- empathy
a mental state whereby a person, experiencing compassion, shows they are affected by another person’s suffering, and takes steps to alleviate that person’s suffering.
- general practice
that area of medicine that is available to us in the community when we have minor ailments, or ailments whose nature and severity are as yet unclear and need the attention of a general practitioner (GP).
- palliative care
care that focuses on alleviating pain and suffering for patients who have no chance of ever being cured from their illness, and who face imminent death.
The chapter highlights the collaborative basis of empathic communication. Through empathic collaboration between the health professional and the patient, the patient can more easily share overt as well as subtle clues about their underlying state. An empathic response on the clinician’s part resonates with the patient’s feelings, and tends to elicit a response from the patient to show that they feel understood.
The chapter further outlines the dangers of a pre-learned, ‘stock empathic’ response from the clinician that fails to reflect and focus on the patient’s feelings. The chapter illustrates how empathy may involve gesture, gaze and touch in concert with or in place of words. By bringing to light what makes for the effective communication of empathy, the chapter generates useful tools for reflecting on your own practice as a health professional.
Introduction
Within the healthcare world, empathy is regarded as a skill that is at the heart of caring and central to achieving patient-centred care (Frankel, 2009). The importance of empathy goes well beyond being friendly with people, or making people feel welcome. Indeed, empathy has real and significant outcomes for all involved in care.
Some studies of clinical communication link empathy to improved clinical outcomes (Hojat, 2007). These improved outcomes are the result of patients being encouraged – through the empathic attitude of health professionals – to provide more detailed information about their medical, social and emotional concerns (Beckman & Frankel, 1984). Where a clinician is empathic, patients are also more likely to adhere to treatments and to follow advice about how to manage their conditions (Squier, 1990). In addition, empathy leads not just to greater patient satisfaction and clinician–patient trust, but to improved health status (Stewart, 1995; Stewart et al., 2000) and enhanced quality of life (Ong, Visser, Lammes, & De Haes, 2000). Clearly, empathy has positive clinical and health effects. But what exactly is empathy and how is it conceptualised by practitioners?
Empathy has been defined as the ability ‘to sense the client’s private world as if it were your own, but without losing the “as if” quality’ (Rogers, 1961, p. 284). The words ‘as if’ are significant in this definition, because they reflect an important distinction between sympathy and empathy (Barrett-Lennard, 1981). Sympathy is an affective state that involves sharing the other person’s feelings. By contrast, empathy is an intellectual attribute that involves:
- a conscious awareness of the patient’s emotions and situation;
- an ability to act on that awareness in ways that key in to the patient’s feeling and concerns, while remaining clinically focused and appropriately therapeutic.
- sympathy
an affective state that involves sharing the feelings and emotions of the other person. Sympathy may involve disclosure of similar experiences of one’s own.
Yet empathy does not suggest detachment. To recognise a patient’s situation and to respond to that patient in ways that resonate with their emotions implies ‘awareness of the range and complexity of the patient’s feelings and of the issues to which they relate’. To achieve this awareness ‘involves seeking to understand what it would be like to be that person, living that person’s life and feeling the way that he or she does’ (Usherwood, 1999, p. 28).
Emotional resonance
In practice, empathy means maintaining ‘a dual perspective’ (Ruusuvuori, 2005, p. 205). A ‘dual perspective’ involves imagining oneself in the same situation as the one the patient is in, so as to achieve a sensitive and detailed understanding of their feelings. Such understanding is what we also refer to as emotional resonance (Halpern, 1993). Emotional resonance occurs when we are sensitised to others’ feelings without forgetting that these feelings are not our own.
- emotional resonance
a term introduced by Halpern (1993) to describe an empathic response that resonates accurately with the patient’s emotions. This is because it is invested with the clinician’s emotional engagement with the patient and informed by their detailed understanding of the patient’s experience.
But how are emotional resonance and empathy actually accomplished between people, and what do they look and sound like? Neither emotional resonance nor empathy are simply attitudes or ‘predispositions’ that the clinician brings to their encounter with a patient. Rather, emotional resonance and empathy are developed collaboratively as patient and clinician engage with each other. As our practice examples illustrate, both emotional resonance and empathy are activities that patient and clinician or clinician and family member jointly achieve in practice and by way of interaction.
Here is an extract from a type of general practice consultation that many clinicians consider to be particularly challenging. Such consultation is one where the patient’s stated reason for coming to see the doctor masks other, often deeper psychological or emotional issues, or issues that are less easily openly expressed (O’Grady, 2011a). Empathy plays a crucial role in precisely such consultations. Empathy may generate an ‘emotional resonance’ through which the patient feels safe to bring underlying worries and issues into the open, so that these worries and issues can be discussed and addressed.
