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Promoting an Empathic Dialectic for Therapeutic Change: An Integrative Review


This integrative review is focused on a formulation of therapeutic empathy. We describe the “empathic dialectic” as therapists’ capacity to emotionally resonate with patients’ internal states, such as during ruptures, and to coregulate their own and the patients’ states through mentalization. The first aim was to provide a theoretical framework for the empathic dialectic, by summarizing background literature on the empathic process, intersubjectivity, rupture repair, relational psychoanalysis, and attachment. The second aim was to conduct an integrative review of peer-reviewed articles published between the years of 2016 and 2021. After conducting a review of 28 articles, we sought to identify (1) research that supports the existence of an empathic dialectic, (2) evidence that therapists’ attachment influences the empathic dialectic, and (3) implications of the empathic dialectic for training and supervision. Results pointed to the central role of therapists’ attachment security in the empathic dialectic, and the negative repercussions of therapists’ insecurity when mentalization is underdeveloped. Results also highlighted the role of supervision as a means of enhancing trainees’ self-awareness of their attachment, and its impact on the alliance. As the American Psychological Association embraces a clinical competencies model in its accreditation of clinical psychology doctoral programs, the importance of attaining an integrative understanding of therapeutic empathy has become increasingly imperative. To this end, we conclude by promoting the empathic dialectic as a key clinical competency, and providing further recommendations for training and supervision.

Since different theoretical orientations often cannot account for variations in treatment outcomes, researchers remain focused on identifying “common factors” that affect therapeutic change, trans-theoretically (Finsrud et al., 2021). A large and still growing body of research has identified the relationship between therapist and patient as one such common factor (Wampold & Imel, 2015). An essential part of this relationship is the “working alliance,” which has been defined in many ways, and most commonly by the patient and therapist’s bond and their agreement on tasks and goals (Horvath, 2018). The therapists’ capacity to develop and manage the alliance is thought to depend upon their navigation of negative shifts, or ruptures, in the alliance (Safran et al., 2011). Research suggests therapists’ interpersonal skills play a key role in this process (Anderson et al., 2016a, 2016b), likely because they enable therapists to resolve ruptures (Anderson & Perlman, 2019). Of these skills, meta-analyses indicate that therapeutic empathy enhances both alliance and outcome (Elliott et al., 2018; Nienhuis et al., 2018). Some researchers even suggest its impact supersedes that of the alliance (Wampold & Imel, 2015).

Despite the importance of therapeutic empathy, there is confusion about what exactly it is, given the myriad ways it has been described and measured (McIntyre & Samstag, 2020). For the purpose of effective training and supervision, a focused discussion on therapeutic empathy is warranted. Our first aim is to provide a framework for this integrative review by summarizing the theories that contribute to definitions of therapeutic empathy as an “empathic dialectic,” marked by therapists’ capacity to emotionally resonate with patients’ painful internal states and coregulate such states. We start with Rogers’ (1975) person-centered approach, and move into a discussion of intersubjectivity (Benjamin, 2018), rupture repair (Muran & Eubanks, 2020), relational psychoanalysis (Buechler, 2008), and attachment theory (Siegel, 2020).

As the field of clinical psychology increasingly acknowledges the importance of the therapeutic relationship, Marmarosh (2015) predicted there would be an enhanced focus on the therapists’ characteristics that intersect with this relationship. In line with this prediction, our second aim is to reference our theoretical framework, and conduct an integrative review focused on the impact of therapists’ attachment status. We present findings which suggest therapists’ attachment is the developmental foundation which underlies the empathic dialectic (Degnan et al., 2016; Palmieri et al., 2018; Talia et al., 2020), and we provide recommendations for training and supervision based on these findings.

