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Blackwell Science, LtdOxford, UKNUPNursing Philosophy1466-7681Blackwell Publishing Ltd 200571310Original articleCloseness and Distance in the Nurse-Patient Relation Sylvia

M. Määttä

Original article
Closeness and distance in the nurse-patient relation.
The relevance of Edith Stein’s concept of empathy
Sylvia M. Määttä PhD RN
The School of Health Sciences, University College of Borås, Borås, Sweden

Abstract This paper emanates from the concept of empathy as understood by the
German philosopher Edith Stein. It begins by highlighting different
interpretations of empathy. According to the German philosopher Mar-
tin Buber, empathy cannot be achieved as an act of will. In contrast, the
psychologist Carl Rogers believes that empathy is identical with dia-
logue and is the outcome of a cognitive act of active listening. The
empathy concept of Edith Stein, philosopher and follower of Edmund
Husserl’s phenomenology, goes beyond these conflicting views and
offers a more complex interpretation, with relevance for both health-
care and nursing education. When studying Stein’s three-level model of
empathy, a field of tension between perspectives of closeness and dis-
tance becomes apparent. The paper concludes by suggesting Stein’s
model of empathy as a strategy to overcome the tension and meet the
demands of empathy.

Keywords: Edith Stein, phenomenology, empathy, closeness and


distance.

empathetic approach is to be expressed. The word


Introduction empathy originally comes from Greek and means
In the Swedish health service today, the importance strong feeling or passion, and at the beginning of the
of having an empathetic approach is stressed in vari- 19th century, when it began to be used more widely,
ous policies, care programmes, and in the wording of it stood for a spontaneous ability to suffer with other
goals. There is, however, no clear indication of what sentient beings. Is it this spontaneous, compassionate
is meant by empathy, or any description of how the ability that the nursing staff is expected to possess? Is
it an ability that is assumed that nursing staff will
acquire during their professional training? In that
Correspondence: Sylvia M. Määttä, Senior Lecturer and Head case, is there a good reason to fear that the concept
of Research, The School of Health Sciences, University College of empathy is in the process of being ‘technified’? The
of Borås, SE-501 90 Borås, Sweden. Tel.: +46 33 435 40 00; fax: meaning ascribed to the concept of empathy will
+46 33 435 40 03; e-mail: Sylvia.maatta@hb.se determine what possibilities there are for developing

