Finding empathy in connection: managing emotional responses as clinicians

"When I work with that person, I feel on edge/ all over the place/ hurt/ confused/ frustrated". How often have we read, spoken or heard those kinds of words....? In relation to therapeutic or mental health care practice with people who might have been ‘given’ a diagnosis of ‘personality disorder’* and who, more often than not, have experienced persistent and severe developmental abuse, neglect or trauma, alongside iatrogenic harm….?

I feel cautious about writing and sharing this blog. What I am talking about here relates, ultimately, to deep personal pain people have experienced. I write to understand, to explore, to learn, to share and, I guess, to try and catalyse change. I am open to learning from the responses to this too. To be clear from the outset, my position is one of the right for everyone to have compassionate care. This is my central point. If there are times where that is not clearly in view, it is in my failure to articulate it well rather than a shifting of the message. 

I started this blog to help me to explore some of the issues involved here, that had been more present recently after reading accounts of people who were rightly deeply hurt by comments and practices they'd experienced. The idea that mental health professionals can feel things in relation to their work with others, which are difficult or uncomfortable or hard to manage, is not new. Clinicians have to bring themselves to work; otherwise they cannot form human connections, develop effective therapeutic relationships and cultivate compassion. With this humanness comes vulnerability too; scope to connect with the pain of self and others. There is a wealth of literature on these topics, with a range of terminology attached: transference and countertransference, enactments, rupture and repair, the therapeutic alliance literature etc. Although I am holding some of that in my mind as I explore, I won’t cite it diligently so as not to detract from the central ideas and reflections, nor to give my words any more air of credence than they deserve by virtue of their utility to myself and the reader. 

In my own reflective practice and clinical supervision, as I’m sure many others do, I sometimes share my own reactions, impressions, emotions, in response to my sessions with people I am working with. This allows me to reflect on the interactions and work I have done with people, to locate and acknowledge the experiences in myself. ‘I felt like I was treading on eggshells’, ‘It was as if I had done something wrong’, ‘I worried about what to say next’, ‘We couldn’t make sense of it together, when now it seems clear’, ‘I couldn’t get a word in edgeways’. Through supervisory discussion, use of the relational therapeutic model and a commitment to compassion, I work on piecing things together and reflecting on the bigger picture. I explore what is my own ‘stuff’, what is the person I am working with’s ‘stuff’- their history and current predicament- and what is happening in the context of our therapeutic relationship. I have to acknowledge what I am bringing - that particular day or as one of my own patterns - that is from my own history. For example, I am prone to be task focused and ‘do’ rather than feel, so if I find us moving quickly on from connecting with difficult emotions in sessions, I often have to own that. And, although I invite challenge and alternative viewpoints, I can be prone to feeling criticised when constructive feedback comes unsolicited, so I have to be alert for any defensiveness in myself and turn that into welcoming the opportunity to learn and adapt.  

As I navigate all this, where I tend to arrive, is at a connection between what I am experiencing and what the person has been through, been subjected to, deprived of or forced through. I empathise with their past and their present (both pain inflicted by others and iatrogenic harm). Of course I felt like I was treading on eggshells - this person has been silenced. Of course I felt like I have done something wrong – this person has been rejected and criticised and blamed. Of course I felt worried about what to say next – this person has lived in a world of threat. Of course I felt confused- this person has been gas-lighted or has memories that are muddled up by trauma. Of course I couldn’t get a word in edgeways- this person has had to fight to be heard. No wonder I felt uncomfortable or wound up or powerless; this person has been through horrendous pain inflicted by others, and through our dialogue and interaction, I am connecting with that. 

This process allows me to return to the therapeutic relationship with a deeper empathy for the person’s past and present circumstances and with ideas for how to manage these responses, in myself and with the person I am working with, in ways that are helpful and compassionate. It is my responsibility to do this, as the healthcare professional; it is my responsibility to ensure I always act with compassion and care and respect, no matter how I feel. 