Theories in Support of Therapeutic Empathy as an Empathic Dialectic

The Empathic Process Theory

Although many empathy theorists preceded him, Rogers (1959) was one of the first to describe therapeutic empathy as a multidimensional process. His work, thus, foreshadowed the subsequent literature on therapeutic empathy. Per Rogers (1959) early definition, therapeutic empathy is a state that entails that the therapist accurately perceive the patient’s hurt and pleasure, and simultaneous recognize that they are perceiving such states in the patient as if they were hurt or pleased. This ‘as if’ condition differentiated Rogers’ theory from others at the time (e.g., Kohut, 1959), as Rogers believed that therapists must acknowledge the separation between themselves and their patients, otherwise, they fall into the trap of over-identification.

As Rogers’ theory evolved, he gained more of an appreciation for the patient’s immediate experience. According to a principle coined by Gendlin (1996), called “focusing,” there is a continual flow of experience that is always unfolding within a person. While one can tune into their own experience to discover its meanings, Gendlin (1996) believed that focusing could also be done with a therapist. Through the process, the therapist offers terms (e.g., anger), which the patient can check against their internal experience. As the patient’s felt sense becomes clear, new associations come to their mind, and their experience shifts. Rogers (1975) incorporated focusing into his process-oriented definition of empathy, emphasizing the importance of therapists’ sensitivity, and capacity to continually check the accuracy of their sensings. Rogers pointed to the challenge of this seemingly simple, egalitarian, process: it requires the therapist to set themselves aside, and be secure enough to know they will not get lost in the world of another; that they can return to their own whenever they’d like.

Rogers’ exquisite focus on the therapist’s mind is crucial to highlight, because it had radical transtheoretical implications. These ideas would eventually inform a number of integrative approaches. At the time, they influenced the field of psychoanalysis; precipitating a shift away from one-person approaches focused on the patient’s mind, and toward two-person intersubjective approaches that consider the minds of both patient and therapist.

Intersubjective Theory

Turning to intersubjective theory, we find an interactive definition of the mind, which considers the therapist as another subject in the relationship with the client-subject (Benjamin, 2018). Benjamin (2018) explicitly highlights aspects of the therapist’s internal state that are vital to the therapeutic process, emphasizing the “shared intersubjective third” that is unique to each dyad, and consists of the therapist’s awareness of two separate thirds: “the rhythmic third” and “the differentiating third.” The rhythmic third is the therapist’s awareness of the unique rhythm that unfolds between themselves and each of their patients. The degree by which a therapist is aware of this third depends on their capacity to accept and surrender to this rhythm. Conversely, the differentiating third refers to the therapist’s awareness of the inherent separation between themselves and their patients. The extent to which the therapist is aware of this third depends on their capacity to see the patient’s intentions as different than their own, and to symbolize aspects of the patient’s thoughts and feelings without having to experience them first-hand. Benjamin (2018) maintains the therapist must be aware of both the rhythmic and differentiating thirds, if they are to genuinely recognize the patient as a subject in their own right. Similar to Rogers’ (1959) early emphasis on therapists’ emotional sensitivity and emotional separation as pre-requisites to accurate empathy, Benjamin’s (2018) rhythmic and differentiating thirds are, thus, pre-requisites to mutual recognition.

Yet, Benjamin’s (2018) theory also deepens Rogers’ theory, by demonstrating how empathy fails when therapists are unable to maintain mutual recognition, and hold both thirds in mind. Namely, during a breakdown into the two-ness of enactment, therapists encounter a forced choice: dominate or be dominated. In this “doer/done to intersubjective mode,” there is no third option, no space for mutual recognition. Held in place by conflictual energies, when a therapist acts out one side of this polarity, they unconsciously identify with the other. Without the capacity to recognize the patient in their own right, a therapist cannot empathize with them either. Therefore, by describing breakdowns in mutual recognition—and, by consequence, therapeutic empathy—intersubjective theory adds dimension to Rogers’ (1975) view of the empathic process. Considering the inevitability of breakdowns, the therapist’s capacity to re-establish mutual recognition would be a key addition to any theory of the empathic process. Rupture repair theory adds greatly to this discussion, as it employs a transtheoretical empirically-based framework to prescribe the elements of communication required for repair.

