Supervised by: Graham Reid, MSc. Graham studied Psychology and Neuroscience at both undergraduate and master’s level and he is now completing a PhD at the University of Oxford in Psychiatry. He is fascinated by human behaviour, thinking, and feeling. His particular area of intertest is in how our brains and behaviour changes as we age, including diseases such as dementia.

Abstract

Empathy is a powerful indicator in the development and treatment of certain psychological disorders. In this paper, we aim to investigate the effects of individual empathetic capacity in the context of different disorders. We focus on empathy in Borderline Personality disorder, Autism, Bipolar disorder, Post-Traumatic Stress disorder (PTSD), Obsessive-Compulsive disorder (OCD), and Psychopathy. We found that individual empathetic levels are correlated with the development of the disorder as well as provide avenues for treatment. The relationships between an individual and their therapist, and those supporting someone afflicted with a psychological disorder all revolve around empathy.

Introduction

Empathy is a multifaceted concept that involves interpreting and understanding others’ emotions, as well as the ability to enter another’s shoes. The capacity to empathise is critical in forming strong relationships, fostering emotional awareness, and for societal functioning as a whole. Principally there are considered to be three different kinds of empathy: affective, cognitive, and motivational. Cognitive empathy is described as the ability to understand and imagine how others may be feeling. Affective empathy is feeling the emotion as if you were in the other person’s position, and motivational empathy involves understanding what one is feeling and the inclination to help them as a way of showing that you understand how they feel. It is possible to feel all these types of empathy at once or to only feel one at a time. However, people with psychological disorders often react differently towards feeling empathetic. 

Empathy has different roles in the development of disorders. Disorders developed from the lack of empathy  are reflected in patients showing antisocial behaviours, due to being unable to feel the emotions of others or incapable of understanding other people’s state of mind. However, patients with some disorders such as PTSD tend to lose empathy following the  development of PTSD, and in a few disorders, it is unclear whether the loss of empathy occurs before or after the development of the psychological disorder. 

This essay will explore roles of empathy in the development and treatment specific to Borderline Personality Disorder, Autism Spectrum Disorder, Bipolar Disorder, Post-Traumatic Stress Disorder, Obsessive-Compulsive Disorder, and Psychopathy. In addition, we will discuss the importance of the relationship between a therapist and patient in providing treatment for these disorders.

Empathy allows people to be more emotionally intelligent and to contribute positively towards society. Empathy in itself is able to help us understand and appreciate the world around us, and though it cannot be “taught”, creating an environment that is caring and nurturing, while demonstrating empathy towards others, is what fosters its development. 

Borderline Personality Disorder

People with Borderline Personality disorder (BPD) tend to have a blurry sense of self, which manifests as enhanced emotional empathy and low cognitive empathy. This means that they have an excessive awareness of others’ emotions, but lack of awareness for their own, causing emotional instability (Salgado, et al., 2020).

People with BPD tend to do something known as splitting, which acts as a defence mechanism where they separate positive and negative emotions. This frays their sense of identity and the way they perceive the identities of others even more dramatically, resulting in a loss of self (Kreisman,et al., 1989). Having a sense of self is very important for empathy because it allows a better understanding of Theory of Mind (where one can infer someone’s state of mind, by using things they already know), and Mentalisation (where one can be introspective). A sense of self also promotes the idea that one is separate from other people. However people with BPD tend to have impaired emotional regulation due to hyper activation of prefrontal regions. This causes them to be unable to effectively execute any of these and causes them to become less emotionally regulated. 

BPD is one of the many psychological mysteries. Most doctors do not have a specific cure for it and cannot place a thumb on how it comes about. The disorder also coexists with, and borders on, other mental illnesses: depression, anxiety, bipolar (manic-depressive) disorder, schizophrenia, somatization disorder (hypochondriasis), dissociative identity disorder (multiple personality), attention deficit/hyperactivity disorder (ADHD), post-traumatic stress disorder, alcoholism, drug abuse (including nicotine dependence), eating disorders, phobias, obsessive-compulsive disorder, hysteria, sociopathy, and other personality disorders (Kreisman, et al., 1989). It then becomes hard for anyone to determine how indeed this disorder develops and where empathy is involved.

