What is Empathic Failure in Psychotherapy?

Most licensed psychotherapists are individuals who are credentialed and skilled in their areas of expertise. I believe the vast majority of psychotherapists are ethical and empathetic individuals who have their clients' best interests at heart and help their clients to overcome their psychological problems. But there can be big differences in terms of skills and experience from one psychotherapist to the next, and I believe that clients should be informed consumers, which is why I'm focusing on this issue.  

Psychotherapists are also human and, like everyone else, they make mistakes in therapy.  In this article, I'm focusing on a particular mistake called "empathic failure" where this is not an occasional problem but a recurrent problem with some psychotherapists (see my article: Why is Empathy Important in Psychotherapy?).

What is Empathic Failure in Psychotherapy?

What is Empathy?
Empathy involves a psychological process where you're able to put yourself in other people's shoes and get a sense of what they're feeling.  For instance, if your friend is upset because her dog died, even if you never had a dog in your life, you can put yourself in your friend's shoes and understand why she's upset about the loss.  You can tap into your friend's feelings and sense what she's feeling and resonate with her sadness about the loss.

What is Empathic Failure in Everyday Relationships?
Empathic failures occur all the time between friends, spouses, family members, students and teachers and so on.  Except when dealing with highly insensitive people, I believe that most instances of empathic failure occur inadvertently.

For instance, a husband might forget that his wife told him that she would like a particular perfume for her birthday. Instead, he buys her a vacuum cleaner and he feels proud of himself because it's energy efficient.

He expects that his wife will be thrilled.  But his wife's reaction is the complete opposite of what he expected--she is upset and angry because she feels he didn't hear her when she told him what she wanted.  She also feels that he sees her only as a "housewife" who cleans the apartment rather than a sensual woman.

While this might be very disappointing for his wife and it's an empathic failure, this isn't a reason to get a divorce if he is usually empathetic and they have a good relationship most of the time.  They can work out this problem and the husband can be more aware next time.

What is Empathic Failure in Psychotherapy?
When clients begin psychotherapy, they usually have a certain degree of trust that the psychotherapist is a credentialed mental health professional who will be attuned to their needs in therapy and help them to overcome the emotional problems.

Aside from all the other clinical skills that psychotherapists learn, one of the most important is how to be empathetic towards clients in therapy.  This is a skill that is honed in graduate school and, if the psychotherapist goes to postgraduate training, this skill usually developed even more.

I believe that most psychotherapists are empathetic individuals and those who go to graduate school who lack this skill are weeded out by supervisors and instructors.  That's not to say that there aren't some people who somehow make it through the screening process at times.

Even the best psychotherapists make mistakes in therapy at times, including empathic failures.  But there's a difference between a therapist who makes occasional mistakes related to empathic failure and those who do it habitually. So, let's start by defining what an empathic failure is in therapy:

An empathic failure occurs in therapy when the psychotherapist isn't attuned to the client.  This can occur in many ways:

• Forgetting important details about the client's life
• Confusing the client's history with another client
• Forgetting what the client and the therapist discussed in the prior session
• Forgetting an appointment with the client
• Focusing on the psychotherapist's life instead of focusing on the client's problems
• Projecting the psychotherapist's needs, wants, and problems onto the client
• Being dismissive of the client's needs
• Failing to be attuned to the client's emotions and mislabeling these emotions
• Failing to take responsibility for the mistakes that the psychotherapist made in therapy

and so on.

As I mentioned, even the best psychotherapists commit empathic failures at times.  For instance, a therapist, who is usually punctual and organized, can confuse his appointment schedule if the therapist is going through a very stressful time in his life.  If things were going smoothly before that, assuming that the therapist takes responsibility for the mistake, most clients would accept an apology and the therapy would continue (see my article: Ruptures and Repairs in Psychotherapy).

The empathic failures that I'm most concerned about are the ones that occur on a regular basis with a client who might have grown up with parents who lacked empathy for him.

Since this client grew up in an environment with chronic empathic failure, he might not recognize that he is in an unhealthy situation with his therapist.  It might seem "normal" to him because this is all that he knows.

The following fictional vignette illustrates how empathic failure can occur between a client and a therapist and steps that the client can take to take care of him or herself.

