Empathy, Compassion and Genuine Relationships

In exploring integrating self-compassion more deeply into mindfulness-based interventions, I have learned that compassion is one of a number of overlapping and deeply inter-related factors, including empathy, congruence (transparency), positive regard and warmth, and responsiveness, key in developing genuine relationships with oneself, others and the world. In this blog, I reflect on the relationship between empathy and compassion in developing genuine therapeutic relationships. 

It may be surprising to learn that something as beneficial and fundamental to psychotherapy as empathy—a robust, medium-level predictor for client outcomes across all modalities (Elliott, Bohart, Watson, Murphy, 2018)—is nevertheless controversial. Paul Bloom, a Canadian American psychologist at Yale has even written a book Against Empathy, which he acknowledged is like telling people he wrote a book against kittens:

Everyone loves kittens, and just about everyone loves empathy. It’s easy to see it as a moral cure-all, making us kinder and more loving, essential for positive change. 

But empathy is surprisingly bad at making us good… 

My subtitle is ‘The Case for Rational Compassion.’ The ‘rational’ part refers to how we should make moral decisions, and it’s pretty obvious what this means. But ‘compassion’ might be less clear. I’m referring here to concern for others, wanting their pain to go away, wanting their lives to improve—but without the shared emotional experience that’s so central to empathy.

The distinction isn’t obvious, which is one reason why some people think that we couldn’t be good without empathy. But they really are different—they even activate distinct parts of the brain—and it turns out that compassion is superior in just about every way. It’s less biased and innumerate [“innumerate” means without basic knowledge of mathematics], less upsetting and exhausting. A compassionate person can help others with energy and good cheer, without the pernicious influence of vicarious suffering.

Interview with Leslie Jamison, retrieved from amazon.ca

In his (2017) paper “How Compassion Became Painful,” Bikkhu Analayo, a prominent German Theravada Buddhist scholar living in the US whose work I respect, makes a similar point based on his reading of the earliest Buddhist scriptures. Compassion, he writes, is a wholesome state focused on the wish and intention that others be free of suffering. He argues that according to early Buddhist teachings wholesome states are free of suffering, and therefore compassion, as a wholesome state, cannot involve emotional resonance with others’ suffering, because it would entail the person feeling compassion suffering as well. He writes that it was later developments in Buddhism that added empathy to compassion practices such as the Tibetan Buddhist practice, tonglen. Analyao and Bloom do not want to feel your pain, viewing empathy as an inherently unwholesome over-identification and fusion with others’ emotions that overturns equanimity and risks eventual burn-out. Jennifer Senior, in her review of Bloom’s book, explains:

If you live in a state of hypercommunion with others, you run the risk of emotional depletion — or “empathetic distress,” as a psychologist might say. It’s useless in the face of suffering. Better to answer with compassion, which doesn’t totally subsume the self.

Jennifer Senior (Dec 6 2016). “Against Empathy,’ or the Right Way to Feel Someone’s Pain. The New York Times Review.

Brian Goldman, an emergency physician at Mount Sinai Hospital in Toronto where I work who has a popular podcast White Coat Black Art on CBC, shares Bloom’s mistrust of emotional resonance as a form of dangerous emotional contagion. However, in his (2018) book, The Power of Kindness: Why Empathy is Essential in Everyday Life, he argues that empathy is not emotional, it is cognitive, involving perspective taking, the ability to take someone else’s perspective, to put ourselves in their shoes and understand with a kind intention what they are thinking and feeling, without ourselves actually emotionally resonating with how they are feeling.  

Consider the therapeutic experience provided by therapists who practice empathy as compassionate perspective-taking without emotionally resonating with their clients compared to Les Greenberg’s description of the kind of therapeutic encounter emotion-focused therapists cultivate:

the therapeutic relationship… is built on a genuinely valuing, affect regulating, empathic relationship in which the therapist is fully present, is highly attuned, and is sensitively responsive to the client’s experience. The therapist also is respectful, accepting, and congruent in his or her communication. In this view, the relationship with the therapist provides a powerful buffer to the client’s distress by the coregulation of affect. A relationship with an attuned, responsive, mirroring therapist provides interpersonal soothing and the development of emotion regulation. 