The prefrontal cortex (PFC) is a large area of the cortical mantle covering the anterior portions of the frontal lobe. Regions of the PFC are bidirectionally connected to the limbic system and it is thought that the brain coordinates and regulates cognitive-emotional processes via these pathways (Kovner, et al., 2019). This includes emotional regulation, cognition, Theory of Mind, abstraction and working memory. As this part of the brain grows it becomes more complex and more interconnected within its different divisions. Its complexity is what is thought to underlie the thoughts, emotions and behaviours we have, but they are also what makes us vulnerable to developing maladaptive responses and psychopathology, which interfere with our ability to adapt to new things. The PFC is the site of higher subjective emotional experience and personality. Studies show that when it is affected personality changes can occur (Harlow, 1998). Empathy depends on the ability to (1) hold emotional information in mind (i.e. a function that requires intact working memory ability), (2) switch attention or concentration between one’s own emotional state and the emotional state of the object (i.e. a function that requires cognitive flexibility), and (3) orchestrate an appropriate emotional response that makes use of the information held in mind about one’s own emotional state and the emotional state of the other person (i.e. a process that likely involves emotion regulation and self monitoring ability). Data from neuroimaging (fMRI and PET), electrophysiological (ERP) and lesion studies support the idea that the prefrontal cortex is an important node in the circuitry that supports the ability to feel what someone else is feeling (Light, et al., 2009). This study also shows that the lateral prefrontal cortex plays a role in representing the affect of someone else. A meta-analysis of brain volume, which comprised 281 people with BPD and 293 healthy controls, and 19 imaging studies noted left amygdala and right hippocampus grey volume decreases in individuals with BPD (Pier,et al., 2016). However, The study also includes people with BPD who were prescribed psychoactive drugs, which attenuate limbic activity. Therefore, the results could be inaccurate. The study also shows that people with more impulsive and aggressive types of BPD have less activity in their frontal cortex, which governs memory and judgement. This evidence could lead us to believe that empathy may indeed be harder for people with more aggressive BPD. The question then becomes if one cannot easily be empathetic then will we be able to help them?

The study continues to state that Dialectical Behavioural Therapy (DBT) was found to attenuate amygdala hyperactivity at baseline, which correlated with changes in a measure of emotion regulation and increased use of emotion regulation strategies. This sort of therapy is supposed to allow the patient to become more mindful of themselves and find ways to manage their emotions. One may argue that a level of empathy is required for this treatment. Empathy tends to be able to connect two people as they both acknowledge that they are focusing on one thing; this connects them and makes the one being empathised feel seen. Sarah Snow argues in “Empathy” that when one person empathises with another, they both feel sad about the same thing and are feeling the same emotion simultaneously. She makes clear that when you feel an emotion for someone such as “feeling sorry Person A has lost their father”, Person B is sympathising because in this case they are sad that Person A is sad, not because they themselves are sad. She goes on to state that because these two emotions, empathy and sympathy, are very similar and can sometimes be a part of the same affective experience, the focus of the sympathiser is what makes it either empathy or sympathy. 

This leads me to believe that empathy could be a key to treatment for a psychological illness such as BPD,especially since many BPD cases, approximately 30%-90% of cases stem from neglect, abuse and childhood trauma (Bozzatello, et al., 2021). All children require empathy and a safe environment whilst growing up, and therapy with empathy may be able to give the patient guidance that they were not able to get as a child, and help them discover a sense of self that may help them better manage their emotions. In fact, therapy may be a more useful treatment for disorders like BPD, compared to mood stabilisers and antipsychotics, which are not as healthy as therapy as you could easily become dependent on them. 