© Blackwell Publishing Ltd 2006 Nursing Philosophy, 7, pp. 3–10 3


4 Sylvia M. Määttä

the empathetic ability and how such a developmental The complexity of the concept is reflected in the
process can best be supported (Holm, 2001). Below number of uses and subdivisions found in scientific
follows a study of what perceptions may support the literature. Affective and cognitive empathy refer to
various statements. emotional and intellectual understanding, respec-
tively. Predictive empathy refers to the ability to pre-
dict reactions, while situational empathy denotes the
Edith Stein – some biographical notes ability of the empathizer to perceive and react to the
other person’s feelings in the situation in question.
The German phenomenologist Edith Stein’s (1891–
Trait empathy is seen as a personal characteristic.
1942) understanding of the empathetic process may
Empathetic understanding and empathetic communi-
be a way of approaching questions of this type. For
cation or empathetic behaviour are other categories
those unfamiliar with Stein some biographical com-
of empathy that occur in this connection (Svärdson-
ments may be of interest. Stein belonged to the inner-
Morgell, 1994; Holm, 2001).
most circle around Edmund Husserl, who was also
The word empathy was introduced in English dic-
the supervisor for her thesis On the Problem of
tionaries for the first time in 1912, and in Sweden it
Empathy (Stein, 1916). It is worth observing that
has been used since the middle of the 1950s. In phi-
Stein, despite documented skill and success as a phe-
losophy it referred at first to the projection and imi-
nomenologist, educationalist, feminist, lecturer, and
tation of an object, but the meaning was widened to
author, and recommendation from such well known
encompass understanding of another person’s feel-
philosophers as Husserl and Heidegger, had little suc-
ings. The concept was later transferred to social and
cess in the German Academy (Baseheart, 1997). With
behavioural sciences and has played, among other
Baseheart one might suspect that a woman of Stein’s
things, a central role in psychology and psychoanalyt-
brilliance was marginalized because she was a woman
ical theory. Empathy won a prominent place in Carl
in addition to being Jewish.
Roger’s client-centred theory and was defined in his
In 1933 Stein joined the Carmelite Order in Hol-
early works as:
land and assumed the name of Sister Teresa Bene-
dicta of the Cross. With the occupation of Holland by . . . to perceive the internal frame of reference of another
the Nazis in 1940, the existence of the Catholic Jews with accuracy and with emotional components and mean-
became insecure. Edith Stein was arrested and exe- ings which pertain thereto as if one were the person, but
cuted in Auschwitz in 1942. She was canonized in 1987 without ever losing ‘as if’ condition. (Rogers, 1959, quoted
and one year later was nominated as one of the three from Wispé, 1987)
women patron saints of Europe.
In an interpretation of Roger’s empathy concept,
Davis (1990) draws attention to an intentional com-
ponent, which provides room for the possibility of
Empathy – a selected review of
learning an empathetic type of behaviour. Under the
the literature
influence of the German philosopher Martin Buber,
Stein’s major work aims to analyse the nature of Roger later came to tone down the intentional com-
empathy. Empathy comes from the Greek word ponent and instead see empathy as a way of being
‘empatheia’ and is made up of en, for in, and pathos, (Davis, 1990).
for feeling and suffering. In Ancient Greece, Aristotle At this time two different approaches to the epis-
and Plutarch used empathy with the meaning of being temological status of empathy crystallized, one that
influenced by. The modern meaning can be traced, mystified it and one that regarded it as banal and
however, to Germany and the end of the 19th century, commonplace (Holm, 2001). Advocates of the first
when they used ‘enfülhung’ in an aesthetic sense to approach thought that empathy involved an experi-
designate the process in which a person is absorbed ence of sudden understanding of the other person and
in contemplating a work of art (Wispé, 1987). often surrounded the phenomenon with an air of

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Closeness and Distance in the Nurse-Patient Relation 5

