Peter R. Breggin
Center for the Study of Psychiatry and Psychology
Abstract: Empathic self-transformation and a healing presence are key to successful therapy. Empathy, the willingness and ability to understand and care about the suffering of another person, requires a loving attitude. Love, in this context, is defined as joyful awareness, accompanied by a desire to nurture and to treasure. Empathic self-transformation is a process of overcoming our personal barriers to feeling empathy and love for our client. Healing presence is a way of being with others that inspires confidence, security, hope and the opportunity to be understood and appreciated. The goal of therapy is to help clients maximize their ability to be empathic and loving toward themselves and others. In contrast, biological psychiatry views people as objects and suppresses their feelings, thus interfering with empathy and the creation of a healing presence.
Empathy lies at the heart of being helpful to other human beings (Breggin, 1997a, 1997b). However, empathy does not necessarily spring forth spontaneously from us in all situations or toward all of our patients and clients. Many clients will challenge our ability to understand and to feel sympathy for their experience and viewpoint of life. We must be aware of our level of empathy toward each client; and we transform ourselves when necessary to reach out as much as possible to all those who seek help from us.! call this process empathic self-transformation. Given the innumerable barriers within us to feeling empathy toward each and every person, empathic self-transformation should become a daily part of our lives as therapists.
One person may seem too angry to us, another too helpless. One person’s self-absorption or another’s self-sacrifice might put us otf. Some of us are more comfortable with people who communicate intellectually and abstractly, others of us may feel more at ease with people who readily share feelings. We might have difficulty reaching out emotionally to parents who mistreat their children or children who reject their parents. My own medical and forensic consultations on behalf of murderers sometimes tests my empathic abilities.
The barriers we experience to becoming empathic are sometimes built so deeply into us that they affect how we relate to most or all people, including many of our patients. For example, our professional training may make it difficult for us to open our hearts in a caring way to our clients or patients. The temptation to diagnose or categorize them may get in the way. Or we may have problems relating in a vulnerable fashion to the opposite sex, or perhaps to the same sex.
Sometimes we may be unaware of why we have difficulty feeling or expressing empathy for another human being. Barriers to empathy can develop in our own early experience with care givers, even before we have become fully sentient and verbal. Regardless of whether or not we can figure out why we have hardened our hearts at any given moment or toward any specific person, we need to be especially alert for those unexpected ,inexplicable failures to remain empathic.To help other people in almost any professional or personal role, we must be willing to change ourselves to become as responsive as we can to their feelings, needs, and viewpoint. Empathic self-transformation is the necessary ingredient in creating a healing presence with a client, friend, or family member – with anyone who puts their trust in us.
The capacity and the willingness to be empathic lies at the heart of what I call “healing presence.” Healing presence is a way of being with our clients that reassures and encourages them, helps them to feel understood and appreciated, and inspires courage and confidence that they can overcome suffering and continue to grow.
The development of our capacity to create a healing presence begins with empathy for ourselves. Empathic self-transformation must spring from a constant renewal of the way we care for and understand ourselves. Some of what I’m about to describe may seem obvious, but I often have to remind myself about one or another principle in order to be at my best in my work.Basically, these principles require an empathic attitude toward ourselves as therapists to facilitate our creating an environment in which we can radiate empathy and caring for others.
To create a healing presence requires, first and foremost, a feelin g of safety within one’s own space and within the professional relationship. If you find the other person threatening or dangerous in some fashion, you will be hampered in creating a healing presence. Your feelings of threat or distrust should be dealt with as openly and directly as possible in an effort to create a safe space for you to work within.
Feeling that you are getting what you need and deserve professionally from the relationship is also important. For example, if you resent having to work so hard, or if you believe you’re getting paid too little (or even too much), you will have difficulty maintaining an empathic view of the other human being. In fact, resentment of any kind is one of the greatest barriers to empathy. If you don’t greatly enjoy doing therapy, you may end up doing more harm than good.
Feeling comfortable and happy in your space is also very important to the creation ofa healing presence. Your own office should closely meet your personal ideals for a workplace. Rather than conforming to a seemingly professional standard, it should meet your personal standard for an inspiring environment. If you feel safe and comfortable, even inspired, in your space you will communicate safety and comfort, and even inspiration, to your clients from the beginning of your work together.