Rupture Repair Theory

A rupture has been defined by the therapist’s struggle to establish a therapeutic alliance, or by negative shifts in the alliance once it’s been established; they are inevitable, and manifest as the patient or therapist’s withdrawal or confrontation (Safran & Muran, 2000). In describing how ruptures emerge, Safran and Muran (2000) proposed that anytime therapist or patient asserts a need for agency or communion, it is possible their need will be incompatible with the others. The resultant shifts correspond to breakdowns in recognition, which the therapist repairs through a series of empirically validated steps (Safran et al., 2011). The therapist’s capacity to effectively navigate these rupture repair cycles is critical, and has been linked to positive outcomes (Eubanks et al., 2018; for a case example, see Samstag & Muran, 2019).

Speaking to the therapist’s stance during the rupture repair cycle, Safran and Muran (2000) recommend they position themselves as a “participant observer,” shifting their focus from the alliance and, mindfully, toward the moment-by-moment intersubjective negotiations between themselves and their patients. Through mentalization, the therapist then gains an understanding of their own and their patient’s internal states. Once they are no longer identified with states underlying the original rupture, they can apply their emerging awareness to work with the patient moving forward. By “meta-communicating,” communicating about their communication, the therapist coregulates their own and their patient’s states (Muran & Eubanks, 2020).

Relational Psychoanalytic Theory

Similar to rupture repair theorists, relational psychoanalytic theorists believe the therapists’ self-regulation is a vital, and they explicitly apply it to the empathic process. Ehrenberg (2010) posited that the intrapsychic boundary between what is formulated and unformulated in the therapist’s mind, during self-reflection, has a reciprocal impact on their awareness of the interpersonal boundary between therapist and patient. Therefore, if the therapist cannot attend to changes within themselves through self-reflection, they are unlikely to attend to changes in the interaction between their self and their patient: “the intimate edge.” Buechler (2008) applied this emphasis on interpersonal boundaries to her theory of the empathic process. For Buechler (2008), therapist’s engagement in this process includes “feeling into” (i.e., emotionally resonating with) the patient’s experience, by recalling memories from their own life that elicited similar reactions, and then “feeling out of” (i.e., recovering from) that experience. This can be difficult, given the sometimes-necessarily-tenuous boundary that can exist between self and the other, and Buechler (2008) points to therapists’ mentalization as a means of regaining balance. Indeed, mentalization has also been described as a balancing capacity by Fonagy and colleagues (Luyten et al., 2020); its origins can be found in attachment theory.

Attachment Theory

According to attachment theory, individual differences in attachment behavioral patterns emerge in response to variations in primary caregivers’ sensitivity and availability (Bretherton, 2013). Children raised by sensitive and available caregivers tend to develop “secure attachment” in adulthood; those raised by rejecting caregivers develop “dismissing attachment”; and, those raised by unpredictable caregivers develop “preoccupied attachment” (Siegel, 2020). While these categories represent organized forms of attachment, there exists a negligible population for whom no organized pattern is ever established. An even smaller number, despite having received insensitive parenting, go onto develop “earned security” (Roisman et al., 2002).

As demonstrated by the Adult Attachment Interview (AAI; Main & Goldwyn, 1983), individual differences in adult attachment reflect variations in one’s responses to questions about one’s experiences with primary caregivers. Secure adults respond collaboratively and coherently to AAI questions; whereas, preoccupied adults become absorbed in their responses to AAI questions, and dismissive adults respond avoidantly. These responses reflect variations in “attentional flexibility” when the attachment system is activated (Main, 2000). Attachment security facilitates empathy by acting as a buffer to hurt feelings (Cassidy et al., 2018), while insecurity is marked by immature defenses that do not confer such protection (Prunas et al., 2019). The resultant deficits in mentalization breed imbalances (Luyten et al., 2020); in a sample of medical students, preoccupied participants were more likely to emotionally resonate with other’s internal states, when compared to dismissing participants who were less likely to do so (Ardenghi et al., 2020). With balanced mentalizing, secure individuals can alternatively resonate with another’s experience and regulate their arousal; this, in turn, facilitates coregulation (Porges, 2011). Through this empathic process, therapists achieve an ever-deepening understanding of the patient’s social-emotional world (Buechler, 2008).