mysticism or a tendency towards the supernatural Stein’s view, empathy appears to be a more complex
(Holm, 2001). Among psychoanalysts and authors process.
such as Sullivan (1953), Olden (1953), Kohut (1977),
the empathetic process appears to be an extraordi- Stein’s concept of empathy
nary ability, a capacity quite apart from common sen-
To begin with, Stein (1916/1989) asserts that empathy
sory perceptions, to perceive another person’s frame
is about recognizing a lived experience. When we
of mind.
meet a person who is happy, suffers pain, or is griev-
Exponents of the opposite view wanted to demys-
ing, we can apprehend, see, and understand the other
tify empathy within the jurisdiction of scientific
person’s feelings, but we can never experience joy,
knowledge (Burlingham, 1967; Buie, 1981). The
pain, or grief as experienced by that person. Conse-
demystifying tendency now dominates, and empathy
quently, empathy is analogous to memory and imag-
has sometimes come to be used in the sense of a
ination, which are also experienced as a second-hand
friendly and helpful manner. In contrast to sympa-
experience. Stein proves this by analysing joy as fol-
thy, which in the English-speaking part of the world
lows:
contains estimation in the sense of liking someone
and agreeing with him or her, empathy has, however, The ‘I’ as the subject of the act of remembering, in this act
a neutral non-estimating meaning. Holm (2001) of representation, can look back at the past joy. Then the
points out that empathy has basically nothing to do past joy is the intentional object of the ‘I’, its subject being
with ‘liking’ someone. For example, says Holm, you with and in the ‘I’ of the past. Thus the present ‘I’ and the
can love someone without having an empathetic past ‘I’ face each other as subject and object. They do not
understanding of the person in question and have an coincide, though there is a consciousness of sameness.
empathetic understanding of someone you do not (Stein, 1916/1989, p. 8)
like.
In the situation in question, we can recollect the joy
The empathy concept was introduced to nursing
we ourselves experience in a similar situation. In
science in 1973 (Svärdson-Morgell, 1994), and has
Stein’s view therefore rejoicing with others means
had a place in the literature of psychiatric care.
that the joy of the empathizer is not original. We are
Empathy has been regarded as part of an ethical and
therefore limited to only having an awareness of the
philosophical foundation for caring (Olsen, 1991),
other’s lived experience and to the realization that we
and the capacity for empathy has been seen as some-
do not live them in person (Bello, 2003).
thing of a condition for nurses’ caring capacity – with-
out empathy care is considered as less effective
The three levels of empathy
(Layton, 1979).
A representative of the mystifying approach to Thus, the situation in which empathy arises is primor-
empathy well known in the field of nursing science is dial, but the content or meaning has another status
Buber (1955) who in Between Man and Man pointed (Baseheart, 1997). Having explained this, Stein shows
to dialogue as central to the relation between ‘you’ that empathy develops at three levels (Stein, 1989).
and ‘I’. A process of ‘crossing over’ may take place in At the first level we experience the other person as
a dialogue and is characterized by a person feeling an object.
very close or allied to the other person in a moment
When it arises before me all at once, it faces me as an object
of shared meaning. Empathy appears to be a special
(such as the sadness I ‘read’ in another’s face.). (Stein,
moment that takes place spontaneously and suddenly.
1916/1989, p. 10)
According to Buber, the moment of alliance cannot
be created but must be allowed. While Roger, as At this level our aim is to try and put ourselves in
shown earlier, thought that empathy arises as a result another’s place. By reading another’s facial expres-
of an act of will, Buber was of the opinion that empa- sion or other signs, we try to obtain an idea of that
thy is impossible to control (Davis, 1990). In Edith person’s emotional and mental state. This constitutes,

© Blackwell Publishing Ltd 2006 Nursing Philosophy, 7, pp. 3–10


6 Sylvia M. Määttä

according to Davis, a serious and intentional ambition


to enter into another’s feelings and an attempt to put Level 1
Self-tranposal
ourselves in another’s place (self-transposal) (Davis, Active listening
1990).
Stein believes that when we, at the second level,
attempt to clarify the other person’s emotional state,
something parallel to a personal experience occurs.
Level 2
Identification
In contrast to contemporary ideas about empathy as Merging
identification between object and subject in the
empathic process, she emphasizes that: ‘The subject
of the empathized experience, however, is not the
subject empathizing, but another’. (Stein, 1916/1989, Level 3
p 10). To be sure, the empathizer feels that he is Sympathy
Self-recovery
identifying with the other, but it is a question of
pseudo-identity or a parallel experience. They can
feel happy or sad about the same event, but that does Fig. 1 The process of empathy as described by Stein (from Davis, 1990).