Allowing sufficient time to be helpful is indispensable. Therapists who work on fifteen-minute schedules cannot possibly offer a healing presence to their patients. To create a healing presence, you must communicate in effect, “We’ve got plenty of time to handle your problems.” While therapists will differ in their sense of time, I find that anything less than fifty-five or sixty minutes makes me feel rushed.
It is impossible to create a healing presence without adhering closely to your highest ethical standards. Unfortunately ethical therapy has become increasingly difficult to achieve for many therapists who feel compelled to encourage or to prescribe medications against their own clinical judgment. Many therapists have voiced to me a fear that they will get sued if they fail to prescribe medication or to refer their patients to doctors who can prescribe. In reality, relativey few lawsuits have been brought against therapists for their failure to encourage medication. By contrast, my medical colleagues are sued in large numbers each year as a result of their prescription practices. I have been a medical expert in many such cases against physicians. In almost every malpractice case in which I have been a medical expert, the patient or family who brought the suit felt that the doctor “didn’t care” or was outright callous. Empathic self-transformation and the creation of a healing presence is the best protection against being sued. But far more importantly, it’s the best approach to helping people.
To create a healing presence, you must feel truly glad and even grateful for the opportunity to spend time with your clients and patients. The grateful therapist is the most effective therapist. You must be able to greet your clients or patients happily and even joyfully. Some religions speak of “greeting the God” within each person we encounter. Whatever your humanistic or spiritual philosophy, as a therapist you must feel honored to have the opportunity to work with each individual. If you don’t feel this way toward one or another client, you need to apply yourself to empathic self-transformation-to finding within yourself the ability to feel empathy and caring toward this individual. Ultimately, you must find peace and joy in yourself and in your own life in order to radiate these feelings in your work. To help people learn to love each other, and to love life itself, the therapist must love people and life.
Love, Empathy and Healing Presence
The conduct of therapy, much as the conduct of life, requires articulated concepts of empathy and love that make sense as attainable ideals to the participants. If there are differences of opinion about love, they should be discussed. Attempts to work without a conscious, shared ideal about love will itself communicate a potentially disastrous value–that relationships can succeed and be improved in a spiritual void. This flawed viewpoint will compound the confusion and despair that’s already felt by those seeking help.
When it seems appropriate and useful, I explain to my clients my simplified definition of love. Love is a joyful awareness of another person, of nature, or art, of life, of God (Breggin 1992, 1 997a). When we feel love, we also tend to feel reverent and treasuring, and we tend to create a healing presence.
My definition of love as joyful awareness also applies to empathy. Genuine empathy involves a joyful awareness of another person in all of their aspects. In fact, the words love and empathy can be used interchangeably in many situations and for most purposes. However, when speaking of empathy, we often mean a particular kind of loving attitude-one that reaches toward another person who is suffering in a conscious attempt to understand that person’s painful feelings and experiences.
The Ideal of Love
People who seek help from me frequently remark that their earlier therapies failed to confront lifelong destructive ways of thinking, acting and communicating. My emphasis on empathy and love helps throw their negative behaviors into more obvious relief. The ideal of love provides a standard against which to measure each person’s communications, decisions, and conduct. Without love as a guiding principle, therapy and relationships in general are likely to flounder or fall short of their full potential, and very negative approaches to life can go unnoticed.
Principled living (Breggin, 1997a) is central to the creation of more loving relationships. Individuals and families who come for help usually lack a set of coherent, rational ideas about how to conduct their lives. They especially lack an articulated concept of love, including how to express and to receive it. They don’t know how to insist upon or to carry out courteous, respectful communication without which the development of vulnerability and love is impossible. As individuals or couples, they may have worked with prior therapists who compounded their confusion by failing to stop or even by encouraging hateful expressions. Their previous therapists may have cynically dismissed love. Usually they have failed to measure the quality of relationships by the quality of love they generate.
