Empathy as a state beyond feeling: a patient and clinician perspective

This article is part of our series on empathy

Introduction

A catastrophic event caused me to question the assumption of empathy as a ‘feeling’. After a traumatic brain injury, I (AP) retained empathy even when the injury did not allow me to feel. I did not know why my empathy remained. I later met others who retained empathy, but not feelings, and I sought to understand this phenomenon. I was taught during an early psychiatric/theology residency that feelings are transitory and they depend on stimulation and that good clinical practice demands on objectivity without involvement. I found objectivity to be unrealistic and empathy to be dependent on more than emotion. Empathy can generate intense feelings and at its best can be life-giving, as well as a source of comfort and hope. However, using feelings as the only basis for empathy can be a trigger for destruction, alienation or unintended consequences. Empathy will be described in this editorial from three perspectives: somatic; affective; and cognitive. ¹ I will explain that full engagement requires all three perspectives to work in harmony. Importantly, I will assert that empathy remains scalable across cultures and circumstances where it can bridge real-world barriers.^2,3

Somatic empathy

Somatic empathy is described as responding to pain and sorrow in others by physically experiencing the same pain through proximity to them. ¹ This is an excellent signal to bring attention to and sense the plight of others before understanding their conditions, but it is not sustainable. Somatic sensation can be deceptive as it draws on immediate internal assumptions to resolve an external state sampled at the level of shared pain, danger, fear, anger or anxiety. Somatic responses can occur in less than 200 ms within the autonomic nervous system and are sometimes referred to as a gut feeling whereas feeling (affective) and thinking (cognitive) inputs require 300–500 ms for the brain to process. The somatic response can be the kindling that starts the fire of empathy, with the fuel of logic and strategy required for long-term benefit.

Affective empathy

Affective empathy sets emotions as the focus of empathy and is described as identification with others, walking as if in their shoes or ‘knowing how they feel’ and is thought to be influenced by but separate from emotional contagion ⁴ and the social drive to respond compassionately to emotional need. ⁵ This can happen at conscious or subconscious levels and may be influenced by somatic empathy and filtered by cognitive empathy. The positive aspects of this perspective are that it can be hope building, recognise suffering and help others sense that they are understood and no longer alone. Affective empathy is considered an essential factor for inhibiting aggression towards others. ⁶ The disadvantages are that it may allow an unequal, capricious and uneven distribution of empathy and deepen emotional vulnerability.

Affective empathy favours those who can elicit a response and excludes those who are most in need. For example, an unattractive comatose patient or someone with mental illness is less likely to be responded to with affective empathy than someone that is charming and beautiful. ⁷ A consequence of the focus on affective or somatic empathy is burnout and emotional exhaustion. ³ People can experience guilt when there is no emotional connection and condemn themselves as unable to ‘care’. ⁶ Feelings are not a reliable moral compass to guide human caring; it is actions with or without feelings that will generate change.

Cognitive empathy

Cognitive empathy is the perspective that acknowledges and identifies with the feelings, intentions, limitations and beliefs of others while maintaining a separate sense of self. ³ The strength of this form of empathy is that it allows for calm thinking in difficult circumstances. Problem-solving is simplified as it is possible to see past emotional interference to a useful answer. When cognitive and affective empathy is joined, emotional warmth and respect can be extended with a realistic understanding of what can be changed and when. For example, a psychiatric nurse or refugee worker might become overwhelmed with tragedy and forget how one act of kindness can change the day for that person, and that healing comes one day at a time. The danger of cognitive empathy or perspective taking is that it can be used to manipulate others and assumptions based on the motivation or ability of others can be wrong.

Scaling empathy across cultures and circumstances

In the quest to understand empathy, I was to find it intrinsically tied to identity. I had to change the inner and outer perceptions of myself as a series of physiological accidents, the victim of fate or the person others used to know and wanted back. Holding a hypothetical funeral for the ‘old’ me was a helpful strategy to move to the future. For me, this was a turning point. I was later to learn from the famed neurologist Oliver Sacks ⁸ that he suffered from prosopagnosia or face blindness with excruciating shyness and still empathy remained. ‘Dr. Sacks shows us that medicine is both an art and a science and that our ability to imagine what it is to see with another person’s mind is what makes us truly human.’ ⁸ Chopik et al. ⁹ measured empathy across 63 nations; it was not surprising that levels of identity and community could predict higher empathy. By surveying 104,365 adults across 63 countries, they found that countries high in empathy score highly in levels of collectivism, agreeableness, conscientiousness, self-esteem, emotionality, subjective wellbeing and prosocial behavior. ⁹ Developing these qualities across nations could promote the growth of an empathic culture.^2,10,11

Can empathy be learned?