Obsessive-Compulsive Disorder

There is a universal misconception regarding Obsessive-Compulsive Disorder (OCD), which  undermines the severity of it as a chronic disorder (Kim, 2021). Media has long reduced OCD to cleanliness and the need for habitual order, whereas in actuality OCD is a taxing condition that interferes with the day to day life of those afflicted with it. OCD is generally defined as intrusive thoughts that lead one to carry out repetitive behaviours, often to lessen unwanted thoughts. It is broken down into two parts: the first is the pattern of worries and thoughts, otherwise described as obsessions, and the second is compulsions, which are repeated activities conducted in an attempt to control the obsessions (Mind, 2019). Oftentimes, obsessions and compulsions are wholly unrelated and feel irrational to even the ones experiencing them. Compulsions manifest differently in everyone, but consistently operate on grounds of relieving anxiety and the idea of preventing bad things from happening (Eddy et al., 2021). This idea that one’s thoughts can impact events in the external world, otherwise known as magical thinking, is key to understanding OCD, its impact, development, and treatment.

Measuring levels of empathy in people with OCD is challenging, as there are various factors that can influence how one demonstrates it. Countless studies on the empathetic capacity of individuals with OCD have been conducted, yet most begin by asserting that there is nowhere near a consensus as to the correlation of OCD symptoms and the extent to which a person can feel empathy. In regards to OCD, it is crucial to understand two particular components of empathy: experience-sharing and mentalizing. Data from empirical studies indicates a trend that those with OCD display higher empathy in their ability to share the feelings of others and put themselves in their shoes (Salazar Kämpf et al., 2021). This idea of sharing the emotional experience of another is referred to as experience-sharing, while mentalizing refers to the capacity to understand and explicitly consider the internal states of others. A study from 2016 found that people with OCD display a deficit in mentalizing systems and in their ability to interpret the behaviour of themselves and others (Pino et al., 2016). The capacity to understand others by ascribing mental states to them (Theory of Mind) involves executive functioning, namely working memory, inhibition, and self-control. Therefore, a lack of executive functioning contributes to the impairment of mentalizing. This likely explains why people with OCD cannot just “stop” the obsessive thoughts. By examining empathy levels in those afflicted with OCD, it appears that having a deficit in cognitive empathy impacts the severity of the disorder.

As mentioned, OCD impacts the way a person exhibits empathy, but it is uncertain whether particular types of empathy affect the likelihood of developing the disorder in the first place. Empathy develops from a very young age and is influenced by an individual’s stimuli, crowd, and environmental enrichment. Environmental enrichment refers to one’s surroundings – both physical and social – and how they influence a person’s behaviour, growth, and emotional reactions. There is little research explicitly on empathy and its role in the development of OCD, but Canadian-American psychologist Albert Bandura explored the idea of social learning and how humans model after the people they are surrounded by. Bandura’s studies found that as children observe their models they unknowingly emulate their attitudes and mannerisms (Bandura as seen in Mcleod, 2011). Considering that, if a person grew up with a model that has poor self-directed empathy and less social interaction, it is likely they will also suffer from these same issues. This could result in them meeting fewer people who model healthy skills in anxiety management, which makes them more prone to developing OCD (Pino et al., 2016). As the relationship between empathy and OCD is still being explored, it is apparent that environmental enrichment and a lack in self-directed and cognitive empathy impairs social functioning, increasing the likelihood of OCD.

Research has consistently shown that empathy is instrumental in helping people with varying psychological disorders. For this reason, empathy is expected to have a similar effect in the treatment of OCD. People with OCD often feel alienated due to the disorder’s misrepresentation and because it is incredibly difficult for them to express what they’re thinking or feeling. Supporting individuals with OCD through empathetic measures is the simplest and most effective treatment, as it allows them to feel heard, while acting as a model for the empathy they lack. Fundamental features of utilising empathy as treatment for mental illnesses are unconditional positive regard and therapeutic empathy. Unconditional positive regard involves showing complete acceptance of a person by putting personal beliefs aside and therapeutic empathy is the concept of communicating an understanding and acting on it (Howick et al., 2018). A therapist must be able to switch from experience sharing and the role of observer in order to truly support a patient without breeding more anxiety (Book, 1988). And so, the presence of empathy – inside and outside of therapy – for those with OCD, is crucial in reducing intrusive thoughts and allowing individuals to detach their worth from those thoughts.

