Therapeutic empathy: what it is and what it isn't

Introduction

Research on empathy in healthcare has blossomed, with the number of PubMed citations containing the word ‘empathy’ in the title increasing 10-fold (from 34 to 354) in the last 20 years. ¹ The references include several randomised trials showing that empathic care can improve patient outcomes.^2–4 It is thus unsurprising that the General Medical Council considers empathy to be an essential component of good communication. ⁵ As a testament to its importance within healthcare, there are now training courses on the subject in the United States, ⁶ United Kingdom ⁷ and South Africa. ⁸

Yet, this enthusiasm for empathy in healthcare has been mixed with some negative reactions. Sceptics have raised doubts about the possibility of empathy, ⁹ while others claim it is harmful. ¹⁰ In October 2017, a group of clinicians, empathy researchers, healthcare managers, philosophers and patient representatives from seven countries gathered in Oxford to discuss what therapeutic empathy is and how it might be attained. The discussions during the course of the meeting – some of which will be explored later this year in the empathy series within the Journal of the Royal Society of Medicine – included:

the definition, phenomenology and application of therapeutic empathy;

how technology enhances (or detracts from) therapeutic empathy;

patient perspectives of therapeutic empathy;

therapeutic empathy as a whole body and everybody experience;

how understanding transference can move us from empathy and patient-centred medicine, towards compassion, self-compassion and a collaborative model of care.

In anticipation of these further thoughts, here we will review and attempt to clear up some of the confusions surrounding therapeutic empathy that arose at the colloquium.

Seven myths about therapeutic empathy

Myth #1. Therapeutic empathy cannot be defined

The term ‘empathy’ (in English) dates back to 1873, ¹¹ and its roots can be traced back to Ancient Greece. ¹² Empathy can be defined in numerous ways ¹³ and is related to other terms (see below). Hence, we adopt the term therapeutic empathy to refer to empathy as it is defined in trials which have demonstrated its therapeutic benefits. ¹⁴ In these contexts therapeutic empathy has been defined as involving three key features: ¹⁵ communicating that understanding and acting on that shared understanding in a helpful (therapeutic) way. ¹⁵ Each of these feature is required. Understanding what a disease means to a patient is required for accurate diagnosis, prognosis and shared decision-making. Communicating that understanding is required to alleviate patient anxiety and doubts about whether they have been understood. Acting is required to maximise the therapeutic benefit of shared understanding. A range of ‘actions’ is acceptable in this context, ranging from prescription or referral to constructively dealing with emotional distress.

Myth #2. Therapeutic empathy cannot be achieved

There are two kinds of empathy: affective and cognitive. Affective empathy is achieved when we mirror the emotions of another person, ¹⁶ so that we actually experience those emotions. Complete affective empathy is probably impossible to achieve, since we will never know exactly what it means to be in another’s emotional state. Certainly for most healthcare practitioners, complete therapeutic cognitive empathy would only be achievable if the practitioner had experienced very similar illnesses and contexts as a patient, which is rare. Hence complete affective empathy may be impossible in most cases. At the same time, it is possible to achieve affective empathy to some degree. Few people do not experience any vertigo when watching someone walk a tightrope across the Grand Canyon. And because pain – in some form or other – is a near-universal human experience, we can all empathise, to some degree, with another’s pain.

More importantly, experiencing the emotions of another is not required for empathy. It suffices to understand – or at least try to understand – what it might be like to be in another’s shoes. This kind of empathy is called cognitive empathy, and it involves imagining, insofar as we can, what it would be like to walk in someone else’s shoes. ¹⁷ Cognitive therapeutic empathy, thus would require a healthcare practitioner to try to imagine what it might be like to be the patient, without necessarily experiencing all of that patient’s emotions. This type of empathy is possible.