In the case study below, the patient is a 58-year-old woman who begins the interaction by asking for advice about ovarian cancer screening. She has had a single panic attack in the past and the doctor is aware of this. As the consultation unfolds, there are hints of a more pervasive anxiety and serious depression.
In the opening moments of the consultation, doctor (D) and patient (P) have discussed the abdominal symptoms that have led to the patient’s request for cancer screening. The doctor has displayed sensitivity to the patient’s concerns and has gone on to share the medical reasoning that would lead her to attribute the patient’s symptoms to a pre-existing and benign condition. By the time the practice example begins, concern about ovarian cancer has been put to rest and the doctor moves to open up discussion about other issues.
D: All right, so how are you apart from that? That’s one worry.
P: Um pretty good but you know when I came last time I told you I had … you said I had, you thought I had a panic attack.
D: Yeah. [Sits back from the desk, takes hands off paper records and places them on lap, focuses gaze on the patient]
P: And I still sort of get that feeling … inside. [Shrugs shoulders]
D: [Leans forward elbows on desk and hands cupping her face]
P: [Shrugs shoulders again]
D: It’s a rotten thing … rotten.
P: Hh.
D: Tell me about the feeling.
P [Indicates chest] Um … seem PK during the day.
D Yeah.
P But when I get into bed at night not relaxed … it sort of goes chooooo. [Gestures to indicate fluttering feeling over chest and abdomen; slight shrug]
D What’s your head doing in that time?
P That seems to be OK, just sort of [pats stomach and chest] in here sort of thing. [Shifts posture quickly in seat]
D So is your heart beating strangely? [Enacts beating gesture across own heart]
P A little bit yeah.
D Mm.
Analysis and reflection
This part of the interaction has been selected for attention here as it is ‘a critical moment’ in the consultation (Candlin, 1987). It is a moment when emotionally sensitive and clinically significant information is being gingerly broached by the patient, and when an insensitive response on the doctor’s part could have led to her retreat into silence. Note how the patient raises the matter of panic attack obliquely: ‘… you said I had, you thought I had a panic attack.’ She appears reluctant to own such a diagnosis, presenting it as the doctor’s assessment of her condition rather than her own.
At this point the doctor might have responded by providing reasons for this assessment. She might have gone on to ask a series of diagnostic questions in order to pursue the provisional diagnosis of panic attack. Instead, she chooses to be silent and attentive. This is important. The doctor’s silence invites the patient to continue: ‘Yeah. [Sits back from the desk, takes hands off paper records and places them on lap, focuses gaze on the patient]’. The doctor’s silence, together with her focused gaze and attentive body language, encourages the patient to elaborate.
The patient responds tentatively, offering her symptoms in rather vague language: ‘sort of’. Her apologetic shrugs, pauses, quavering voice and intake of breath all underline her discomfort as she attempts to talk about her experience. These subtle signs suggest feelings of disquiet. If the doctor reads these signs and responds to them with silence, inviting the patient to elaborate, she capitalises on those signs as offering an ‘empathic opportunity’ (Suchman et al., 1997). An empathic opportunity is offered by the patient by presenting a hint about or a clue to her emotional state. If the doctor responds to such a hint or clue, inviting more from the patient, the doctor shows empathy.
Critical to achieving empathy is acknowledging the patient’s right to determine the direction of the conversation. Such acknowledgment is made apparent here by the doctor’s attentive silence and interested gaze. By saying nothing, reorienting her body towards the patient, intensifying her gaze and looking interested, the doctor heightens her engagement with the patient. Then, as the patient shrugs apologetically once more, the doctor transforms the patient’s understated, hesitant account of her experience with an utterance that seems to resonate with its true intensity: ‘It’s a rotten thing … rotten.’
With a small intake of breath the patient acknowledges this assessment of her state as ‘rotten’. This assessment made by the doctor resonates with feelings that the patient was unable or unwilling to voice. It displays the doctor’s awareness and emotional acknowledgment of the patient’s experience. The patient’s intake of breath indicates that the doctor’s assessment acts as an empathic response: the doctor’s assessment and the patient’s response ‘resonate’. Thus, here we have an example of how empathy results in ‘emotional resonance’ (Halpern, 1993).
For its part, the emotional resonance diffuses the patient’s embarrassment and discomfort. The patient’s experience of recurring panic attacks is now out in the open as a matter that can be talked about quite freely. The emotional resonance moves the conversation into a franker tenor. By asking the patient, ‘Tell me about the feeling’, the doctor confirms her personal engagement with the patient, while not losing sight of the patient’s symptoms. This triggers a response from the patient in which she provides a more detailed, clinically useful description of her symptoms. It ushers in a series of more focused diagnostic questions and responses through which the character and intensity of her experience of debilitating panic attack begin to emerge.
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