Autism

Autism, also known as Autism Spectrum Disorder (ASD), is a neurodevelopmental disorder that affects communication, behaviour, and social interaction. It is called a “spectrum” disorder because it presents itself in a wide range of symptoms and severity levels, varying from person to person. Autism affects individuals throughout their lives, but its specific manifestations can change over time. Common characteristics of autism may include impairments in social communication and interaction; people with autism may have difficulty understanding and using verbal and nonverbal communication cues, such as facial expressions, gestures, and body language. They may struggle with making and maintaining eye contact and can have challenges in forming and maintaining relationships. Moreover, they exhibit repetitive behaviours and restricted interests, displaying intense focus towards specific topics, often to the exclusion of other activities or interests. Many people with autism may have heightened sensitivity to sensory stimuli, such as lights, sounds, textures, and smells, which can lead to overstimulation or discomfort. Individuals with autism may also find it challenging to cope with changes in routines or unexpected situations, preferring predictability and sameness.Autism is a neurological condition, not a mental illness or a result of poor parenting. Its causes are not entirely understood, but research suggests that genetic factors play a significant role.

The perception that autistic individuals lack empathy is not entirely correct. Studies indicate that a lack of mutual understanding between autistic and non-autistic people is also at play; it is not solely due to the autistic person’s cognitive thoughts. This is referred to as the double empathy problem. In the context of autism, the double empathy problem occurs when neurotypical people struggle to empathise with autistic people and vice versa (Milton, 2012).

In the article entitled“Autistic peer-to-peer information transfer is highly effective” published by the SAGE journal, the authors explored the double empathy problem by studying how information is exchanged between the different neurotypes. The study found that autistic and non-autistic empathy levels did not differ significantly (Crompton et al., 2020). Although people often perceive autistic individuals to have less empathy, it is not true as autistic individuals are shown to be very empathetic towards other autistic people. 

Cognitive empathy can be taught to children with autism, according to older research published in the Journal of Applied Behavioral Analysis. While these techniques can be used to teach empathetic behaviour, they cannot teach empathy at the emotional level. Schrandt et al. (2009) conducted a study with the purpose of teaching empathetic responses to 4 children with autism. Instructors presented vignettes with dolls and puppets demonstrating various types of affect and used prompt delay, modelling, manual prompts, behavioural rehearsals, and reinforcement to teach participants to perform empathy responses. Increases in empathetic responding occurred systematically with the introduction of treatment across all participants and response categories. Furthermore, responding generalised from training to non training probe stimuli for all participants. Generalisation occurred from dolls and puppets to actual people in a non training setting for 2 participants. Generalisation was observed initially to the non training people and setting for the other participants, but responding subsequently decreased to baseline levels. Introduction of treatment in this setting produced rapid acquisition of target skills.

Bipolar Disorder

Bipolar Disorder is a mental health condition characterised by extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). These mood shifts can be severe and disruptive, significantly impacting a person’s thoughts, behaviours, and daily functioning.

There are two main types of Bipolar Disorder. Bipolar I Disorder involves periods of intense mania, where the individual experiences elevated or irritable mood and impulsive behaviours. Depressive episodes, characterised by deep sadness, loss of interest, changes in sleep and appetite, and thoughts of suicide, also occur in Bipolar I Disorder.

Bipolar II Disorder involves milder episodes of mania, known as hypomania, and depressive episodes. Hypomania is less severe than mania but still involves increased energy and impulsivity. Bipolar II Disorder is typically characterised by more extended periods of depression.

Symptoms of bipolar disorder can vary from person to person, and the frequency and duration of mood episodes can differ as well. Some individuals may experience rapid cycling, where they switch between manic and depressive states within a short period.