Fictional Vignette:  Mistakes Psychotherapists Make in Psychotherapy: Empathic Failure

Mike
Mike began therapy after a recent breakup. He told his new therapist that he felt unlovable and not good enough for most of his life.  This began in early childhood when his mother let him know that neither she nor his father wanted to have children, and Mike was "an accident."

He grew up feeling like he was "an inconvenience" to his parents, who paid very little attention to him.  As soon as he was old enough, they sent him to boarding school, which was a lonely experience for Mike.

When Mike looked up, he saw that his therapist had fallen asleep.  He wasn't sure what to do, so he cleared his throat hoping to wake the therapist up.  The therapist was startled by the sound and woke up with a jolt, "Oh, ah...what were you saying?"

Mike wasn't sure how much his therapist missed, so he started again at the beginning to describe his breakup and his family history.

Over the next few weeks, there were several other incidents.   There were a couple of times when Mike's therapist double booked appointments and Mike had to go home instead of seeing the therapist.

There was an incident where the therapist seemed to completely forget what Mike had told him about his family history and about the breakup, so Mike had to tell the therapist about these issues again.  Then, there was one day when Mike showed up for his regularly scheduled appointment and the therapist wasn't there.  Mike checked his voicemail to see if the therapist had left a message, but there were no messages.

Later that evening, when Mike met his close friend, Larry, and told him what had happened when Mike went to his therapist's office and the therapist wasn't there, Larry asked him questions about the therapy and if there were other problems in the therapy before this.

Mike thought about it for a minute and then told Larry about the other incidents.  While Mike spoke, Larry, who had good experiences in therapy before, listened carefully.  After Mike told him about the incidents, Larry told Mike that he needed to find another therapist because his current therapist seemed irresponsible and not attuned to Mike.

Since Larry knew Mike a long time, he also knew about Mike's childhood history and knew that Mike's experiences with his therapist were harmful.  He told Mike that he thought Mike's therapist wasn't treating him well and gave him all the reason why he thought this.  Mike listened, realized that what Larry was telling him resonated with him and that he probably had a blind spot about this.

When he went to his next session, Mike explained to his therapist why he thought the therapy wasn't working out for him and specifically why he felt he wasn't being treated well by the therapist.  His therapist looked uncomfortable, but he acknowledged that he had made mistakes with Mike.

Mike thought about it and decided that he ought to have consultations with other psychotherapists.  After two other consultations, Mike chose to work with another psychotherapist who seemed much more attuned to him.

He had one more session with his current therapist for closure and then began to meet regularly with the new therapist.  During that therapy, Mike began to understand why he had a blind spot in his former therapy.

He was also able to make connections between his history of emotional neglect with his family and the empathic failure that he experienced with his previous therapist.  This work helped Mike to feel that he deserved to be treated better in all areas of his life.

Conclusion
As I mentioned earlier, I believe that most psychotherapists are empathetic individuals who got into the mental health field to help people.

There can be empathic failures in any relationship.  Ideally, they are few and far between and when they occur, the person who made the mistake is able to admit it so there can be emotional repair.

An occasional mistake can occur in therapy, and the therapist should acknowledge the rupture and make an effort to repair the therapeutic relationship.  But when there are consistent empathic failures in psychotherapy with a particular psychotherapist, the client would do well to address these issues in therapy and to make a decision as to whether s/he wants to stay or find a different therapist.

Unfortunately, clients who grew up being emotionally neglected or abuse often have a blind spot for empathic failures because it seems "normal" to them.

Although this is a blog article and of necessity it's short, I hope it will be helpful to clients who might be experiencing consistent empathic failures in their therapy to become more aware of it and to take care of themselves by finding a therapist who can meet their needs.

Getting Help in Therapy
If you are struggling with an emotional problem that you have been unable to resolve, you could benefit from seeing a licensed mental health professional.

A consultation or two with a therapist (or more than one therapist) can help you to decide if you and the therapist are a good match (see my article: How to Choose a Psychotherapist).

About Me
I am a licensed NYC psychotherapist, hypnotherapist, EMDR and Somatic Experiencing therapist who provides integrative psychotherapy to individual adults and couples (see my article: Integrative Psychotherapy).

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.

Psychotherapy: Ruptures and Repairs Between You and Your Therapist

In the last two blog articles, I discussed transference in psychotherapy in the context of the erotic and the idealized transference( Psychotherapy and the Erotic Transference and Psychotherapy and the Positive Transference). I also mentioned "ruptures" in treatment and discussed this briefly. 