Myth #3. Empathy is harmful

Bloom has argued that empathy is harmful because it leads us to feel connected to one group and he argues more likely to harm another group. ¹⁸ Yet, even he acknowledges that empathy, defined as trying to understand what another person is going through, is helpful. A weaker claim is that empathic care leads to fatigue and burnout. While this could happen in some cases, therapeutic empathy has been shown to reduce practitioner burnout. ¹⁹ Also, good leadership and support can ensure that burnout is not induced, ²⁰ and there is some evidence that mindfulness practices may mitigate additional fatigue caused by empathy. ²¹

Myth #4. Healthcare practitioners already practice empathy

The extent to which healthcare practitioners express empathy varies widely across medical practitioners and medical specialties, with female practitioners outperforming males. ²² The fact that empathic skills can be learned also suggests that the extent to which therapeutic empathy is practiced is sub-optimal. ²³ Additionally, whether a healthcare practitioner is viewed as therapeutically empathic will differ from culture to culture and profession to profession. Several of the patients in our colloquium, for example, noted that in some cultures unless the healthcare practitioner touched the patient (in an appropriate way), that the patient would not feel cared for.

Myth #5. Empathy can be achieved by training practitioners

Empathy is a relational concept and optimising therapeutic empathy requires that patients and healthcare managers are also committed to therapeutic empathy. In paediatric care and many other settings, therapeutic empathy may often require engagement with patients’ family members. Practitioners operating in an environment burdened by paperwork, where time caring for patients is undervalued, and where they are fearful of litigation, cannot optimise how they express therapeutic empathy. Likewise patients cannot play their potentially important role when there are so few mechanisms by which patients can provide feedback about how they feel about their care. Meanwhile, managers who impose targets and guidelines yet arguably display little understanding of what it is like to be a clinician, hinder therapeutic empathy. Empathy training for practitioners has been shown to be effective in some studies, ²³ but it will only flourish if all stakeholders involved in healthcare are committed to empathic care. Eventually, the horizon of empathy could expand towards a global culture of empathic understanding.

Myth #6. Empathy is the same as compassion, patient-centred care and other concepts

There is overlap between the definitions of compassion, empathy, sympathy and patient-centred care; and the extent of their differences will depend partly on how the concepts are defined, which varies. We have attempted to overcome this conceptual confusion by adopting the term therapeutic empathy, which is empathy, as defined in clinical trials where it shows a benefit (see above). By contrast, ‘compassion’ is traditionally defined as suffering with another person. ¹² This joint suffering can be different from (cognitive) empathic understanding. Relatedly, ‘sympathy’ has been defined as a similar reaction to a situation ¹² or pity. Unlike therapeutic empathy, neither of these requires action. ²⁴ Meanwhile, patient-centred care has been defined in numerous ways, and usually requires seeing things from a patient’s perspective.^25–27 As such patient-centred care arguably requires empathy. Hence, it is fair to say that therapeutic empathy is distinct from these other concepts.

Myth #7. Empathy is opposed to evidence-based medicine/is not cost-effective

Because evidence-based medicine involves combining best research evidence with patient values and clinical expertise, empathic care is required for rather than opposed to evidence-based medicine. Empathy is useful for making treatment decisions based on the combination of evidence, values and expertise. Related to this, some fear that empathic care will take too much time. It is true that empathic care will require more time in some cases, and patient representatives attending the colloquium noted the importance of time (where it is required) and continuity of care for facilitating therapeutic empathy. However, since empathy involves both caring for as well as curing, rigorous cost-effectiveness studies are required to confirm the extent to which therapeutic empathy is cost-effective. Adding a dose of empathy to a consultation may be cost-effective when it improves patient outcomes, especially when it does not require additional time. ²⁸

There are other myths besides, especially the myth that new technologies facilitate empathy (sometimes they do and sometimes they don’t – we dedicate a special paper to this topic in the forthcoming series).

Conclusion

The evidence that therapeutic empathy benefits patients is new, growing and evolving. We anticipate that this evolution will be enhanced by our clarification of the term therapeutic empathy. Other developments including new managerial structures that facilitate therapeutic empathy, and optimising the use of technology, will provide further understanding of the benefits, requirements and limits of therapeutic empathy.