What exactly is empathy in clinical practice?

  • February 19, 2024

In a recent British Journal of Psychiatry editorial summarising key points from the latest NICE guideline on management of self-harm, the authors led with a section headed “The need for empathy” – a rallying call that seems on the face of it unproblematic. Empathy is however underspecified in their article (as it so often is in psychiatry) both in terms of its defining features and in relation to what exactly should be the interventions to ensure it happens.

Interestingly the word empathy appears for the first time only in the supplement to the OED. It has gained currency since then but with a rather blurry feel-good meaning. The OED defines empathy as: “The power of entering into the experience of…emotions outside ourselves”. An early use referred to the experience of a work of art, the ability to “feel oneself into it”. These definitions too are rather hard to grasp but they suggest a state that it is unrealistic to expect a clinician to achieve – especially in relation to somebody met only briefly and in unusual circumstances, whose emotions and responses to them are likely to arise from experiences well outside the clinician’s own.

Some people claim that they can teach healthcare professionals how to be empathic. What it seems to boil down to is usually something like being attuned to implicit or non-verbal expressions of emotion, acknowledging and responding to them. This of course isn’t empathy but a sort of social practice. For that reason the more sophisticated versions of acknowledging and responding to patients has been likened to method acting.

Instead of continuing with this (frankly rather pretentious) focus on empathy, there are some less nebulous aspects of sensitive and non-aversive care that can be taught.

First is courtesy and professionalism. These, unlike empathy, can be taught and supervised by attention to behaviour – how to introduce yourself, asking how the patient wants to be addressed, paying attention to privacy and confidentiality and so on. And if that fails there is a question about lack of professionalism for which there are other remedies.

Second is being well-informed about causes and consequences. My own experience suggests that many clinicians are not au fait with what is now known about reasons for self-harm – in the sense of what its functions might be. One indication is the frequency with which discussions centre around diagnosis, which is except in a minority of no help in understanding what is going on. Another is the persistence of stereotypes about self-injury. It is difficult to undertake a sensitive and meaningful psychosocial assessment if you don’t know what you’re looking for. I wouldn’t downplay the importance of person-centred care or the value of service user involvement in training, but clinically oriented postgraduate education also needs to develop in this space. This sounds too fact-based to have anything to do with “empathy” but then I have always thought that a better word than empathy is sympathy – the sense of feeling onside with somebody that comes from a shared understanding of the situation. And how to elicit that shared understanding can be taught.

Third is the question of competence in practice and here there is a real challenge. Hardly anybody provides comprehensive psychological or psychosocial treatment services in the post-acute period – not in liaison psychiatry where most acute presentations are seen, nor in clinical psychology, nor in CMHTs. Good management involves, for sure, a professional attitude and behaviour and sound knowledge both about therapies and about the specific problem being tackled – but also the generic (transferable) skills, behavioural and emotional repertoire and expertise that come from experience. How can we enhance care in this area if we don’t provide the services within which all this can be developed?


If we are to improve how we treat people we need to go beyond rather general appeals to good practice. We need to develop self-harm services and to specify the curriculum for education and supervised training that will develop those working in such services to act professionally and sympathetically, as well as with a competence derived from education and from experience in practice.  

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