In this post, I would like to focus on the effect of ruptures in treatment and how they can be repaired so that the therapeutic relationship between therapist and client can be preserved and, in many cases, even thrive after a rupture.

Psychotherapy: Ruptures and Repairs in Therapy

What are Ruptures in Psychotherapy?
In any long-term psychotherapy, there are bound to be treatment ruptures. Usually, these ruptures occur when the therapist unwittingly commits an empathic failure with the client. Even the most empathic psychotherapist will, at times, either misunderstand what a client is saying or give a response that is less than empathic. This is usually not intentional. It's a mistake.

When a client, especially a client who might be emotionally fragile, feels that his or her therapist has been either insensitive or doesn't hear or understand what the client is saying, the client often experiences this as a rupture in treatment. 

Sometimes these ruptures are small, as when a therapist forgets a particular small detail of a client's history and this becomes obvious to the client. And sometimes, these ruptures can be big, and I'll give an example of this later on.

Whether the rupture is perceived by the client as big or small is determined by many factors, including the strength of the therapeutic relationship at the time of the rupture, how fragile the client is feeling what the therapist actually did or said and so on

If the therapeutic alliance is strong and there haven't been many ruptures in the past, clients can overlook a therapist's mistake, especially if the client knows that this was a mistake. 

However, if the client and therapist have just begun to work together or if there have been frequent ruptures or if the client has a personal family history where he or she was neglected or abused, any kind of empathic failure can lead to a big rupture between client and therapist.

If there are egregious offenses by the therapist, like sexual boundary crossings or other serious offenses, this not just a rupture. This is a serious ethical and legal breach, and that's not what I'm referring to in this article.

How Can Ruptures Be Repaired?
If we consider that in most long-term psychotherapy treatments there will be inevitable and unintentional empathic failures or mistakes on the part of the therapist, how can these empathic failures be addressed and repaired so that the rupture doesn't lead to the failure of the treatment?

The most important part of repairing a rupture in treatment is for the therapist to be able to acknowledge that he or she made a mistake. Except for the most narcissistic psychotherapists, most therapists can and will do this. Even if it wasn't originally perceived as a "mistake" by the therapist, once the client feels misunderstood or not heard, the therapist needs to acknowledge and take responsibility for it.

Almost any rupture, if it's not egregious, can be repaired in treatment if the therapist acknowledges that he or she either made a mistake or failed the client in some way. For most clients, the acknowledgement on the part of the therapist that there was a mistake or the client was hurt in some way is often enough to repair the treatment.

Ruptures in Therapy Can Be Repaired

Many clients have grown up in homes where their parents never owned up to mistakes they made, so the experience of having the therapist take responsibility for an empathic failure can be reparative in itself, especially if the client feels that the therapist's acknowledgement is heartfelt.

Even Experienced and Skilled Therapists Can Commit Unintentional Empathic Failures:
I remember early on when I was training to be a psychotherapist at a psychoanalytic institute, my peers and I were very concerned about making mistakes in treatment. As therapists in training, most of us feared that our inexperience could lead to irreparable damage to clients.

In the context of a discussion about empathic failures, one of our instructors, who was much admired, told us a story about a rupture in treatment due to an empathic failure that he had committed with a client. 

Before I discuss what the empathic failure was, I should mention that not only was this instructor much-admired by the psychoanalytic trainees and faculty, but most of the trainees had a strong idealizing transference for him, which relates to my prior blog post.

Most of us, at the time, were very surprised that someone of his talent and skill could make such a mistake. This is another example of the effects of the idealizing transference between students and instructors.

Our instructor was well aware of this and he used the story he told us not only to show that ruptures can be repaired in treatment but in his humility, to show that even seasoned and skilled therapists can make mistakes in treatment. He didn't want us, as therapists in training, to be so afraid of making a mistake that we would be too self conscious with clients, which would have, in and of itself, interfered with treatment.

His main point in telling us about a mistake that he made was: While it's not great to make mistakes with clients, in most cases, it's not so much about the mistake that leads to the rupture-- it's more about how the therapist handles the mistake and repairs the rupture.