Now, what if I ended this process where it started, with an awareness and sharing of how I felt; ‘attacked, silenced, anxious, messed up’ as a result of my work. It connects me with my emotional response to the interaction, but that’s all. What if I shared that with colleagues. What if I wrote it in papers and books and articles, what if I spoke it on social media and podcasts. What if I used that emotional response to give that person a label. What if I used that emotional response to change what care I offered, to step back or withdraw or deny or refuse….? What if I disconnected from my own and other’s humanity in order to manage that response?  In doing that I would be repeating the cycles of abuse, neglect and trauma. I would be playing out the same stories, the same patterns, the same injustice. 

Without connecting to the root of experiences with compassion and a shared sense of humanity, any process- even reflective practice- risks being corrupted by and perpetuating harm. So why, sometimes, does this happen? Maybe because staff are not given the spaces, support and relational understanding to fulfil this process. Maybe because we focus on technique and strategy rather than relational skills in selection and training. Maybe because we have not acknowledged the insidious nature of power and how that subverts attempts to be helpful. Maybe because we have not committed to rooting our practice in human rights above all else. Maybe because we let intellectualisation distract us from connection. Maybe because we don’t feel safe or equipped enough to engage with ourselves and our work in this way. Maybe because we do not invite outsider or lived experience perspectives into our practice sufficiently.  

And so, I don’t believe we should abandon or reject the idea of staff reflecting on their own emotional responses; it is essential - in formal therapy, in every therapeutic and care-based interaction. But we must couple this with a commitment to empathy, with the structures to facilitate the process in full, with a foundation of human rights based practice and focus on safety and compassion for all. What do we do if we are only able to do the first step? It’s where we need to start but on its own it might be damaging. What do we do when those we supervise or support are only able to do the first step? We recognise, we respond, we safeguard, we support them, gradually, to engage and connect and process and understand further, while ensuring their and our practice is safe. 

How do we balance the need for staff to be supported in this growth, with the absolute right of the person accessing services to experience compassionate care? What if someone is practicing therapy or providing therapeutic support without the ability or support to connect with their own internal world and connect with another with compassion? What if someone is practising therapy or providing therapeutic support who has not had the space to explore their own needs, patterns, pain and therefore carries this into the therapeutic relationship blindly?  Because- it doesn’t matter what technique or strategy or model we are implementing- if we cannot recognise, understand and manage our own responses in ways that enhance empathy and facilitate compassionate care rather than perpetuate harm, then the cycle will continue, as it has done in so many cases. 

Do we mandate personal therapy, alongside clinical supervision for all mental health staff? What if clinicians are not yet ready for personal therapy; should they be practising? What if the clinical supervision is facilitated by someone who also struggles to connect with their own humanity, vulnerability and  patterns? What if, without an ‘outsider’ perspective, both supervisor and supervisee are lost in the same traps together? For me, this brings us to a crux of sorts; how to recognise the humanity and vulnerability in both clinicians and those using services. How to support staff to flex in and out of the varying positions of empathic connection, boundaried and compassionate guidance and care, vulnerable reflection. How to foster a sense of mutuality? How to reorganise systems and services collectively so that they serve the helpful cycles rather than perpetuate pain? 

This is why I focus on how to cultivate, protect and utilise the therapeutic relationship, and all it entails, in my own practice. This is why I research and learn about it from others. This is why I am so passionate about supporting staff with this; because it’s essential. Managed badly and it perpetuates harm, managed well and it can bring healing and resolution. 

*I do not personally agree with the utility or validity of this term or find the conceptualisation of the diagnosis helpful. I recognise that there are varying views, experiences and preferences. I use the term here so that the issues I explore can be seen alongside other texts, offering differing viewpoints, that use this term. I believe in the persistent, painful and complex effects of trauma, abuse and iatrogenic harm on people’s lives. Maybe in using this term here, I am falling into the trap of perpetuating its use.....? I wanted to offer a response/ challenge/ elaboration to some other texts and reflections. The process I describe applies generally to my clinical practice, often with those who have experienced complex, relational trauma. I do not actively use or endorse the term or conceptualisation in my own practice.