by Martha Stark, MD / Faculty, Harvard Medical School


Many years ago I was seeing a chronically depressed and suicidal patient who had just been diagnosed with breast cancer.  Shortly thereafter she came in to a session having learned that her axillary lymph nodes had tested "negative" (that is, "no cancer").  Through angry tears, she told me that she was upset about the results because she had hoped the cancer would be her ticket out. 


I had to think for a few moments but then I managed to say, softly:  "At times like this, when you're hurting so much inside and feeling such despair, you find yourself wishing that there could be some way out, some way to end the pain." 


In response to this, she began to cry much more deeply and said, with heartfelt anguish, that she was just so tired of being so lonely all the time and so frightened that her (psychic) pain would never, ever go away.  Eventually she went on to say that she realized now how desperate she must have been to be wishing for an early death from cancer.


What I managed to say was, I think, empathic; but to say it, I needed to put aside my own feelings so that I could listen to my patient in order to understand where she was coming from.  And so my response, although empathic, was not terribly authentic – because what I was really feeling was horror.  What I was really feeling about my patient's upset with her negative test results was "My God, how can you even think such an outrageous thing!"  To have said that would have been authentic – but not particularly therapeutically useful.


Although the response I offered my patient was not authentic, it was empathic.  I think it enabled her to feel understood and then to access deeper levels of her pain and her anguish (and eventually her own horror that she would have been so desperate as to "want" cancer).


Now had I been able to process my countertransferential response of horror more quickly, I might have been able to say something that would have been therapeutically useful, something to the effect of "A part of me is horrified that you would want so desperately to find a way out that you would even be willing to have (metastasizing) cancer, but then I think about your intense loneliness and the pain that never lets up – and I think I begin to understand better." 


I present this example because it highlights the distinction between empathic attunement

(Model 2 – the corrective-provision perspective of self psychology and other "deficit" theories) and authentic engagement (Model 3 – the intersubjective perspective of contemporary relational theory).