In the current climate of healthcare there is growing workforce discontent, patient dissatisfaction, litigation, complaints ¹² and a surge of healthcare practitioners leaving the profession. ¹³ Therefore, skills for conflict resolution, grief management, conflict negotiation and strategies for connecting with those who are unable to be a ‘respondent’ are a critical need. Training in these areas might increase cognitive empathy and reduce burnout. ¹⁰ People can be skilled in one empathy perspective and learn how to recognise and build the remaining perspectives and perhaps work in teams to increase empathy potential. Storytelling, curiosity, detailed observation, mentored exposure and modelling offers compelling options for learning empathy.

When all three forms of empathy operate in balance, they can empower others and bring healing. Empathetic awareness is nurtured through storytelling and exposure, where common ground and psychological safety are combined with opportunities for joint problem-solving. The neurologist Oliver Sacks used a series of descriptive essays to share a day in the life of those with unusual psychiatric conditions. People everywhere learned what it was like to be the person without a working memory or one who mistook his wife for a hat. ¹⁴ He shared life and solutions from the perspectives of working together with unusual people and making life better. Readers were able to experience the pain (somatic empathy) from a position of psychological safety while identifying with the characters (affective empathy). After meeting people with these conditions, they were better able to identify the condition, connect with patients, understand the prognosis and extend empathy (cognitive empathy).

Philosopher and epidemiologist, Jeremy Howick, ¹⁵ provides evidence for self-empathy and a relationship to healing, while reporting that overtreatment and passive medicine can obscure the body’s ability to heal. Self-empathy sustains the capacity for continuous empathy with others. In aeroplane safety, we are admonished to put on our oxygen first, as in helping another when we have a deficit risks both lives. Howick summarises evidence on the human body’s chemical responses to treat pain, cure some joint problems and treat mild depression through the self-management of internal ‘endorphins’ which can be translated literally into ‘morphine made by the body’. Somatic (feeling the pain) empathy is recognised in the evidence summarised concerning endorphins and self-regulation, followed by the application of affective (emotional) empathy to own and identify internal challenges with self-compassion and to then apply cognitive (perspective seeking) empathy to generate internal solutions. This evidence has been reproduced in English, Chinese, Italian, Polish and Romanian attesting to the international interest in growing the empathy culture.

The concepts of joint self and co-produced empathy are presently enacted, for example, through the Medicine X ¹⁶ platform that uses ‘Everyone Included’ ¹⁷ to model empathy through shared objectives, mentored exposure and action plans built together by patients and healthcare trainees. These teams have gone on to develop care plans for those with brain cancer, an artificial pancreas, new medicine options and medical software platforms. The Medicine X graduates have informed policy at national levels, spoken at the White House and changed their world with limited resources. ¹⁶ Since 2017, Medicine X has reached 20 million people and generated 700 million social media impressions, leaving a record of empathy across cultures and circumstances. ¹⁸ Larry Chu, ¹⁹ the founder, shares principles that work. Stay curious, build mutual respect to replace hierarchies, include everyone, laugh together and build a stage form which the most difficult stories can be told. Instead of the healthcare revolution which is problem-focused and not empathy-based, he suggests that we invest ourselves in empathic healthcare redesign.

Atul Gawande ²⁰ writes on intractable migraine pain and other conditions in the face of uncertainty and identifies characteristics of sustained empathy: curiosity; mutual trust; and incremental care. The tension in having no easy answers when you are expected to ‘heal’ and be the ‘healer’ is seldom addressed. Empathy means not walking away, managing expectations and grows organically as doctors and patients incrementally build knowledge together. These actions are constant across cultures, within reach of all and can deliver sustained empathy to make room for the best in both the art and science of medicine.

Conclusion

Abraham Verghese ²¹ imprints life-building empathy in his book Cutting for Stone by sharing human limitations across cultures and circumstances; he embeds the perception that even with the best of intentions, tragedy overtakes us, and still empathy can find a way:

‘Life, too, is like that. You live it forward but understand it backward. It is only when you stop and look to the rear that you see the corpse caught under your wheel.'²¹

‘Tell us please, what treatment in an emergency is administered by ear? “I met his gaze, and I did not blink. “Words of comfort,” I said to my father.'²¹

‘We are all fixing what is broken. It is the task of a lifetime. We'll leave much unfinished for the next generation.'²¹

Empathy is as complex as human nature; it is more than a feeling, it is a state of choosing and being, with a call to action. Empathy is in your hands; we collectively own the future of empathy and healthcare. Might we face the uncertainty of change by redesigning healthcare empathy together, everyone included?