The exact cause of bipolar disorder is not fully understood, but it likely involves a combination of genetic, biological, and environmental factors. It tends to run in families, suggesting a genetic component.

Impaired Theory of Mind (cognitive empathy) may account for the aberrant social behaviours exhibited by those with Bipolar Disorder. A study investigating the Theory of Mind differences between euthymic people with Bipolar Disorder and those without Bipolar Disorder found that euthymic patients with Bipolar Disorder struggle with advanced ToM tasks (Bora et al., 2005). The tests used by Bora et al. (2005) have been used before as measures of Theory of Mind, so we know that they are an accurate measure. However, there is not a clear distinction between Theory of Mind and cognitive empathy, as they may have different definitions but psychologists tend to use them interchangeably, so this may not be an accurate measure of cognitive empathy at all. 

There is increased interest in understanding how positive psychological features affect the outcomes of medical illnesses (Galvez et al., 2011). This topic is rarely studied and has never been done in the context of Bipolar Disorder. Certain psychological traits that are often seen as beneficial – morally or socially – may develop from the experience of having this affective disorder. They examined the impact of these positive psychological traits in the lives of people with Bipolar Disorder based on the little published studies available. These include: spirituality, empathy, creativity, realism, and resilience. They found 81 articles that involve descriptions of positive psychological characteristics of Bipolar Disorder. They found evidence for enhancement of the five above positive psychological traits in individuals with Bipolar Disorder. People with Bipolar Disorder may therefore be more likely to have enhanced empathy because of the experience they have with a mental disorder. 

Understanding empathy in the context of Bipolar Disorder allows us to treat it better. Certain drugs prescribed to those with Bipolar Disorder may increase empathy in those with the disorder. In one study, people with Bipolar Disorder who were taking particular antipsychotic and other drugs for the treatment of their Bipolar Disorder understood the pain of other people better and therefore had increased empathy. This was not true of anti-anxiety medication. The researchers think this may be because anti-anxiety medication works by suppressing people’s emotions. Since their emotional responses are being repressed and empathy is an emotional response,  empathetic feelings are also repressed and empathy cannot be felt as strongly.

Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder results from experiencing or witnessing a scary, distressing, or dangerous event, and can affect an individual’s ability to empathise (Farrow et al., 2007). PTSD symptoms look different in everyone, but are generally characterised by hypervigilance, intense distress, disconnection from self, feeling emotionally numb, and reliving aspects of the traumatic event (Mind, 2021). Numerous studies have shown that people suffering from PTSD exhibit lower emotional empathy, but no disturbances in their cognitive empathy levels. This impairment in emotional empathy could be a coping mechanism to stop them from being overwhelmed with stress, or can be the outcome of deficits in the structural and functional regions of their brain. People with PTSD regularly demonstrate higher levels of distress, or hypervigilance, compared to control groups. This can lead to irregularities in the anterior cingulate cortex and ventromedial prefrontal cortex, which are the regions of the brain responsible for stress regulation and fear response (Mazza et al., 2015). Moreover, there is decreased activation in the parts of the brain in charge of explicit emotional empathy and working memory. It is clear Post-Traumatic Stress Disorder plays a large part in reduced empathy levels, making it difficult for people with PTSD to feel connected to themselves and share the emotional states of others.

In addition to being a result of Post-Traumatic Stress Disorder, it is hypothesised that lower empathetic capacity and social cognition are also major risk factors for PTSD. The development of PTSD is a process concerning an individual’s inability to recover long term from a traumatic experience. Heightened PTSD symptoms are displayed immediately after the event occurs, but the majority of people begin to recover naturally in the next three or four months. Those who do not recover during this period make up the six to ten percent of individuals who are then properly diagnosed with chronic PTSD (Stevens et al., 2018). What determines how susceptible someone is to the development of PTSD is still unknown, but research has presented a trend that those with PTSD have a deficit in social cognition. Social functioning or cognition are processes that make up how an individual interacts with their environment, with its major aspects being perception, emotions, and behavioural responses. A common symptom of PTSD that correlates with lower social functioning is emotional numbing, or the tendency to avoid particular feelings and memories. This leads to lack of trust and difficulties with expressing and accepting affection. All of this attaches to their preexisting hindrance in social cognition and manifests in the inability to move past the initial traumatic event. Considering the cognitive behavioural dimension of empathy, an initial failure to recover is more likely to appear in an individual with lower social functioning, due to impaired interactions between themselves and others.