not mean that they are filled with the same feeling
(Baseheart, 1997). The empathizer experiences the
other’s state of mind as if it were his or her own.
Discussion
This other subject is primordial although I do not experience
it as primordial. In my non-primordial experience I feel, as Stein’s conception of empathy may be understood as
it were, led by a primordial one not experienced by me a synthesis of the ideas of Rogers and Buber. The first
but still there, manifesting itself in my non-primordial moment in her model may be said to correspond to
experience. (author’s italics, Stein, 1916/1989, p. 11) Roger’s idea of the dialogue and the cognitive direc-
tion of will as a prerequisite for creating empathy. The
Davis (1990) describes this moment as being sur-
second step is more analogous with Buber’s view.
prised or overcome by a sudden feeling of actually
Like him, Stein sees empathy as something that unex-
being in the other person’s place. It is the character-
pectedly affects the empathizer in conversation with
istic of this feeling that an emotional understanding
another person.
replaces intellectual understanding, and that the
empathizer experiences a deeper understanding and
greater awareness. Davis (1990) writes that this Empathic tip
moment has come to be called a ‘shared moment of
As far as the health services and caring sciences are
meaning’ and is not infrequently described as analo-
concerned, the consequences of Stein’s conception of
gous to blow to the stomach. The connection and
empathy may appear to be something of a paradox.
sympathy with the other person is experienced so
In her view, it is in fact impossible to mediate empa-
keenly that a form of identification occurs, and for a
thy. However, as Davis points out, it is certainly pos-
moment it is as if they are one. In that moment we
sible to prepare oneself for the empathetic process
ignore the fact that we are two separate, independent
with the help of training.
individuals in an inter-human encounter.
At the third level, the feeling of affinity ceases and Empathy can be facilitated by teaching humanistic inter-
we become ourselves once more. Sympathizing with viewing skills, by helping students identify their prejudices
the sense of affinity that just arose, we stand side by and fears, and by developing students’ confidence in their
side with the other person again. The process can be therapeutic skills so that they can be free of anxiety and thus
described according to the model below (see Davis, more likely to establish a therapeutic presence for others.
1990, p. 709). (Fig. 1) (Davis, 1990, p. 711)

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Closeness and Distance in the Nurse-Patient Relation 7

On the other hand, Stein’s second level, with its


Closeness and distance
characteristic feeling of affinity, can neither be
learned nor taught. In the same way as it is impossible Stein’s three levels of empathy can be connected to
to train or learn to fall in love, we cannot train the research and literature on empathy, in which it is
capacity for experiencing the affinity that occurs in possible to distinguish a field of tension, characterized
the empathetic process. Following Stein’s concept, by the extremes of closeness and distance. Closeness
training for empathy during professional education to the patient and an intimate understanding of his or
will be ineffective and maybe also counterproductive her needs is stressed throughout the literature on the
as it can result in a superficial or technified under- subject of caring science. In contrast to the medical
standing of the empathic process. profession, which has, in their view, become perme-
Nevertheless, there may be approaches that, in ated by a technocratic and instrumental approach,
addition to Davis’ suggestions for training, promote nursing has characterized itself as expert in caring,
the susceptibility to unexpected affinity that distin- humanity, human kindness, and empathy (Holm,
guishes Stein’s second level. Wittgenstein offers 2001).
such a possibility in his Philosophical Investigations. Several newly published theses touch upon this
The way to learn humanity is teaching allied with pattern of closeness and distance. Caring conversa-
experience. tion is described in Fredriksson’s (1999) research
review as a continuum of connection and contact: ‘In
Can someone else be a man’s teacher in this? Certainly.
a connection the nurse is listening, using caring and
From time to time he gives him the right tip. – This is what
connective touch and is present as “being with” the
‘learning’ and ‘teaching’ are like here. – What one acquires
patient. In a contact, the nurse is hearing, using task
here is not a technique: one learns correct judgements.
orientated touch and is present as “being there” for
There are also rules, but they do not form a system, and
the patient’ (p. 1167). ‘In caring conversations’, writes
only experienced people can apply them right. Unlike
Fredriksson, ‘there is an interdependence of closeness
calculating-rules. (Wittgenstein, 1953/2001, p. 227)
and distance.’ Carlsson’s (2003) thesis is a thought-
According to Wittgenstein, the right tip can only be provoking study where the emphasis is laid on the
given by wise people with experience of life, people patients’ perspective. The study, which was conducted
that the health services have not always had the sense in a psychiatric context, shows the patients striving
to appreciate (Alsterdal, 2002). It could be rewarding for contact and close encounters. However, their
to follow Wittgenstein’s recommendation and find strivings risk being met with dismissive and evasive
ways of safeguarding the teachers so that they assist manoeuvres on the part of the staff. The staff avoid
us in the promotion of an empathic approach. coming close, claim the patients.
Even if an empathic approach can therefore only This conduct may possibly be the effect of the rec-
be learned and taught indirectly, teachers in both the ommendations and exhortations to keep your dis-
health service and the caring sciences can contribute tance, found both in the literature and among studies
to removing obstacles to the realization of the of the perceptions of hospital nurses. Many of them
empathic process. Anguish, worry, prejudices, lack of declare that in the patient–caregiver relationship they
self-confidence and self-reliance are some of the fac- can be overwhelmed by an uncontrollable closeness
tors that can limit the clinical staff and students’ pos- to the patient. A study of psychiatric nurses in a hos-
sibilities of experiencing empathy. Caring for patients, pital department provides a fresh example (Rusner,
students, and colleagues with sympathy, respect, and 2004). The phenomenon is described by the words
understanding, which reflect this process, can pave ‘losing yourself’, being swallowed up by the other’s
the way for the empathic process. Activities that feelings’, or ‘being broken down’.
increase self-awareness, active listening, respect, and The fear of losing yourself can, however, be dealt
tolerance for differences can facilitate the occurrence with by keeping a certain distance to the patient. In
of empathy. dictionaries it is defined as to have the ability to see

