unsettling about this type of unhelpful empathy because you almost want to like a Bleeding Heart. You want to believe in what they see in you. Instead, you find yourself sublimating rage as it’s nearly impossible to express your dislike for them during the conversation.

The Shoe Stealer

Overly identified empathy

Patient: So I’m just really struggling here to cut back on my drinking.

Shoe Stealer: Oh, tell me about it. I’m so sorry this is happening. I totally know what that’s like. I get it. I get it. I know what you are going through. In fact, you are just like me, but maybe 5 years ago when I was really lost. I had a lot going on at the time…[insert story here]. Actually, do you want to come to my AA group with me?

It’s nice to feel as if someone knows what it’s like to be in your shoes. But Shoe Stealers really think they are in your shoes, or that even your shoes are their shoes. They understand the speaker to the extent that they actually see themselves in the speaker too much and there is no more room for the speaker to express their problems. On a basic level, this can include comments like the classic, “I know what that’s like,” or “I totally understand,” which are meant as empathic but communicate the opposite. We can see this in conversations about race or gender or sexuality. (Cis straight white folks- I’m looking at you. Please avoid these kinds of “knowing” statements. It’s not empathic, it’s actually just making the conversation about you.)

There may be several types of shoe stealers depending on the psychology of the listener. Some Shoe Stealers are actually so ego-centric that they have what might be called narcissistic identification. They can’t actually identify with another person or listen to them without fully seeing themselves in that person. Closeness for the Narcissistic Shoe Stealer is about how similar the other person is to them, or how likely it is they reach some mind-meld with the narcissist’s mind.

Closely related to the Narcissistic type is the enmeshed or hyper-intrusive Shoe Stealer. This person may cross-boundaries with the speaker, or have overly amplified emotional identification. This could include inappropriate disclosures about their life when they are “listening” to the other person. I’ve seen Intrusive Shoe Stealers invite their patients to join in personal settings or somehow turn therapy into a social environment that the patient can’t escape. Thankfully these versions of the Shoe Stealer don’t tend to do very well in objective rankings of empathy once they start to cross boundaries; they transition from unhelpful empathy to unhelpful therapy quickly.

The Know-it-all

Avoidant empathy

Patient: So I’m just really struggling here to cut back on my drinking.

Know-it-all: I’m here for you. I have some strategies in this booklet that will help you. The first step is to recognize you have a problem. We can do an assessment today to determine if you are a problem drinker.

Now with this archetype, I am not talking about all therapists that give advice or talk more than their patients. I am describing the cases where the therapist relies on advice and problem-solving specifically to avoid empathic connection.

I have hypothesized that the Know-it-all does have an emotional understanding of their patient. They can synchronize, and feel what their patient is feeling, but when they begin to reckon with their patient’s feelings their defenses are raised and they avoid empathic connection. As the Know-it-all begins to experience the gravity of being affected by another person they may have what’s called a “parallel process” or feeling of what the patient is feeling (e.g., helplessness). When that feeling becomes too much to manage, they begin to immediately shut it down through a type of intellectualization through problem-solving, educating, and giving advice. This is a form of avoidant empathy where the anxiety is projected back to the client. In this projection, we might see the Know-it-all demonstrate intolerance of ambiguity and over-reliance on external expert information. We might see exchanges that take the form of “ask-tell” where the therapist asks many closed-ended questions about facts and the patient responds.

Sometimes Know-it-alls may focus on checklists and advice because they lack other tools or were trained to think this is what to do in the therapy room. Yet I don’t think this is a full explanation for avoidant empathy. I have seen many doctors and therapists that are not Know-it-alls but DO make room for empathic connection in the style and manner they deliver their advice, and by integrating reflective listening.

In true Know-it all fashion, I’d like to add that randomized control trials and other research have revealed that people don’t experience therapy as empathic when they are only given advice or told what to do. Patients don’t want to know a quick solution to solve the problem without first fully being heard, without having a moment of witnessing, and mourning for the struggle they have endured. Before solution finding, they need compassion for the dilemma they have found themselves in and validation for what they’ve experienced. Then they will become the author of their own recovery.

So in the end, after experiencing unhelpful empathy from a Know-it-all, the patient is left with the implicit feeling that they should have known better, or that they could have tried harder, or that ultimately their experience or knowledge was somehow inadequate or wrong. Like with the Bleeding Heart, it is very difficult to truly enjoy the experience of being with this avoidant therapist but their relational style makes it difficult to talk about in the session.

The Flourless Cake

Out-of-alignment empathy

Patient: So I’m just really struggling here to cut back on my drinking.

Cake: It’s as if you are balanced on the edge of a black hole, unclear if one step will mean either destruction or expansion. Time. Life. A never-ending circle of decisions. Oh, the pain is there alright, and it’s very real.

[Cake leans back with eyes closed, sighs and exhales deeply. Seconds pass. The patient is aware of the atmosphere of gravitas but also has an urge to check their text messages. Cake resumes…]

Cake: Very real.

This therapist is frankly too much. You want to like this therapist, but like a flourless cake, this therapist is too rich, too dense, and ultimately not what you needed. It’s nice sometimes to feel understood by a Cake therapist — it’s a special treat, but it can’t be the main meal. You need water. You need to breathe. Otherwise, you might fall asleep or feel sick afterward.

This kind of therapist fails to synchronize with the patient, or accurately judge perceived closeness. They may succeed in synchronizing in some parts of the session, but the patient may leave feeling totally exposed or in a kind of twilight zone state. The Cake is similar to the Shoe Stealer in that some of the comments from this kind of therapist are intrusive, but they can also be off-base. They are also similar to the Know-it-all in that there is a type of isolation experienced by the patient when the Cake talks.

In the myriad of ways we have to rate a therapist’s performance objectively, it is difficult to capture the flourless cake of unhelpful empathy. On a technical level, these therapists are doing the right things at the wrong moments. For example, if I were to identify the skill that the Cake therapist used in the example above we could call this a “complex reflection,” which is good. Complex reflections bring out depth and meaning in what the patient is saying. Complex reflections also have to be accurate. In this case, the reflection could be accurate, but it’s too intense of an interpretation for this moment.

I think I do all of these things, so am I unempathetic?

Maybe? These archetypes are illustrative of moments that most people fall into at one time or another. Therapists and people vary in their empathic abilities one conversation to the next, and with one patient to the next. I’m sure there are also many other ways unhelpful empathy occurs. I also believe there is also a reverse phenomenon of people doing all the textbook “wrong” things but somehow being amazingly empathic.

It’s worth reflecting on whether you fall into one of these patterns and why. Part of making room for understanding other people involves reflecting on yourself. But of course, as a therapist, I would say that.

If you are certain that you have a case of unhelpful empathy, I’ll be writing another article specifically dealing with the question of whether empathy can be trained.

x Dr. Lord

Special thanks to my mentor Dr. Chris Dunn and mentee Brian Pace for their feedback on early drafts of this article. They are genuine empathic masters.