EmpathyWorks Reaches 25,000 Views!

Since my First Post on EmpathyWorks on July 11, 2009, the blog has now reached 25,000 views!

My 79 posts on EmpathyWorks have covered a range of topics that reflect my interest in the role of relationship-building in health care and the impacts of empathy, compassion and patient engagement on patient experience and health outcomes.

Some posts have shared new research findings on the value of clinician empathy or have featured the wisdom of  Carl Rogers, Jodi Halpern, Brené Brown, Bernie Lown, Jessie Gruman, and many others who have made empathy, compassion or patient engagement a focus of their professional careers. 

Other EmpathyWorks posts have featured the experience of people, like myself, who are coping with the challenges of living with a chronic condition. When I first started blogging, several posts were linked to a column I wrote for MPNforum, an online magazine for people, or loved ones of people, with myeloproliferative neoplasms (MPNs). 

My heart goes out to my fellow "MPNers", who regularly demonstrate empathy and compassion for others in their posts on support sites on Facebook, such as Polycythemia Supportive Friends, and MPN Foum.

Since I have started blogging, I have found many inspiring and helpful blogs, websites and social media sites that address the topics of empathy, compassion and patient engagement. Links to these sites are available in the right column of the EmpathyWorks blog page. I particularly recommend Edwin Rutsch's Culture of Empathy website, a treasure trove of links, resources and commentary on empathy and its application to a wide range of topics, from health care to education to international relations.

You will also find links to organizations that focus on training clinicians in patient-centered communication skills, such as the American Academy on Communication in Healthcare (AACH) and the Institute for Healthcare Communication (IHC). IHC and AACH have played critical roles in my personal and professional development as an educator and advocate for patient-centered communication training.

Other organizations, such as Center for Advancing Health and the Institute for Patient and Family-Centered Care offer approaches and resources for advancing patient and family engagement at all levels of health care, from patient involvement in self-care and self-management to patient and family engagement in health care policy and health system redesign.

I hope you will continue to visit EmpathyWorks and that you will also share your reactions, insights and resources.

Enjoy!

Michael

Against Empathy?

Paul Bloom, Professor of Psychology and Cognitive Science at Yale University, recently wrote a thought provoking (and emotion provoking) post on Boston Review, entitled, Against Empathy?. He writes about the downside of relying on empathy, particularly "emotional empathy", as a guide to action. Emotional empathy, he argues, is biased, clouds our thinking, and promotes moral errors, which may have dire consequences. He writes:

"Empathy is biased; we are more prone to feel empathy for attractive people and for those who look like us or share our ethnic or national background. And empathy is narrow; it connects us to particular individuals, real or imagined, but is insensitive to numerical differences and statistical data." 

"Our policies are improved when we appreciate that a hundred deaths are worse than one, even if we know the name of the one, and when we acknowledge that the life of someone in a faraway country is worth as much as the life a neighbor, even if our emotions pull us in a different direction."

Too much emotional empathy, he notes, can also produce "empathetic exhaustion", particularly among those who try to apply empathy as a clinician or aid worker. Some may also experience "pathological altruism" and seek to heal or soothe others at their own expense.

Bloom concedes that it is appropriate for clinicians to respond to a patient's pain or angst, though he argues that too much clinician empathy will generate burnout and promote ineffective and even unwanted clinician behavior. 

Bloom contrasts emotional empathy with compassion, which he describes as "concern and love ....., and the desire and motivation to help" which need not involve mirroring or experiencing the anguish of others. Compassion, he argues, is a more effective, and more sustainable response.

Personally, as I read his blog, I found myself arguing against Bloom and for empathy. When I think about the application of empathy in clinical settings, I have trouble seeing the cognitive and emotional components of empathy as separate processes. 

Though there may be distinct neural pathways for these 2 aspects of empathy, clinical empathy is a therapeutic interactive process that integrates eliciting, exploring, listening, observing, perceiving, imagining AND responding to others' expressed emotions, values and needs. 

As I noted in a previous EmpathyWorks blog post, Brene Brown has described empathy as having 4 critical elements:

1. perspective taking
2. staying out of judgement
3. recognizing emotion; and
4. communicating what you notice

In another EmpathyWorks post, I cite others' conceptualization of clinical empathy as a relational process that includes both cognitive and emotional elements. See: Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA: 1997;277(8):678-682.

Jodi Halpern, another clinical educator, emphasizes the relational process of "emotional attunement"  that comes from perspective taking (the cognitive aspect) together with exploring and responding to the "meaning" of the feeling. 

For those interested in learning more about clinical empathy, I also recommend the book, Empathy Reconsidered, New Directions in Psychotherapy (Eds: Arthur Bohart & Leslie Greenberg. American Psychological Association, Washington, 1997) which provides further perspectives on the role of empathy in clinical encounters, particularly in psychotherapy. 

In my own experience, empathy happens when I:

• allow myself to be fully present,

• listen generously,

• seek to fully understand the meaning of the patient's feelings,

• respond with genuine reflections about what I am hearing and experiencing, and

• allow the patient to correct, refine or elaborate upon my attempts to understand.  

This process may continue for a bit, as the patient elaborates about the meaning of their situation or feeling. More often than not, the patient eventually responds by saying, "Yes, that's it, exactly".  Afterwards, some will indicate that they felt better being heard and responded to.

In previous posts on EmpathyWorks, I have shared the evidence for clinicians' use of empathy and a wide variety of positive outcomes, including enhanced patient satisfaction, increased patient follow through, positive health behavior change and even improved illness outcomes. For just 1 example, see: Hojat, M., D. Z. Louis, et al. (2011). "Physicians' empathy and clinical outcomes for diabetic patients." Acad Med 86(3): 359-64.