My definition of love as joyful awareness with aspects of caring, reverence and treasuring, although somewhat simplified, has proven helpful to people in couples and family therapy. Love is essentially happy or joyful, even ecstatic at times. Depending on the viewpoint of the participants, it bathes loving relationships with secular reverence or spiritual holiness. It allows us to set the goal of communication as the nurturing of respectful, empathic and loving relationships.
Romantic love is sexually passionate love. Romance uses physical intimacy to create or amplify closeness and mutual fulfillment. Romantic love is not an illusion. It expresses the most profound reality of human life–our capacity to take extraordinary delight in each other, to be joyful in knowing or experiencing each other, to be devoted to each other through the good and the bad times and to feel blessed by each other’s existence. In loving relationships, passionate love can become a part of everyday life. Lovemaking can become part of a reverence for each other and for life.
The role of empathy in lovemaking receives much too little attention in therapy or in married life. For lovemaking to become truly fulfilling, each person must bring a deep concern with the partner’s fulfillment. That is, we must feel empathic toward our partner’s sexuality in order to offer as much as we can.
Love and Relationship
Love is not the same as a relationship. Love can be felt without any reciprocity or mutuality. We can love people who have disappeared from our lives, and even people we’ve never met face-to-face. Similarly, we can also love persons who don’t love us, who have rejected us, or who have betrayed us. Love is our own self-generated feel ing toward someone or something else. As I emphasize in Beyond Conflict, unconditional love is possible because love is generated, felt, and expressed from within us without requiring reciprocity or even a relationship. Yet unfulfilled love is also deeply painful. Rejection from loved ones can easily cause us to withdraw our love. The challenge of life is to remain loving, to generate unconditional love, in the face of the inevitable vulnerabilities that it creates.
Loving relationships, the sharing ofJove and the expression ofJove with others, is one of life’s most fulfilling experiences. But relationships can also endanger and undo love. A loving relationship is much more complex than love itself. It requires hard work to remain loving through the ups and downs of relationship.
Often one of my clients will arrive in the office flush with feelings of love but equally awash in fear. They have begun to fall in love and the experience is both exhilarating and terrifying. But most of the emotional pain that seems associated with love is actually caused by relationships, including our past and ongoing experiences of rejection, abandonment, and betrayal. A feeling of love can re-stimulate the pain of earlier painful relationships. By encouraging so much hope, love also raises the specter of disappointment. However, attempts to remain safe by denying feelings of love can mire people down in helplessness, self-pity, and depression.
The painful emotions so often falsely ascribed to love can occur in relationships that utterly lack love. They can occur in hateful relationships. When people collapse emotionally after losing someone, it’s not necessarily a sign of their love. It can signal the intensity of their helpless dependency with its fear, resentment and other negative emotions.
Reclaiming and Encouraging Love
As a therapist, I usually talk briefly but directly about the importance of love, offering my definition of love as joyful awareness with caring, reverence and treasuring. But I discuss my ideals only to the extent that people feel it provides helpful direction and only a few minutes at a time are explicitly devoted to my views.
When clients seem baffled about love, I help them to find examples of love to help them understand what it’s about. A careful search may disclose that the person loved an animal, a tree, or a place in childhood. Perhaps there was an aunt or grandparent, or a baby sitter, whose very presence made them happy. Perhaps a hobby or a book still elicits joyful awareness. Perhaps a recreational activity or a work project continues to capture their full attention in a way that delights them. Most important in couples work, perhaps there was a time–hopefully there are still moments–when the participants felt love for each other.
When people have always felt cynical and hopeless about love, they usually have been exposed to rejection and abandonment from their own parents or childhood care givers. When they have not recovered from these experiences, even after years of treatment with other therapists, I frequently find that they remain mired down in loveless or even hateful interactions with one or more of their parents. If the person being helped remains unable to grasp the idea of love–the therapist should carefully examine whether or not current relationships, especially with parents, are reinforcing their cynicism or disbelief about love (Breggin, 2001b).
