Converging through difference: A case of empathic incongruence in treatment of an elderly woman with psychosis.

Contemporary person-centered psychotherapy often references empathy as a basic component of the therapeutic alliance and, thus, effective treatment, such that nascent clinicians study this basic skill early in training. However, the psychotherapy literature often presumes a collective agreement about how empathy manifests as a clinical tool, in the process institutionalizing the ideal of omnipresent alignment with a client, applied across populations of patients, regardless of their conditions, ages, and personal and cultural characteristics. Misalignments between clinicians and clients have the potential to bely broadly imagined ethics of empathy (and the notion of collective agreement about what it is) by demonstrating the ways tension, difference, and incongruence promote treatment. Through an autoethnography of a 12-month psychotherapy dyad with an elderly woman committed for treatment at a U.S. psychiatric hospital, we discuss how moments of incongruence between clinician and client expand conceptualizations of empathy in treatment of psychosis. Specifically, in this context, deployment of empathy-as-alignment becomes a fallacy of care, risking the effectiveness of treatment through impossible epistemological assumptions of and counterproductive joining with the client. As such, this transtheoretical discussion presents two types of incongruence in the dyad—developmental and subjective—as a backdrop for expressing empathy. This paper makes space for a theory of empathy as the practice of working in genuine and careful service of the client's psychology through acts of incongruence as much as alignment. • Definition of the construct of empathy lacks consensus in the clinical literature. • Clinicians may struggle struggle to empathize with the life stage and extra-realistic perceptions of elderly clients with psychosis. • Unavoidable elements of incongruence between clinician and client do not need to point to empathic failure. • Use of incongruence through metaphor and radical genuineness may build experiences of empathy and the therapeutic alliance. • Empathy may be delineated as both affective and cognitive affirmation and as shifts between congruence and incongruence. [ABSTRACT FROM AUTHOR]