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8 Sylvia M. Määttä

things objectively ‘to avoid becoming too friendly nursing staff can help patients because they care, but
with someone or too closely involved in something’ ought not stand so close that they lack objectivity
(Longman’s Contemporary English Dictionary, (Alsterdal, 2002).
1987). In other words, to keep your distance means There may be several explanations why keeping
to remove yourself intellectually and emotionally. A your distance has come to play such a vital role in
method in creating or maintaining the supposedly nursing. One explanation that seems plausible is the
required distance is to have a professional attitude, psychoanalytical tradition with its classic aim of
exemplified in Rusner’s (2004) study where hospital objectivity. According to this, the one conducting
nurses state that they have deliberately made an treatment should keep a certain distance in analysing
effort to keep a distance in certain situations. In many and not show his or her own feelings, thereby facili-
cases, professionalism has probably also been tating the transfer that is required in the therapeutic
regarded as a way of establishing a necessary distance relation. This attitude appears to be particularly effec-
to patients. Behind such an opinion lies an implicit tive in a psychiatric care context, but may also have
assumption that it is amateurish or actually danger- been transferred to other specialities.
ous to come too close to patients. A certain distance Another important explanation may be found in
and objectivity are therefore signs and the result of a the striving towards professionalization that has char-
suitable approach. acterized many of the professional categories existing
Stein’s concept of empathy gives a strategy for in the health service in Sweden today. As part of this,
handling situations like those described in the study university-nursing education has tried to increase the
mentioned above. Following her explanation of academic connection in the past few decades. The
empathy nurses in situations where they experience reaction of the nursing body to this striving towards
a fear of being overwhelmed, instead of retreating to professionalization has been mixed. It has partly met
step one, could be encouraged to go through steps with criticism from nurses actively engaged in practi-
two and three. Knowledge of Stein’s second level of cal work, who among other things think that the
affinity and of the third level, where the feeling of increased amount of theoretical material in the nurs-
affinity ceases and we become ourselves once more, ing programme is to the detriment of the practical
offers an opportunity to meet the demands of parts of the education.
empathy. Their attitude is supported by some researchers,
In research and nursing literature the exhortation who believe that the striving towards academization
to keep your distance appears both implicitly and is often accompanied by distancing yourself from that
explicitly. The exhortation to keep our distance is which should be at the centre of nurses’ interest,
supported in an article by Reynolds & Austin namely the care of the individual human being. In
(2000), where it is shown that many caregivers several, now classic, studies of medical training and
express a fear of being overwhelmed by the patients’ nursing education, it has been shown that the stu-
emotional distress. Josefsson (1998) also believes dents’ empathetic ability tends to decrease during the
that it is absolutely necessary to keep a certain dis- training period (Carkhuff et al., 1968; Rezler, 1974).
tance in certain situations. You must be able to Later research shows that education can affect
‘switch off a little’ and so avoid being too concen- empathic ability in both a positive and a negative
trated on one’s own self. Nursing arouses strong direction. Multiplicities of courses of different lengths
feelings and demands great commitment from those aimed at developing empathic ability have been set
who practise it. In such a demanding profession, the up. It is, however, unclear whether the courses in
art of controlling yourself has sometimes been ethics and empathy training have any lasting effect
described as a virtue, and the ability to ‘keep cool’ is (Svärdson-Morgell, 1994). It is apparent though that
regarded as being a good attribute in nursing. Some- the attitude at the workplace is of the greatest signif-
times it is even thought that the ability to keep your icance and that the climate can both reinforce and
distance is a prerequisite for being able to help; suppress the effects of training.