Whether or not you agree with Bloom's arguments, the post is worth reading, as are the many insightful and often brilliant responses written by a broad spectrum of commentators, including: Marco Iacoboni,  neuroscientist; Peter Singer, ethicist; Barbara Fried, law professor and public policy expert; Maryanne LaFrance, psychologist and women's studies expert; Nomy Arpaly, philosophy professor; Christine Montross, physician/poet; and Leslie Jamison and Simon Baron-Cohen, writers/commentators with  strong interests in empathy.

More on the Brene Brown Empathy Video

My last post was about a brief video on expressing empathy that featured Brene Brown, PhD. You can find the video at:https://www.youtube.com/watch?v=1Evwgu369Jw

Many liked the video, though some colleagues who are experts in clinician-patient communication felt that Dr. Brown was off target in her conceptualization of sympathy. Dr. Dennis Novack, Professor of Medicine and Associate Dean of Medical Education at Drexel University College of Medicine, wrote:

"I like what she says about empathy, but disagree completely with her definition of sympathy, which really undermines the value of the video for me. Sympathy is derived from the Greek sympatheia which means "feeling with." In one sense it might be empathy on steroids. We send a sympathy card to someone because we feel the loss as well. We feel sorrow for and with another, though maybe not as deeply, and in some ways identify with the other. 

The classic studies of Nightengale et al show that physicians who adopt a more sympathetic stance toward patients’ emotional situations do too many tests and perform CPR longer – they lose their objectivity (Nightengale, S.D., et al. JGIM:1991; 6:420-23.)
Empathy is conceived as a more objective process. All the actions you listed are components of the empathic process, that allow the physician to feel for patients and communicate that understanding, while still being able to make good decisions about their medical care free of the effects of the emotions elicited.By the way, a recent study Suely Grosseman and I and others recently did suggests that another component of the empathic process is checking to ensure that the patient got the empathic communication. We found that residents’ self-assessment of their empathic communication to standardized patients in 5 OSCE stations had zero correlation with SP assessments of their empathic communication."

Richard Frankel, Professor of Medicine, Indiana University School of Medicine noted the value of focusing on the interactional dynamics of empathy and referred interested folks to Jodi Halpern's use of the concept of "attunement" in her 2003 Journal of General Internal Medicine article (Halpern J. What is clinical empathy? Journal of general internal medicine. Aug 2003;18(8):670-674.) He added:

"Our group in Rochester also published a paper in 1997 in which we described the interactional dynamics of empathy, (Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA: the journal of the American Medical Association.1997;277(8):678-682.).
The model was later validated by Hilde Eide (Eide H, Frankel R, Haaversen AC, Vaupel KA, Graugaard PK, Finset A. Listening for feelings: identifying and coding empathic and potential empathic opportunities in medical dialogues. Patient education and counseling. Sep 2004;54(3):291-297)

Rich also endorsed the empathy video created by the Cleveland Clinic, featured in my March 23 2013 post:

http://empathyworks.blogspot.com/2013/03/watch-this-wonderful-video-empathy.html

I agree with both Dennis and Rich about the importance of both the cognitive and interactional aspects of emapthy and I, too, have found Jodi Halpern's conceptualization of clinical empathy quite helpful. Her thoughtful and erudite book, From Detached Concern to Empathy: Humanizing Medical Practice (Oxford University Press, New York, 2001) is highly recommended for all those interested in promoting and studying clinical empathy.

For those interested in learning more about clinical empathy, I also recommend the book, Empathy Reconsidered, New Directions in Psychotherapy (Eds: Arthur Bohart & Leslie Greenberg. American Psychological Association, Washington, 1997) which provides further perspectives on the role of empathy in clinical encounters, particularly in psychotherapy. I especially recommend the introductory chapter by the editors, in which they describe 3 different types of therapeutic empathy:

1. "empathic rapport" - the clinician expresses understanding and acceptance of the client's feelings (this is closest to what Brene Brown was describing in the video);
2. "experience - near understanding of the client's world" - a deeper understanding of the client's experience or "world". This usually results from exploration of the client's perceptions and reactions, including how the client's past experiences may have shaped their current emotional response; and
3. "communicative attunement" - characterized by moment-moment attunement based on reflections or other attempts to understand what the client is trying to communicate.The therapist is actively trying to, not only understand what the client is saying, but also trying to "help the client make sense of their ever-emerging experience."

In a future post, I will share some simple strategies and approaches clinicians might use to enhance their capacity to develop empathic rapport.

A Short Video on Empathy Featuring Brené Brown

Sue Raffa, PhD, a colleague at Alpert Medical School, Brown University,  recently shared a wonderful animated video on empathy with me. The brief video was created by the Royal Society of the Arts (RSA) and features Brene Brown, PhD, LMSW, a research professor at the University of Houston Graduate Colleage of Social Work.

You can find the video at: https://www.youtube.com/watch?v=1Evwgu369Jw

The video offers a wonderful, quick,and amusing lesson on empathy and how if differs from sympathy. 

I particularly like Dr. Brown's  reference to the 4 key qualities of empathy:

1. perspective taking
2. staying out of judgement
3. recognizing emotion; and
4. communicating what you notice

I also like her idea that empathy "fuels connection", contrasted with sympathy, which "drives disconnection". Empathy, she states, can be operationalized as "feeling with" other and requires a "vulnerable choice". She adds, "To connect with you, I have to connect with something in myself that knows that feeling", which can be painful. Empathy, she notes, is not about trying to make things better, it's about being present and expressing understanding to a person who is struggling>

"Rarely can a response make something better....what makes something better is connection."

Awesome!