by Martha Stark, MD / Faculty, Harvard Medical School


In Model 2 (self psychology and other deficit models), the emphasis is on the therapist's empathic attunement to the patient – which requires of the therapist that she decenter from her own experience so that she can immerse herself empathically in the patient's experience.  We might say of the Model 2 therapist that she enters into the patient's experience and takes it on as if it were her own. 


By contrast, in Model 3 (the contemporary relational model), the emphasis is on the therapist's authentic engagement with the patient – which requires of the therapist that she remain very much centered within her own experience, ever attuned to all that she is feeling and thinking.  We might say of the Model 3 therapist that she allows the patient's experience to enter into her and takes it on as her own.


Although empathic attunement and authentic engagement may sometimes go hand in hand, they involve a different positioning of the therapist and, therefore, a different use of the therapist's self.


Let me now offer a clinical vignette that I think demonstrates the distinction between empathic decentering and authentic centering. 


Clinical Vignette:  Empathy vs. Authenticity


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 terribly 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 at all 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 think such an outrageous thing!"  To have said that would have been authentic – but probably not analytically useful! 


Although the response I offered my patient was not authentic, it was empathic.  And 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 reaction of horror more quickly, I might have been able to say something that would have been both authentic and analytically 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 an empathic response and an authentic response, between empathic attunement (Model 2) and authentic engagement (Model 3).

I believe there is a place for both "empathy" and "authenticity" in the work that we do – neither one is "better" than the other.