In light of aforementioned theories on the empathic process (Rogers, 1975), intersubjectivity (Benjamin, 2018), rupture repair (Muran & Eubanks, 2020), relational psychoanalysis (Buechler, 2008), and attachment (Siegel, 2020), we propose an integrated definition of therapeutic empathy as an “empathic dialectic,” which includes the therapist (1) flexibly resonating with the patient’s painful states, such as during ruptures, and (2) effectively coregulating their own and their patient’s internal states. Research has implicitly captured the empathic dialectic (Safran et al., 2011), and identified security as an underpinning of empathy (Cassidy et al., 2018). Yet, for the purpose of training and supervision, it seems crucial to review contemporary literature explicitly related to the empathic dialectic.


In order to investigate the empathic dialectic, an integrative review of empirical and theoretical literature was conducted. Eligibility criteria included articles that were peer-reviewed, written in the English language, and published between the years of 2016 and 2021. Articles that centered on therapists practicing individual talk therapy with adults were selected, while other modalities (e.g., group therapy, dance/movement therapy) were excluded. Dissertations, validation studies, and case studies were excluded. Literature that focused on non-therapists, patients, or therapists working with certain patient populations (i.e., those with a particular DSM-V diagnosis) was also excluded. Three research questions were asked: (1) do contemporary research methods support the existence of an empathic dialectic? (2) is there evidence that therapist attachment plays a role in the empathic dialectic? (3) assuming the existence of empathic dialectic, what are its implications for training and supervision?

On June 21, 2021, the first author conducted the final literature search utilizing the PsycINFO database. Three consecutive searches were conducted with the following terms: therapist AND attachment AND empathy; therapist AND attachment AND alliance; and, therapist AND attachment AND training. These searches rendered a total of 147 peer-reviewed articles. Of these articles, 12 were identified as duplicates, and another 100 were excluded due to not having met eligibility criteria. After reviewing the full-text of the remaining 35 articles, ten were excluded, while three were retrieved from the reference sections. Ultimately, a total of 28 peer-reviewed articles were referenced in the current integrative review (Fig. 1).

Fig. 1

Flow diagram of integrative search


Empirical Support for the Empathic Dialectic

Of the 28 articles included in this integrative review, five pertained to the concept of empathic dialectic as a formulation of therapeutic empathy. Some of the studies appeared to suggest that researchers tend to utilize unidimensional measures of empathy, whether they are referring to therapeutic empathy as a unidimensional trait or process (McIntyre et al., 2019; Watson et al., 2020). Yet, research is emerging which suggests therapeutic empathy may be best measured by examining the physiology that is shared between therapist and patient (Kleinbub et al., 2019). “Physiological synchronization,” marked by changes in the patient and therapist’s physiology, is measured by the dyads’ cardiac activity and skin conductance (Kleinbub et al., 2020a). Kleinbub et al. (2020a) cite research that has taken a macrolevel approach to this concept, examining whether the dyads’ physiology largely rises and falls together, and finding that synchronization is linked to better outcomes and therapeutic empathy.

Kleinbub et al. (2020a) contend that it’s also possible to examine therapeutic empathy at a nuanced level, examining moments when participants experience similar reactions, when there is turn-taking, or when participants exit synchronous states entirely. In line with the empathic dialectic, Kleinbub et al. (2020a) suggest that therapists’ coregulation—marked by their ability to flexibly enter and exit synchronous states—is a component of therapeutic relationships that best support change. After demonstrating the importance of synchronization in therapeutic empathy, Kleinbub et al. (2020b) attribute therapists’ effectiveness to their capacity for the “unconscious interpersonal regulation” which is inherent to their attachment status.