Geller and Greenberg (2012) suggested that a therapist’s presence is a precondition for therapist attunement and responsiveness as it allows for a particular kind of sensing, seeing, and listening to the other that then promotes a response that is attuned to the client’s present moment. Therapeutic presence involves being fully immersed in the present moment without judgement or expectation, being with and for the client. Therapeutic presence is defined as bringing one’s whole self into the encounter with the client, being completely in the moment on a multiplicity of levels—physically, emotionally, cognitively and spiritually. 

Being present provides the therapist with the capacity to notice and be aware of different levels of what is poignant in the moment in the client’s inner world and provides the type of relational encounter that infuses the client’s moment-by-moment experience with significance. That which was ignored becomes infused with significance and is attended to. Having previously lived in an experiential desert where experience was not relevant, people suddenly begin to listen to themselves and take their experience as valid and as conveying something important. 

(Greenberg, 2015 [2002], page 94)

In their paper on empathy in the most recent edition of Therapy Relationships that Work, Elliott, Bohart, Watson & Murphy (2019, pages 247-248) explain that empathy is not a single process:

empathy is a higher order category, under which different subtypes, aspects, and modes can be nested. There are different ways one can put oneself into the shoes of the other: emotionally, cognitively, on a moment-to-moment basis, or by trying to grasp an overall sense of what it is like to be that person. Within these subtypes, different aspects of the client’s experience can become the focus of empathy (Bohart & Greenberg, 1997). Similarly, there are many ways of expressing empathy, including empathic reflections, empathic questions, experience-near interpretations, empathic conjectures, responsive use of other therapeutic procedures, and a wide range of responsive and carefully tuned nonverbal expressions. Accordingly, empathy is best understood as a complex construct consisting of different acts used in multiple ways. 

Elliott et al. (2019, pages 246-247) describe how current neuroscience research focuses on three forms of empathy: a fast, almost automatic route of emotional simulation and resonance; a slower, deliberate, conceptual, perspective-taking process, and “an emotional regulation process that people use to reappraise or soothe their personal distress when vicariously experiencing the other person’s pain or discomfort, allowing them to mobilize compassion and helping behavior for the other.” This helps to contextualize Bloom’s, Analayo’s, and Goldman’s warnings about emotional resonance — for it to be helpful, we need to be able to tolerate, reflect on, and respond to our emotional resonance with a client in a way that is compassionate and soothing for ourselves and them.  

Elliott et al. (ibid, page 248) distinguish three main modes of empathy emphasized by different therapies. CBT emphasizes empathic rapport in which “the therapist exhibits a benevolent compassionate attitude toward the client and tries to demonstrate that he or she understands the client’s experience, often to set the context for effective treatment.” Humanistic and person-centred therapies emphasize communicative attunement which “consists of an active, ongoing effort to stay attuned on a moment-to-moment basis with the client’s communications and unfolding experience,” often finding expression in empathic reflections and conjectures. Psychodynamic and psychoanalytic therapies emphasize person empathy involving 

experience-near understanding of the client’s world, [consisting] of a sustained effort to understand the kinds of experiences the client has had, both historically and presently, that form the background of the client’s current experiencing. The question is: How have the client’s experiences led him or her to see/feel/think/act as he or she does? 


They go on to explain that just as empathy can be viewed as a higher order category with different subcategories and modes, it is most usefully understood as one of a number of overlapping and inter-related ingredients key in developing genuine relationships between therapists and clients. Other key components include congruence, positive regard and warmth, compassion, and responsiveness. The degree of overlap between them is exemplified by how, while empathy is only therapeutic when it is compassionate, it has also been used to define compassion. For example, a recent, influential definition of compassion (Strauss, Lever Taylor, Kuyken, Baer, Jones, & Cavanagh, 2016), which incorporates previous definitions such as Krstin Neff’s and Paul Gilbert’s, includes several key aspects of empathy including perspective-taking, emotional resonance and the ability to tolerate suffering in others and oneself:   