By the time they seek help, individuals and families are usually enmeshed in complex, subtle but devastating conflicts. In couples work, it quickly becomes apparent that they have lost empathy for each other. Even if they profess love for each other, they are likely to emphasize the least flattering interpretation of every aspect of the other’s behavior. They have usually lost sight of love and no longer believe in it. They may be bitter, cynical and skeptical about the very idea of love. They need help in turning that cynicism around. Remembering, recognizing and recovering lost love is a central aspect of healing relationships.
To recover lost love, I encourage individuals and couples to recall and to talk about times when they took delight in each other. I may ask directly about moments in the past, however brief, when the mere thought or sight of the loved one or each other made their hearts sing. Often they have forgotten or repressed the wonderful promise that blossomed early in their relationship and then withered with unresolved, escalating conflicts. If love has been present in the past, then it’s cause for increased optimism in regard to healing the relationship.
Simply asking a person to talk a little about love often results in the immediate confession of immense frustration and confusion. In therapy, I try to identifY the person’s ideas about love, and then to trace them back to their origins in past experiences. I keep a watchful eye on how the participants communicate their feelings to me and to each other, always against the backdrop of my viewpoint that loving communication is the goal. The therapist can point out each destructive communication and show how it perpetuates conflict and suffering. If the individuals are well motivated, awareness of these largely unconscious or reflexive patterns may be quickly appreciated. If more positive alternatives can be drawn to their attention and illustrated, the participants may rapidly begin to work on changing their behavior. When the goal of a more rational and loving life together is made explicit, progress can proceed even more readily.
Healing Presence in Family Therapy
Toward the aim of cultivating my own healing presence in each session, I actively discourage hateful and destructive communications toward me. At the same time, I discourage them from being made toward each other in couples therapy. It’s important for people to acknowledge how frustrated they have become with each other; but it’s more important for them not to take it out on each other. Anger as an expression of emotional pain can be helpful; anger as an intentional tool for retaliating or causing injury is not.
Rather than enforcing an artificial, superficial sense of love, I encourage the flowering of love by clearing away the threats and communications that make vulnerability too dangerous to risk. I point out negative communications each time they occur and encourage everyone involved to think about more benign and hopefully more nurturing alternatives for getting across to each other. I try to show people that respectful communication is required before anyone will dare to express underlying feelings and needs. Only when people are determined to avoid purposely hurting each other, can they begin to show their more tender sides to each other.
It is difficult to help people love each other if, as helping persons, we don’t respond with empathy and affection to them as individuals and to their positive feelings for each other. Therapists should feel free to show delight as their clients recover their capacity to love each other. However, empathic self-transformation may be required to overcome the stultifying effects of professional training. It’s up to us as therapists, teachers, parents or friends to find in ourselves the capacity to treasure the people we are trying to help and to delight in their experiences of love.
Relationships can generate very destructive feelings and it’s important not to gloss over these in our emphasis on the ideal of love. By the time parents seek help about their children they may be secretly wishing for the death of their offspring. Husbands and wives in severe conflict may be harboring murderous feelings toward each other.
People are usually relieved to know that intimate relationships frequently generate feelings of violence. These feelings reflect the degree to which people feel dependent on each other. The therapist, of course, must be comfortable with his or her own similar reactions to stress and conflict with loved ones. The therapist’s healing presence can help to ease anxiety over aggressive and violent feelings.
Advantages of Family Therapy
Most of my practice involves individual therapy but family therapy is often the most challenging and potentially productive. Working with families is a particular challenge to our empathic capacities. It requires feeling empathic toward two or more different people who are in conflict with each other. For example, therapists must learn to be empathic not only toward the abused or neglected child, but also toward the stressed, confused parents who perpetrate the abuse and neglect.
Working with couples and families can become one of the most exciting opportunities because it can help the clients themselves learn to help each other live more loving lives. Even young children can participate in loving, empathic relationships, and sometimes they can lead the way for their parents during therapy (Breggin, 200 I a). Family therapy should teach the participants to develop a healing presence for each other.
Family therapy can bring to light issues that too easily remain hidden during individual therapy. A man may seem a model of patience and understanding when talking with his therapist, only to become short-tempered, hostile and manipulative when his wife arrives with him for a session. A young boy who is intensely focused while working with me alone may become “hyperactive” and “distractible” the moment his parents enter the office. A woman may hide her alcoholism, a man may hide his sexual fears and difficulties – until a spouse discloses the secret in a couples session.
