Empathy,transference and compassion

The gleaming pillars of modern medicine were expected to replace the destitution and squalor of Dickensian London. Yet, in 2010 and 2013, we were reminded through Robert Francis’s report on Mid Staffordshire NHS Foundation Trust that the gloss of these pillars is in need of polish. ¹ The reports suggested that patients were being ‘left in excrement stained sheets and beds, enduring filthy conditions and experiencing incidents of callous treatment’. ¹ Francis told the ‘story of appalling and unnecessary suffering’ endured by hundreds of patients. A popular response to the report claimed that healthcare professionals lacked empathy and compassion – a view reiterated by Jane Cummings, Chief Nursing Officer for England. She suggested that colleagues who fail to demonstrate ‘compassion and empathy’ towards patients should have no place in the National Health Service (NHS). ² The use of the terms ‘compassion’ and ‘empathy’ interchangeably is common in healthcare and the mainstream media. In this instalment of the empathy series, we consider if there is a difference between compassion and empathy, and how we might move from empathy towards more compassion.

Introduction

Previous editorials within this series have explored the broader challenges and complexities of defining the term ‘empathy’. In brief, we define empathy as the capacity to understand or feel what another person is experiencing from their perspective, i.e. the capacity to place oneself in another’s position. This encompasses two related concepts:

‘Cognitive empathy’ simply knowing how the other person feels and what they may be thinking. This is also known as ‘perspective-taking’.

‘Affective empathy’ is feeling what another person feels as if their emotions were contagious. This is also known as ‘emotional resonance’ or ‘emotional contagion’.

Although these are recognised definitions, we acknowledge that the meaning of empathy is dynamic and can change over time. This is evident from the Oxford English Dictionary which originally defined empathy as ‘the quality or power of projecting one’s personality into or mentally identifying oneself with an object of contemplation, and so fully understanding or appreciating it’. ³ It appears that empathy is difficult to disentangle from a related concept: transference. To this end, it is worth taking a moment to detour and consider examples on the meaning from transference that we have collected from our discussions with working doctors.

Transference is:

‘when my patient is sad, I start to feel sad too’ (one of the commonest formulations)

‘When my patient gets angry, so do I. I can’t help it’ (almost as common)

‘If I start feeling X, Y, or Z, it may be that my patient is feeling X, Y, or Z too’

‘be aware that the feelings you're feeling may not be your own’ (a useful rule of thumb)

These working definitions, although useful, are a misunderstanding of Sigmund Freud’s concept of transference (in German, ‘Übertragung’). He described the concept as a ‘phenomenon characterized by unconscious redirection of feelings from one person to another’ or ‘a whole series of psychological experiences revived, not as belonging in the past, but as applying to the person… at the present moment’. This was a phenomenon to observe in a patient, when trying to explain their condition, and was either to be utilised or overcome, depending on the school of psychotherapy. A related concept, countertransference is the ‘redirection of a therapist's feelings toward a patient, or more generally, a therapist's emotional entanglement with a patient’. Transference involves experiences and relationships from the past affecting those in the present. For example, transfer of feelings towards one’s parents onto one’s partner or children, or repeating patterns of feelings and behavior with somebody new. This transfer is due to the unconscious inferences drawn from previous experiences with similar individuals.^4,5

Our working doctors’ definitions above are therefore not merely transference, but a form of affective empathy, closer to ‘emotional resonance’ or ‘emotional contagion’. Such affective empathy may be highly valued by patients and healthcare systems. However, for the individual doctor, this form of empathy can be emotionally exhausting. A colleague once shared a story about an emotionally intense family discussion in hospital. She remembered one relative asking ‘Doctor, are you sure you’re ok? Would you like a glass of water?’ She was visibly suffering some fraction of their distress and the family were concerned for her. She remembered this offer, this show of kindness, feeling strange and rare. The shared humanity – the family member noticing and tending to the doctor’s basic human needs – is not empathy, but is a central component of compassion.

Compassion can include ‘the feeling or emotion, when a person is moved by the suffering or distress of another, and by the desire to relieve it’ and ‘sensitivity to the distress of self and others, with a commitment to try to do something about it and prevent it’. The common elements of compassion would seem to be shared humanity and kindness, with an ensuing commitment to help where necessary. There is no requirement that an individual feel another’s suffering or distress, only be sensitive to it and willing to step in to help. This would appear a healthier, more sustainable approach than limitless affective empathy or emotional contagion.

Our patients may be afraid, sad or in pain. If we needed to completely feel what the patient feels, to understand their suffering, we risk our own emotional stability and may lose our valuable position of professional detachment. Patients come to us for help, when they are at their most vulnerable. We may serve them best by meeting their anxiety with calm, their fear with professional interest, their sadness and pain with uplifting, caring kindness – not by matching their distress with our own.

What about self-compassion?

Self-compassion – being compassionate to one’s self – may be the type of compassion that doctors think about least. An example is when one feels a patient’s expectations or needs are unmet but understands and accepts that perfection is not always possible without unintended harms. A doctor’s compassion for self is critical for the sustainability, wellbeing or ‘resilience’ of those in profession of caring.