Empirical Support for the Role of Attachment in the Empathic Dialectic

A review of 19 studies was conducted in order to assess the extent to which therapist attachment facilitates the empathic dialectic. A systematic review by Steel et al. (2018) suggests therapists’ attachment impacts their capacity for empathy, their countertransference, and their client-rated evaluations. Research focused on the impact of therapist attachment on the alliance, however, is more complicated. There is evidence that the interaction between the patient and therapist’s attachment status may be more important than the therapists alone (O’Connor et al., 2019). Lingiardi et al. (2018) similarly suggest that therapist security impacts treatment outcome, but only through its interaction with other variables, like patient pathology and the alliance. Systematic reviews indicate that suggest therapists’ security has more of an impact on the alliance with severely disturbed patients (Bucci et al., 2016; Degnan et al., 2016). In such treatments, therapists’ reactions are likely to activate their attachment system, and their capacity to regain their balance through mentalization is all the more important (Slade & Holmes, 2019). Perhaps for this reason, Cologon et al. (2017) suggest that—although therapist security can play a compensatory role—mentalization is what drives therapists’ effectiveness.

A group of researchers have more explicitly connected therapists’ attachment to the empathic dialectic, through their use of innovative methods. For example, Palmieri et al. (2018) primed security in 50 therapist-participants, and examined the degree to which their physiology (i.e., skin conductance and cardiac activity) rises and falls with their patients. As a parallel to the affective synchrony seen among secure mother-infant dyads (Siegel, 2020), their findings demonstrated that therapists’ security facilitates physiological synchronization with patients; which, again, has been linked to therapeutic empathy (Kleinbub et al., 2020a). After administering their novel Therapist Attunement Scale (TASc) and the AAI to a sample of 50 therapists, Talia et al. (2020) then found that secure therapists are more emotionally attuned to their patients, when compared to their insecure therapists. Others suggest that rupture resolution is facilitated by the patient’s perception of the therapist as an attachment figure (Ben David-Sela et al., 2020), which is likely also enhanced by the therapist’s security. Indeed, there is evidence that security facilitates openness to rupture resolution (Miller-Bottome et al., 2018) and successful repair according to patients and therapists alike (Miller-Bottome et al., 2019). This research suggests that, due to its capacity to foster physiological synchronization and attunement, therapists’ security enhances one’s capacity to navigate the empathic dialectic.

Since roughly thirty percent of therapists report insecure attachment (Fleischman & Shorey, 2016), it is also imperative to consider the impact of therapist insecurity on the empathic dialectic. Fuertes et al. (2019) suggests therapist insecurity negatively impacts their ratings of patients’ improvement, from the beginning of therapy onward. In addition, a study cited in Degnan et al. (2016) suggested that both dismissing and preoccupied therapists rate the alliance lower than their secure counterparts (Black et al., 2005). Despite these findings, the majority of reviewed studies suggest that preoccupied therapists struggle most markedly to maintain strong therapeutic alliances (Bucci et al., 2016; Degnan et al., 2016). It may be that dismissing therapists’ low levels of emotional resonance inhibits them from developing the alliance, while preoccupied therapists’ high emotional resonance leads to dysregulation, which interferes with their capacity to manage the alliance. There is some evidence that supports this idea.

For example, Talbot et al. (2019) found that preoccupied therapists struggle to detect alliance ruptures, compared to their secure and dismissing counterparts. Using a dimensional measure of attachment, Kivlighan Jr. and Marmarosh (2018) also found that preoccupied trainees’ alliance ratings tend to be more dissimilar to their patients’ ratings. Researchers explained these results by suggesting preoccupied trainees are most likely to attend to what they’d like their interactions to be, rather than what they actually are. Earlier studies cited in these papers suggest that this disconnect culminates with preoccupied therapists experiencing more tension (Marmarosh et al., 2015) and less empathy in response to ruptures (Rubino et al., 2000). Either way, insecurity inhibits attunement, and the capacity to navigate the empathic dialectic.