More subtle conflicts may quickly become apparent in family therapy. People withhold love, express disdain, and make threats in subtle fashions within their families. An arched eyebrow may mean, “I’ll get you for that when we get home.” A slight smile may mean, “You’re being a jerk again.” A frown may indicate, “I’m going to act depressed the entire weekend.” In individual therapy without the husband or wife, these communication styles may never surface. In the presence of the spouse, they may quickly become apparent.
People who are very emotionally injured and distressed, including those who carry the diagnosis of “schizophrenia,” can often benefit from family therapy. Like everyone else, their way of being has been influenced by significant other people in their lives during their formative years. In the case of especially impaired people, some of whom continue to live at home in a dependent fashion, ongoing family relationships are critical to their healing. By helping families develop less conflicted, more loving communication and relationship, we help to heal the most emotionally disabled member (Leff & Berkowitz, 1996). At the heart of the experience of “schizophrenia” lies shame and alienation from other human beings and withdrawal into a private world of humiliation and anger (Breggin, 1991). The way out is through more trusting, safer relationships with people.
Our Importance to Each Other
People not only need to love each other, they simply need each other. These truths about human nature can be dealt with most directly in family work. Even without very negative childhood experiences, or harmful adult relationships, modern society and modern therapy tends to disparage love and relationship. This denigration of human connectedness is seen in the emphasis on being “independent” to the degree of denying our fundamental inter-dependence with each other.
There is too much emphasis in our society on what might be called pseudo-independence–making believe we don’t need or affect each other. I have also called it nondependency: the failure to relate masquerading as independence. Therapists too often tell their clients, “No one can make you feel unhappy or make you feel happy. It has to come from within yourself.” Nonsense. From birth to death, our lives are so interwoven with others that when we try to handle life on our own, we are literally tearing apart our own fabric.
People have an extraordinary capacity to make each other miserable and to bring joy to each other. There is too much emphasis on “getting along” in oppressive relationships. Grown children are often encouraged to “make up” with their parents, or to reach an accommodation, without the parents changing their abusive ways or learning to be more loving. One of the keys to successful living is to learn how to surround oneself with loving, empowering, ethical people (Breggin, 2001b). This can begin with setting higher standards for how we are treated, and how we treated others, especially in our own families.
Biological Psychiatry and Empathy
The technological view has long competed with the psychological, social and spiritual views of therapy and life; but in recent years, insurance cut backs and controls have pushed the balance toward the mechanics of the assembly line. Cost cutting, and hence brevity, dominate the philosophy of managed care.
Biological psychiatry sometimes tries to grab the high ground of empathy. Organized psychiatry and the drug companies are currently spending millions of dollars on the “Anti-Stigma” campaign which essentially preaches that “mental illness” is a physical disease exactly like diabetes or heart disease. Therefore, they conclude, depressed or anxious feelings are not caused by our life experiences or by our own conflicts or conduct. In the extreme, even sexually abusive parents are not blamed for the “mental illness” in their children (cited in Breggin, 2001a).
Ironically, the advocates of biological psychiatry call “uncaring” those who are critical of psychiatric diagnosis, electroshock, medication, and involuntary treatment. Supposedly, if we cared we would do anything-including involuntary shock and lobotomy-to relieve symptoms and suffering. Unfortunately, when we become overly focused on symptom relief, we forgot to look more deeply into the roots of the person’s suffering. And when we leap too quickly to relieve suffering, we often do so out of our inability to listen to and to share the person’s suffering. We fail to find the time, patience, or wisdom required for understanding the individual’s suffering.
Diagnosing and medicating patients is often the doctor’s method of escaping from the difficult process of empathizing with the patient. The act of diagnosis, for example, telling someone that they have “clinical depression” or “schizophrenia,” crams the individual into an artificial category. The diagnosis becomes the period at the end of a very brief sentence about the individual’s emotional life. Once the diagnosis has been made, its existence reduces our motivation to deepen our understanding of the person’s struggle with life. Empathy and understanding require instead an understanding of the individual’s life story- how the individual became enmeshed in the psychological state and life that feels so painful and overwhelming.