Empathy in all dimensions is fundamental to therapy for Post-Traumatic Stress Disorder, as it allows therapists to support and engage with someone who feels intensely alone with all their scary thoughts and memories. Trauma work requires the immersion of the therapist so they can truly understand a patient’s feelings as well as their way of processing everything. While empathic attunement is crucial for healing, good clinical therapists must have a balance between being empathetic and also being effective in their treatment (Wilson et al., 2004). Without this balance, they will be unable to decode and interpret their patients’ traumatic stories and how they manifest in specific reactions and behaviours (trauma specific transference). Not only is outward empathy necessary from the therapist, but they must also have a large capacity of self-directed empathy, considering how taxing listening to stories of trauma can be. A lack of self-directed empathy in a therapist can lead to heightened distress levels which, at its extreme, can lead to vicarious traumatization. Therefore, empathy is essential for both parties involved, whether that’s for treatment itself or to aid the caregivers in supporting those struggling with PTSD.

Psychopathy 

Psychopathy is a disorder associated with a deficiency in emotional response, lack of affective empathy, hyporeactivity to fear, impulsivity, and manipulativeness, which results  in increased prospect to conduct antisocial and criminal behaviour (Anderson & Kiehl, 2014; Hare, 1996). The media have viewed psychopaths as deranged and apparent murderers, which in reality is not true as they can look like everyone and even be charming. The constructs of psychopathy are emotional dysfunction and impulsive-antisocial characteristics (Anderson & Kiehl, 2014). A researcher made a model which indicates the deficits in emotional regulation results from dysfunction of the amygdala, which mainly functions for generating emotional response to fearful stimuli to ensure survival (Blair, 2007; Šimić et al., 2021). Furthermore, studies show reduced activity in the prefrontal cortex of psychopaths compared to non-psychopaths. The prefrontal cortex plays a crucial role in inhibiting impulsive behaviour and affecting decision making, and patterns of prefrontal cortex dysfunction associated with Psychopathy emerge from a young age (Meyers et al., 1992). Both genetic and environmental factors can influence the outcome of Psychopathy and can be distributed into primary factors and secondary factors. Primary Psychopathy is genetically influenced and the clients tend to have lower anxiety, low reactivity to stress, a tendency towards committing fundamental crimes and a deficient behavioural inhibition system (Anderson & Kiehl, 2014). On the other hand, secondary Psychopathy is caused by indirect factors such as trauma exposure. The person tends to be more anxious, have a higher degree of emotional volatility, and commit more radical and impulsive crimes (Anderson & Kiehl, 2014). Secondary Psychopathy is related to the term ‘sociopathy’ which is the unofficial term for Antisocial Personality Disorder. There are arguments about how the two types are distinct, for example, by their behaviour, anxiety level, basis of reactivity and arousal to stress or individual’s criminal activity.