To bring together the various definitions and considerations above and to aid the review of existing measures of compassion, we propose a new definition of compassion as a cognitive, affective, and behavioral process consisting of the following five elements that refer to both self- and other-compassion: 1) Recognizing suffering; 2) Understanding the universality of suffering in human experience; 3) Feeling empathy for the person suffering and connecting with the distress (emotional resonance); 4) Tolerating uncomfortable feelings aroused in response to the suffering person (e.g. distress, anger, fear) so remaining open to and accepting of the person suffering; and 5) Motivation to act/acting to alleviate suffering.

(Ibid, pages 11-12)

Strauss et al.’s definition of compassion refers to both self-compassion and compassion for others. For them, whether compassion for self and for others are the same or different is an empirical question to be resolved through research, and they hope their definition will help with this. In contrast, in an attempt to bring clarity to a confusing topic that has been defined and measured in many different ways, Elliott et al.’s definition of empathy is focused on interpersonal rather than self-empathy. However, clearly, the point of therapists cultivating genuine relationships with their clients is so that clients can develop genuine relationships with themselves, others and the world: 

Therapists’ empathy in the context of an accepting, prizing, congruent relationship enables clients to develop new ways of relating to themselves and others. Clients become more empathic, respectful, and accepting of their experience and learn more positive ways to regulate it to enhance their well-being. 

(Watson, 2019, page 114)

In this way, in contrast to the meditative concentration practices for cultivating friendliness and compassion found in some Buddhist traditions which may exclude empathic emotional resonance (Analayo, 2017), in emotion-focused mindfulness therapy (EFMT), the cultivation of self-compassion goes hand in hand with cultivating a more empathic, respectful and accepting relationship with one’s own and others’ experience. 

As we have seen, different therapies emphasize different forms of empathy. Mainstream mindfulness-based interventions (MBIs) have either behavioural or cognitive behavioural orientations, and so it makes sense that the way therapists respond to clients’ meditation experience would emphasize empathic rapport. MBCT therapists model acknowledging, accepting, decentring from and letting go of their own difficult emotional resonance with clients’ painful experience in a way that enables them to regulate their own emotions and respond in a compassionate, validating way that in turn supports clients in approaching, accepting, decentering and letting go of their own difficult thoughts and emotions. 

In contrast, EFMT therapists emphasize communicative attunement in the way they empathically explore clients’ meditative and current experience in “an active, ongoing effort to stay attuned on a moment-to-moment basis with the client’s communications and unfolding experience” using empathic responses such as empathic reflections and conjectures. EFMT therapists also practice approaching and accepting their own and their clients’ difficult emotions and thoughts in a nonjudgmental, decentered way, but, unlike mainstream MBI therapists, they use this to respond differentially to emotions. EFMT clients internalize this as compassionate empathy towards their own experience learning to stay attuned to, reflecting on and deepening their experience and responding to their own emotions in a differential way. Where mainstream MBIs emphasize accepting, decentering and letting go of secondary, defensive emotions associated with rumination and worry, EFMT emphasizes staying attuned to and symbolizing emotional processes in therapeutic encounters and in meditation in order to arrive at underlying primary emotions and discerning if they are adaptive or maladaptive, transforming primary maladaptive emotions with adaptive emotions and making sense of and carrying forward primary adaptive emotions. 

It’s not that EFMT meditation requires practitioners to be always thinking, it is that EFMT meditators also value reflecting on and symbolizing emotions in order to deepen our experiencing. There are periods where we may be resonating with whatever is present without much thought happening at all, for example, as defences soften and a richer felt sense of the moment emerges. Thoughts may also fall away in deep states of calm. Nonjudgmental awareness enables us to reflect on and discern which emotions are unhelpful and which are helpful and then respond in a variety ways, letting go of or transforming unhelpful emotions, and making sense of and carrying forward helpful emotions. 

Les Greenberg has described emotion-focused therapy as involving “oceans of empathy with islands of work.” In EFMT, both therapists and clients learn to cultivate this in our meditation and lives.