The act of medicating a person in effect declares that the individual’s personal efforts and the therapeutic relationship are inadequate to deal with the person’s suffering and confusion. The patient’s agreement to accept the prescription can become a form of surrender to the authority of the doctor and to the medical viewpoint that the individual is helpless in the face of his or her “disease” (Breggin, 1992).
Once the psychoactive drug is taken, it invariably distorts the mental and psychological life of the individual. I have written extensively about how psychiatric drugs work by disabling the highest functions of the brain and mind (e.g., Breggin, 1997a; Breggin, 2001b; Breggin & Cohen, 1999). Whether the individual experiences a lobotomy-like indifference, emotional anesthesia, or an artificial euphoria, the end result is a person with less awareness and less capacity to enter into an empathic relationship.
Overall, the medical model turns people into objects. Both the patient and the therapist are encouraged to view the patient as a defective mechanism rather than as a struggling, thinking, feeling, choice-making human being. This effectively blocks any kind of empathic exchange between the patient and the doctor.
Organized psychiatry has been successful in recent years in increasing the power of health professionals to drug people against their will, even after they have been released from a hospital. Involuntary outpatient treatment is now lawful and increasingly practiced in many states. Advocates of involuntary treatment on occasion will claim that locking up someone for their own good is an ethical and even loving act.
Setting aside the complex legal and constitutional issues that make involuntary treatment wrong in principle, it is also wrong as a therapeutic approach. Coercion discourages empathy and is incompatible with a healing presence. As I describe in detail in Beyond Conflict (Breggin, 1992), whenever we coerce people, we lose interest in understanding them. Instead, we seek to get them to do what we want them to do, and resort to threats and ultimately to force as our means. At such times, we usually prefer not to see ourselves through the eyes of the people whose lives we control through force. We don’t want to experience their resentment.
Conversely, the people we coerce will tend to hide themselves from us. Thus patients on hospital wards will talk secretly among themselves about how to avoid getting more drugs, electroshock, or a lengthier enforced hospitalization. None of this will reach the ears of the doctors. Put simply, it’s not in the interest of the victims of coercion to share their intimate thoughts with their oppressors (Breggin, 1992).
Coercion of course can take many subtle forms. We can imply to our patients that they cannot get along without us or that they will suffer grievously if they reject our help. We can act as if our feelings are hurt in order to make our patients feel guilty about defying or rejecting us. To create a healing presence, we must respect the autonomy, separateness, and free will of our clients. We must seek always to empower our clients to make choices-even choices that we don’t agree with.
In the meantime, it’s up to us to take a stand on principle against the dehumanizing biological model and drugs. Our therapeutic relationships can be conducted from the perspective of maximizing the empathy and respect for individuality that we bring to our work. Through empathic self-transformation, we can learn to reach out to our fullest capacity to all of those who seek help from us.
Breggin, P. (1991). Toxic psychiatry: Why empathy, therapy and love must replace the drugs, electroshock and biochemical theories of the ‘new psychiatry’. New York: st. Martin’s Press.
Breggin, P. (1992). Beyond conflict: From self-help and psychotherapy to peace making. New York: St. Martin’s Press.
Breggin, P. (1997a). The heart of being helpful: Empathy and the creation of a healing presence. New York: Springer.
Breggin, P. (1997b). Psychotherapy in emotional crises without resort to psychiatric medications. The Humanistic Psychologist, 25,2- 14.
Breggin, P. (2001a). Talking back Ritalin (2nd ed.) Cambridge, MA: Perseus.
Breggin, P. (2001b). The antidepressant fact book. Cambridge, MA: Perseus.
Breggin, P. & Cohen, D. (1999). Your drug may be your problem: Why and how to stop taking psychiatric medications. Cambridge, MA: Perseus.
Leff, J. & Berkowitz, R. (1996). Working with the families of schizophrenic patients. In P. Breggin & E. M. Stern (Eds.), Psycho-Social approaches to deeply disturbed persons (pp. 185-211). New York: Haworth Press.