Carl Jung described the concept of the ‘wounded healer’, whereby those drawn to caring professions may have particular psychological ‘wounds’ cut by the emotional content of their role. ⁶ This is exemplified by the Royal College of Anaesthetists’ and Association of Anaesthetists of Great Britain and Ireland's ‘Fight Fatigue’ campaign, which aims to improve safety by helping doctors on night shifts function more effectively. The campaign highlights that doctors, like all humans, have physical limits and that ‘physiological factors cause fatigue. Neither pride nor professionalism can overcome them’. Their report described the need for ‘changing attitudes across the workforce’, away from a macho culture of ‘doctors who regard their ability to function at all hours as a desirable trait, the “machismo” or “In my day” mentalities’. In other words, doctors are human and need to recognise this. ⁷

Charles Dickens provides some of the most vivid depictions of the human condition using the English language. In A Christmas Carol (1843), when the ghost of the money-lender Jacob Marley describes ‘business’, he could just easily be describing good medical practice today:

“Business!” cried the Ghost, wringing its hands again. “Mankind was my business. The common welfare was my business; charity, mercy, forbearance, and benevolence, were, all, my business. The dealings of my trade were but a drop of water in the comprehensive ocean of my business!” ⁸

Marley had become so bound by the ‘dealings of [his] trade’ that he had no time left for life, or ‘the comprehensive ocean of [his] business’. In death, he realises he has squandered his ‘life’s opportunity misused’ and implores Ebenezer Scrooge to avoid the same fate. Scrooge, visited by three further ghosts, realises the importance of cultivating ‘the kindnesses of life for his own happiness with his own hands’. He becomes compassionate, towards others and himself, and resolves to ‘live in the Past, the Present, and the Future’. Today, we might recognise this as mindfulness. Leicester Medical School has introduced a Health Enhancement Programme for first-year students, with sessions led mainly by general practitioners in mindfulness – ‘stopping, and reflecting on the moment’. This emphasis on wellbeing will, with hope, foster a practice to sustain the next generation of doctors in their careers. ⁹

Kristin Neff has described the necessary components of self-compassion as ‘self-kindness, common humanity, and mindfulness’. She also offers a useful insight: that we often try to jump straight from ‘there is a problem’ to ‘I need to fix it’, without taking the time to accept and acknowledge the suffering. Although health professionals may get far by relying on ‘doing mode’, there is more to understanding the human experience beyond thought alone.^10,11

As cognitive behavioural therapists are fond of pointing out, ‘you can’t think your way out of a thinking trap’. Cognitive behavioural therapy advocates action, or changing behaviour, as an effective means to alter emotional states. In the case of healthcare professionals dealing with others’ problems (as well as their own), we are often unable to take this approach, as the emotion is the patient’s and any behaviour change would need to come from them. Compassion, then, with sensitivity to the distress of self and others, and a commitment to try to do something about it, may be the most realistic way forward.

Supporting compassion in practice

When surveyed by Sinclair, patients valued compassion, and could distinguish this from empathy. ¹² In Dickens’ Bleak House, Allan Woodcourt attended his patient with ‘much solicitude and compassion’ and was described as the ‘kindest physician in the college’. ¹³ In turn, he enjoyed stable employment, a family and a home. We cannot all be the kindest physician in the college, but all clinicians have the capacity to be kind, to care, to show compassion, if we give them the right support.

A healthy work environment is vital rather than insisting on a resilient workforce. Adequate time allows staff to be compassionate instead of being at risk of ‘dispassion’. The increasing demands of complex medicine – an ageing population with multiple co-morbidities, large numbers of patient contacts under time pressures, long shifts, inadequate staffing levels and endless targets – lead to compassion fatigue. In addition, lack of time for basic human needs – time to eat, sleep or go to the toilet – leads to a workforce that may become numb to patient needs and basic humanity. Longer term, this leads to burnout, declining levels of performance, depersonalisation, emotional exhaustion and poor personal achievement. In the short term, this dispassion inevitably adversely affects patient care.

Just as transference, as discussed, is a doctor-centric concept, empathy may well be a key component of patient-centred care. However, in the current environment, with low morale, doctors in short supply and higher rates of stress, burnout and mental health disorders than the general population, we can ill afford any approach that risks harm to the workforce. Further, an enlightened view would be that happy, healthy doctors make for happy, healthy patients. We may find it more sustainable to move towards a more collaborative model, neither patient nor doctor-centred, but compassionate and honest. Key elements of this may include clear boundaries to the relationship, a therapeutic alliance of mutual respect between doctors and patients, and compassion (to include self-compassion, on the part of both doctor and patient). We note NHS England’s current commitment to defragmentation, ‘integrated care systems’ and ‘accountable care’, ¹⁴ which have the potential to transform health and social care services, and cautiously welcome this where it furthers the principles above.