© Blackwell Publishing Ltd 2006 Nursing Philosophy, 7, pp. 3–10


Closeness and Distance in the Nurse-Patient Relation 9

Although there is a substantial literature that same time, and simultaneously be prepared to show
stresses keeping your distance (for an overview, see appropriate feelings and make correct observations
Fredriksson, 1999), an important factor underlying of the patient’s condition.
the pattern of closeness and distance is the fact that
the nursing profession since the very beginning has
been characterized by distancing itself from the Conclusion
patient. In her Notes on Nursing, Florence Nightin-
An understanding of empathy following Stein’s
gale (1859/1952) imprinted the importance of careful
example may contribute to solving the tension
observations of the patient. To listen, see, and do are
between closeness and distance. According to her, the
indispensable to a nurse, writes Nightingale, but she
capacity to feel empathy cannot be taught. But Stein’s
does not mention anything about the importance of
concept of empathy is useful in another way. By refer-
having a heart in this connection. She writes that the
ring to Stein’s three levels, there is a way to go
skill of making correct observations is fundamental
through the whole empathic process and retaining
to the nurse, and anyone who is incapable of devel-
empathy without feeling submerged. According to
oping the habit of observation has in fact no place in
her second level of affinity the empathizer’s experi-
the profession.
ence of solidarity and intimacy is of a temporary
But if you cannot get the habit of observation one way or nature, and as such is generally neither a danger nor
the other, you had better give up being a nurse, for it is a threat to the ego. If nurse educators, clinical nurses,
not your calling, however, kind and anxious you may and supervisors are able to transmit this knowledge
be. (Nightingale, 1859/1952, p. 117) and give the courage and wisdom that allow nurses to
work though the second level of empathy, it may be
It is solely correct observations and the ability to
a strategy to overcome the fear of being over-
draw conclusions from one’s own and others’ obser-
whelmed. With knowledge about Stein’s second level
vations that save lives, she affirms. Even though she
of empathy as a part of the empathic process, we have
does not deny the importance of being able to sit
the ability to fully understand the patients’ life-world.
oneself down and understand the suffering and pain
Even if nurse educators and clinical nurses cannot
of the sick, the lasting impression that one gets of the
teach empathy, they can promote it in a secondary
message in Notes on Nursing is the emphasis on the
manner by removing barriers to offering empathy in
nurse’s ability to make careful observations. Follow-
clinical areas. One of the barriers to be considered,
ing the example of Nightingale, this rule has been
and perhaps dismantled as well, is the implicit and
transferred and has had repercussions both in clinical
explicit emphasis on an assumed risk, which exists as
practice and educational contexts.
an effective undercurrent in research and which is
However, in parallel with this there also exist
also expressed in clinical practice. A prerequisite for
implicit demands that the caregiver should feel and
this is to throw light on and make people aware of
also express adequate emotional reactions in the face
the conflicting demands for closeness and distance
of human suffering (De Raeve, 2002). Anything else
that exist in research and clinical practice. This
would point to emotional illiteracy or indicate that
requires further research.
the caregiver had not fully understood the implica-
tions of the situation. Linked with this is also a
request for the caregiver’s good ability to control her- References
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