Psychopathy is characterised by behavioural, cognitive, and affective problems that go beyond the lack of empathy alone. However, empathy plays a very important role in Psychopathy development. Impaired amygdala activity results in lack of affective empathy, an incapability to feel others emotion or feel remorse, and insensitivity to the emotional states of others. With the presence of cognitive empathy or Theory of Mind, psychopaths retain emotional recognition and an intellectual understanding that the emotion can affect other people’s behaviour without sensing the emotion (Blair, 2007).The “Zipper Model of Empathy”, considers the combination of affective empathy and cognitive empathy as a build up of empathic behaviour (Rijnders et al., 2021). The model can be understood by visualising one side of someone’s teeth as cognitive processing and the opposite side as emotional processing, with zipping up meaning to approach mature empathy or expressing empathetic behaviour through affective and cognitive empathy (Rijnders et al., 2021). The model explains that although psychopaths have the ability to correctly interpret others emotional expression (functional cognitive teeth), they are unable to process emotional contagion (destruction of the emotional teeth). Therefore, psychopaths are unable to zip up to a significant extent and do not show empathetic behaviour, and instead follow their self-centred life goals through manipulation and deception. Furthermore, published research finds that people with psychopathic traits (self-reported third degree Psychopathy) do experience the feeling of regret during an experience of a gambling task but could not use those experienced emotions to adjust their behaviour in future experiences of the task. The research suggested that antisocial behaviour emerges from difficulty in using the emotion for a better outcome rather than the inability to feel others’ emotions (Baskin-Sommers et al., 2016). However, with participant requirements of third degree self-reported Psychopathy, participants are not officially diagnosed, which may mean that the findings cannot be generalised to psychopath patients. According to the “Zipper model of empathy”, deficit in affective empathy plays an important role in development of Psychopathy with normal functioning in cognitive empathy. In contrast, motivational factors may heighten the chance of emotional processing, allowing Psychopaths to empathise. Moreover, Baskin-Sommers’ research suggests antisocial behaviour is the result of difficulty in adapting future behaviour following regret. 

Empathy may not be necessary in therapeutic treatment with psychopaths as Psychopathy is a chronic and untreatable disorder (Larsen, 2019). Therapeutic intervention and rehabilitation used to treat Psychopathy in adults were found to have an ineffective or adverse impact on the patient, even though some strategies using social reasoning techniques were seen as effective when practised in younger age (Anderson & Kiehl, 2014). The ineffectiveness of treatment is due to the fact that psychopaths do not see themselves as abnormal and have an extreme sense of self-worth and superiority. Therefore, this makes it unlikely that psychopaths seek treatment or have the motivation to change (Anderson & Kiehl, 2014). They rather use the treatment sessions with the therapist to manipulate and exploit the therapist’s vulnerabilities (Galloway & Brodsky, 2003). Identifying incarcerated psychopaths and using behavioural control strategies are better in reducing Psychopathy, in comparison to empathy, temperament, or other cognitive interventions typically utilised in conventional therapeutic settings (Anderson & Kiehl, 2014).

Importance of the Relationship Between a Therapist and Patient

The simple definition of empathy is to put oneself in another’s shoes or understand the emotional state of others. This requires many empathetic dimensions, including affective, cognitive, behavioural, and motivational empathy, to fully understand and respond to others (Riess, 2017). However, clinical empathy is defined as the act of acknowledging the emotional state of the other without experiencing that state oneself (Halpern, 2003). It is a combination of predominantly cognitive understanding and concerns of the perspectives of another person with a capacity to communicate this understanding (Hojat, 2009). One study has aimed to define clinical empathy from the perspective of healthcare workers and patients from a multicultural setting (Tan et al., 2021). They concluded that clinical empathy refers to trust and rapport between healthcare workers and patients resulting from imaginative, affective, and cognitive processes, and the expression of empathy through behaviour and good communication skills which convey genuine concern (Tan et al., 2021). Therefore, clinical empathy has many definitions to be taken into account and still varies in different fields.