The Implications of the Empathic Dialectic for Training

In order to understand the implications of the empathic dialectic for training and supervision, a review of four studies was conducted. This literature suggested that supervisors can best facilitate trainees’ professional development, if they are aware the trainees’ attachment status, and can help them identify how it contributes to the psychotherapy process (e.g., countertransference reactions, and the ruptures that follow) (Talia et al., 2019). Mammen (2020) suggests this could be accomplished is through supervision that’s attachment and trauma-based, and parallels the parent–child relationship. One study similarly suggests the supervisory alliance can act as a buffer to the trainees’ vicarious traumatization, enhancing trainees’ therapeutic empathy (DelTosta et al., 2019). There is evidence that this is most helpful to preoccupied trainees, who experience a greater sense of self efficacy in supervision, compared to their dismissing counterparts (Mesrie et al., 2018). Relational supervision that is mindful of these individual differences, and brings about high degrees of trainees’ self-awareness, stands the best chance of helping trainees engage in the empathic dialectic.

Summary and Discussion

The first aim of this paper was to provide a theoretical basis for our integrative review, by reviewing theories on the empathic process (Rogers, 1975), intersubjectivity (Benjamin, 2018), rupture–repair (Muran & Eubanks, 2020), relational psychoanalysis (Buechler, 2008) and attachment (Siegel, 2020). We argued that therapists’ attachment security is the foundation upon which they engage in the empathic dialectic. This dialectic involves resonating with patients’ painful states, such as during ruptures, and coregulating these states. Akin to the rupture repair cycle, the empathic dialectic is most impactful when it contradicts patients’ past relational trauma. By navigating the empathic dialectic in these challenging moments, therapists co-create corrective social-emotional experiences with (and for) their patients—an outcome many consider the epitome of therapeutic work (Buechler, 2008; Safran & Muran, 2000).

The second aim of this paper was to conduct an integrative review of the literature, based upon this empathic dialectic theoretical framework. Specifically, we examined contemporary literature on the relationships between therapist attachment and empathy, alliance, and training. Findings highlighted emerging measures of physiological synchronization, which have been linked to therapeutic outcome and empathy, and require the therapists’ unconscious interpersonal regulation (Kleinbub et al., 2020a, 2020b). Indeed, therapists’ secure attachment tends to improve the alliance in treatments with more disturbed patients (Degnan et al., 2016), and has been found to enhance their attunement (Talia et al., 2020) and physiological synchronization (Palmieri et al., 2018). In turn, therapists’ subsequent capacity to serve as attachment figures enables them to better resolve alliance ruptures (Ben David-Sela et al., 2020). This review clearly demonstrates the centrality of therapists’ security to the empathic dialectic.

Given security facilitates one’s capacity to navigate the empathic dialectic, it would make sense that its absence inhibits it. Insecure attachment breeds imbalanced mentalization (Luyten et al., 2020); dismissing therapists are unlikely to emotionally resonate with patients’ distress, while preoccupied therapists resonate (Ardenghi et al., 2020), perhaps to a degree that leads to dysregulation (Slade & Holmes, 2019). These imbalances inhibit therapists’ capacity to coregulate patients’ distress, which negatively impacts the alliance in different ways. While dismissing therapists may be unable to establish an alliance (Black et al., 2005), a number of studies suggest that preoccupied therapists are unable to effectively address alliance ruptures (Marmarosh et al., 2015; Rubino et al., 2000; Talbot et al., 2019). Without the capacity to physiologically synchronize with the patients’ internal states, and especially their pain, insecure therapists are relatively unable to navigate the empathic dialectic.