To that end, he told us about a time when he forgot about a client's appointment and he left the office. The client had been coming to treatment for a few years, and he had a great deal of difficulty trusting people, including his therapist.

During these sessions, the client often talked about wanting more from the therapist in terms of being more like friends rather than client and therapist. Since this would be an ethical breach of the treatment frame, the therapist explained, as gently and tactfully as possible, that this wasn't possible and explained the reasons why.

Most clients would understand that the client-therapist relationship, albeit caring and, at times, intense, is still a professional relationship. However, some clients, for a variety of reasons (sometimes, due to a history of neglect or abuse), want more from the therapist and it's up to the therapist to preserve the safety of the therapeutic relationship and the treatment to maintain the treatment frame.

All of this is to say that, even after a few years of treatment where the client came multiple times per week and kept his appointments, the therapy sessions were often rocky because the client wanted a more personal relationship with the therapist and, in some ways, he felt deprived that the therapist would not give in to his wishes.

So, in a nutshell, that's the background of the case, and you can picture many sessions where the client attempted to get the therapist to break the treatment frame and the therapist was holding the line for the sake of the client's emotional safety, although the client didn't realize it at the time.

One day, the therapist received a call from his young daughter's school that his daughter was sick and he needed to pick her up from school. At the time, the therapist had a very busy schedule that included a full-time private practice; being an instructor and supervisor at the psychoanalytic institute; involvement in various professional committees, and so on.

Tired, distracted and focused on his concerns about his daughter, he left the office completely forgetting about the client's appointment. He picked up his daughter, brought her home, and called the pediatrician. Fortunately, it turned out to be only a cold, and his daughter went right to sleep.

Relieved that his daughter didn't have a major illness, the therapist began to relax after a busy, stressful day. It was only then that he realized that he had forgotten about his client, something that had never happened to him before in his many years of practice.

Being very concerned, he called the client to apologize, but the client was too upset to accept the apology. He didn't tell the client that he had to pick up his daughter. It would have been too hurt for a client, who wanted more of a personal relationship from his therapist, to feel that the therapist's daughter took precedence over him. He simply apologized and told the client that he was called away from the office, he forgot about his appointment, and he was deeply sorry.

As an aside, one could speculate as to whether there was an unconscious wish on the part of the therapist to avoid dealing with this client on this particular day. While this might have been a factor, if and when that occurs, it's up to the therapist in this situation to do some self-analysis to explore this question.

In any case, the client was unable to accept the therapist's apology immediately. In fact, he focused on this empathic failure and the rupture in the treatment for about two months in every session. They were unable to move beyond this problem and it consumed the client's thoughts. Not only was the client very angry, but he was very deeply hurt that the therapist forgot about him.

This empathic failure fed right into his worst fear that the therapist really didn't care about him and he wasn't important to the therapist which, of course, was not the case at all. However, for a client who grew up with emotional neglect, he was very sensitive to any kind of empathic breach. In many ways, he was always vigilant and suspecting that this would happen because he found it difficult to trust people. So, in terms of empathic failures, this couldn't have happened to a more emotionally fragile client.

The therapist knew the client was unconsciously"testing" him. The therapist needed to withstand the client's anger and hurt to show the client he cared about him. 

After a few months of the client venting his anger and hurt and, together with the therapist, making connections to how this empathic failure triggered his history of emotional neglect, over time, the client and therapist were able to repair their relationship.

What's more, the relationship was more than just repaired to its former state, it was actually enhanced. 

Over time, the client was able to see that his therapist actually did care about him a great deal and that the empathic failure was an unintentional mistake. He realized that his therapist was human and he let go of some of his idealization (much as I and the other psychoanalytic trainees did on the day when our instructor told us this story).

Feeling cared about, over time, the client stopped demanding that the therapist be his friend. He realized that it was enough that the therapist was compassionate and cared about him.

As psychotherapists in training back then, we were much relieved to hear that, even a therapist who was known to be highly skilled, could make such a mistake. It served to take a lot of pressure off us, and I've always remembered this story.

For most clients, a sincere and caring apology can go a long way to repairing a rupture in treatment. And, in many cases, the reparative experience is more important than the rupture.

About Me

I am a licensed NYC psychotherapist, hypnotherapist, EMDR, AEDP, EFT and Somatic Experiencing therapist.

I work with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 or email me.