Clinical empathy or the empathetic relationship between the therapist and patient is very important as it is the key to improving the patient’s mental health and well-being, along with finding the right treatment. Moreover, mental healthcare workers have to sense the patient’s emotion with active listening and maintain the engagement as it conveys trust and self-acknowledgement (Awdish & Berry, 2017). Studies have shown that empathy leads to fewer disputes, more satisfaction, improved treatment compliance and outcomes as patients feel heard and understood (James, 2023). The caring connection between health professionals and their patients enhances collaboration in designing personalised treatment plans, resulting in increased patient satisfaction with the therapeutic process and positively enhancing the level of care and compliance with the therapeutic course (Moudatsou et al., 2020). Moudatsou et al.’s (2020) research was conducted in the form of a meta-analysis, which includes studies published in English and Greek. This could result in translation errors, biases in the inclusion of particular studies, and the exclusion of relevant studies in other languages or from different geographic regions. These weaknesses could lead to an inability to generalise findings to other cultures. In addition, although we could clearly see the importance of empathy, a great percentage of health professionals seem to find it a challenge to adopt the model of empathetic communication in their practice (Moudatsou et al., 2020). As such, the empathetic relationship between the therapist and patient is important as it leads to positive treatment compliance and patient outcomes. Despite this, there are difficulties in the generalizability of the findings and in the adoption of empathetic communication in practice.

Therapists should maintain appropriate boundaries between themselves and the patients. There are wide debates about the connotations of clinical empathy. One argument developed by physicians in the 1950s suggests that clinical empathy should be based on detached reasoning. This means that physicians will do what needs to be done without feeling grief, regret, or other difficult emotions, in order to treat the patient from an objective point of view and maintain the balance of emotional involvement (Halpern, 2003). Although the therapist still has to show quality caring and empathy, they should maintain emotional distance and avoid personal involvement as overinvolvement is not necessary to have a good therapeutic relationship (Galloway & Brodsky, 2003). A therapist’s overinvolvement may result from not setting clear boundaries with the client,  turning therapeutic relationships into a more personal or friendship relationship, frustration by the lack of progress of the clients, and taking on the clients’ problems as their own (Galloway & Brodsky, 2003). Evidence shows, using measures of affective empathy and cognitive empathy, that high levels of emotional empathy are correlated with poor mental health in caregivers to those with dementia and neurodivergent diseases (Hua et al., 2021). Similarly, the professional therapist that is overly involved can lead to loss of objectivity, countertransference, and job burnout. This can involve feelings of hopelessness and difficulties in working effectively, as they might internalise lack of progress to be the result of personal failure (Galloway & Brodsky, 2003; Stamm, 2010). Therapeutic detachment or distancing of therapists from clients is beneficial to both the therapist and the client. This can be done by altering the mindset about therapy and the clients, and changing the value of empathy which lies as a foundation of the therapy (Galloway & Brodsky, 2003). It is also crucial to have therapeutic detachment from clients that are unable to interpret empathetic behaviours or lack fundamental relationship skills. For example, a client with a personality disorder might demonstrate remarkable proficiency in testing a therapist’s patience and defences, adeptly identifying and exploiting their vulnerabilities (Galloway & Brodsky, 2003).

However, there are counter-arguments, which suggest that compassion fatigue does not come from overinvolvement of emotional empathy or having too much empathy with a person in distress. Some studies show that regulated emotions can prevent social workers from feeling overwhelmed (Nilsson, 2014). Therefore, boundaries and therapeutic detachment between the therapist and the patients are necessary to maintain a healthy therapeutic relationship. Emotional regulation is also important, to prevent therapists from engaging in countertransference.

Discussion

Empathy is crucial to the development of psychological disorders, but the way in which it presents itself within these disorders varies. In our exploration of several different disorders we found that in some there is a deficit in particular kinds of empathy, which is seen in PTSD and Borderline Personality Disorder. Lower empathy is best understood as a risk factor in some disorders, while in other disorders like Autism, there is no apparent difference in empathetic capacity. Moreover, our research found that people with Bipolar Disorder exhibit higher empathy levels overall. Lastly we investigated OCD, whose relationship with empathy is still widely debated, as it is unclear whether a lack of certain kinds of empathy manifests before or after the development of OCD.

Empathy is also important in treating and aiding those afflicted with different psychological disorders. Our findings show that empathy is beneficial in allowing people to feel understood and accepted, but a balance between empathy and effective treatment is necessary to facilitate healing. Empathy in the treatment of a disorder is a two-way process, as self-directed empathy is just as important as having an empathetic therapist.

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