The empathic dialectic has several implications for supervision and training. A topic of debate has been whether supervisors should address therapist trainees’ psychological issues, or if they are best addressed in personal therapy. Relational supervision that includes both teaching and treating (Sarnat, 2012) would best facilitate trainees’ understanding of their own attachment history, and its influence on their work with patients (Talia et al., 2019). The resultant self-awareness is what countless theorists have highlighted as a crucial component of a therapists’ effectiveness (Benjamin, 2018; Rogers, 1975; Safran & Muran, 2000; Slade & Holmes, 2019). Certainly, it plays into the empathic dialectic, equipping one with the attunement to resonate with patients’ internal states and the mentalization to effectively co-regulate such states.

Limitations and Future Research

Our review has provided support for the existence of an empathic dialectic, though there were gaps in the literature, which future research could address. Given several of the aforementioned studies were conducted with therapist trainees (Kivlighan Jr. & Marmarosh, 2018; Rubino et al., 2000), they could not examine the conditions under which preoccupied therapists show improvement. A number of studies suggest that patients matched with therapists whose attachment orientations complement their own (e.g., preoccupied therapists with dismissing patients) tend to benefit from treatment more than patients matched with therapists who have the same attachment (Degnan et al., 2016). Complementary attachment patterns are helpful, because they highlight the interpersonal boundary between the therapist and patient, demarcating the intra-psychic boundary between what is formulated and unformulated in the therapist’s own mind (Ehrenberg, 2010). This, in turn, facilitates therapists’ mentalization.

Future research could work toward further validating the empathic dialectic, and explore the extent to which training and personal therapy also serve to enhance therapists’ self-regulation. This may be accomplished through the use of cutting-edge measures of therapists’ attunement (Talia et al., 2020), physiological synchronization (Kleinbub et al., 2019) and coregulation (Kleinbub et al., 2020a, 2020b). These studies could serve to illuminate the microprocesses that unfold within the context of the empathic dialectic, and provide a fuller understanding of the impact of therapists’ attachment, training, and personal therapy.


Our first recommendation is that the empathic dialectic be added to the current list of clinical competencies (Fouad et al., 2009), as it offers an integrated definition of therapeutic empathy. This is crucial, as trainees’ attachment can diminish their ability to navigate the empathic dialectic in ways that are largely outside their awareness. Consistent with the principles of beneficence and non-maleficence outlined by the APA’s Code of Ethics (2017, Principle A), educators have a responsibility to address these issues early on. If trainees’ difficulties meeting this benchmark cannot be addressed by relational supervision (Sarnat, 2012), which is mindful of the trainees’ attachment and trauma history (Mammen, 2020), a recent review has indicated that personal therapy also enhances empathic accuracy (Moe & Thimm, 2020). We argue that psychodynamic therapy would be most effective, due to the unconscious processes involved in the empathic dialectic, and evidence that psychodynamic approaches promote mentalization among those for whom it is lacking (Levy et al., 2006).


We believe the empathic dialectic is a crucial clinical competency to enhance in trainees, especially those who enter the field without strong attachment-based capacities, such as mentalization and coregulation. A focus on the empathic dialectic would also be helpful in the context of the current pandemic, when stress levels are high, and therapists must work harder to achieve and maintain a sense of security. To further identify factors that facilitate or inhibit the empathic dialectic, future research should continue to conduct studies on therapists’ attachment, utilizing cutting-edge measures of attunement, coregulation, and rupture resolution.


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The authors have no relevant financial or non-financial interests to disclose.

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SLM initially had the idea for this paper and wrote the first draft, as it formed the theoretical basis of her dissertation, which she completed as a doctoral student in LIU’s Clinical Psychology Doctoral Program in January of 2017. LWS supervised this work, critically revised every draft, and made significant modifications to the main idea.

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Correspondence to Shannon L. McIntyre.

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McIntyre, S.L., Samstag, L.W. Promoting an Empathic Dialectic for Therapeutic Change: An Integrative Review. J Contemp Psychother (2021).

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  • Therapeutic empathy
  • Empathic dialectic
  • Empathic process
  • Therapist attachment
  • Rupture–repair cycle