My Journey with Empathy

I have chosen to speak on empathy, which has been dear to me through my formative years and continues to guide me in my personal and professional life. As we all know, empathy is now acknowledged as an essential ingredient of well-being because it nurtures positive and meaningful relationships as human beings. Though we all value individuality in our innate core, we crave togetherness. One of the important components of early years, along with self-control, grit, and integrity, empathy has played a significant role in my life. My teachers and my family members have played an important role in making me what I am today and continue to guide me.

What is Empathy

Empathy is considered as an emotional connection or vicarious awareness of another individual's thoughts, emotions, or attitudes.^1,2 It is derived from the Greek word EMPATHEIA—meaning physical affection or passion.

While many factors have shaped my personal and professional life, empathy has been an important determinant of my happy and contented journey.

Empathy and Medicine

We all know that the role of touch in clinical examination builds bonding, more so in our field. Although psychiatry is more reliant on history and MSE, a general physical examination and thorough neurological examination instill a great deal of confidence in patients and facilitate bonding.

A few of the determinants of empathy have helped me to choose not only psychiatry as a subject but also to pursue it with great passion. Traits like resilience, readiness to accept change, putting others’ interests before mine, honing interviewing skills, and empathetic approach to involving patients and caregivers have shaped me into the clinician I am today. My post-graduation training at the Armed Forces Medical College, Pune, was greatly responsible for my medical training. An important aspect that was ingrained in me was giving adequate time to the patient’s history and discussing emotional upheaval. This gave them a sense of feeling fully heard and understood, which helped build empathy. Going forward, collaborative decision-making, discussing treatment options, and acknowledging failure and poor response to treatment have been pivotal in improved patient care, longer follow-up rates, and willingness to reach out after dropout in treatments.

Neurobiology of Empathy

Data gathered from an expanding body of studies employing a broad range of techniques, including fMRI, lesion, and electrophysiological measures, indicate that the dorsolateral and frontopolar regions of the prefrontal cortex are involved in empathy processing. ³ The right hemisphere dominantly supports empathy. The role of mirror neurons in the prefrontal cortex in sharing the emotions of others is well known. Cognitive perspective-taking or mentalizing—the ability to understand the intentions, beliefs, and desires of others is subserved by the areas in the anterior insular cortex and other parts of the prefrontal cortex. The Sally Anne test, ⁴ has been used in psychological research to investigate the theory of mind, which gives insights into the psychological aspects of empathy. Hormones like oxytocin and vasopressin are the main hormones responsible for empathy.

Types of Empathy

Three components of empathy have been recognized by psychologists Daniel Goleman and Paul Ekman: cognitive, emotional, or affective, and the addition of “compassionate empathy,” which serves as a bridge between Hougaard and Carter’s difference between empathy and compassion. ⁵ They are cognitive, emotional, and compassionate. We will briefly discuss the following. Cognitive empathy: Essentially, empathy is the ability to understand another person’s feelings and possible thoughts; this may also be referred to as perspective-taking. ⁶ When we physically experience the other person’s feelings as though they are contagious, we are demonstrating emotional empathy. When we have compassionate empathy, we are driven to act instinctively to assist someone in need and understand and get involved with their situation. ⁷

My Reflections from Personal Experiences

While my basic foundation of empathy grew through my parents and now through my wife and daughter, a few of the incidences in my professional life have further the need for empathy in my clinical practice:

The Al-Jihad experience: While being posted in the counter-insurgency operations in Kashmir on one of the night duties in the casualty department (even as psychiatrists we were posted as duty medical officers), about eight Sikh jawans from a regiment brought a be-headed Indian Army soldier, which was almost stitched on his chest & the word Al-Jihad etched below. Martyred, but they stated that no, he has to be alive because he has to proceed on leave for his marriage —they all knew nothing could bring this jawan back. However, the amount of camaraderie, love, affection, and empathy really touched me a lot as to what people can think about each other in spite of all the odds against them. This and a few other incidents have really had a deep impact on me, and I still re-live them often.

My second example is a mid-30s man who admitted to deliberate self-harm and was referred to me for evaluation. He was diagnosed with borderline personality disorder and poly-substance dependence. There was severe impairment in interpersonal and social relationships. The next few years had a stormy course. Good rapport building with patient and family members kept him under follow-up for about four years. It finally had an abrupt ending after the patient completed suicide. However, the family continued to be in contact. They felt grateful for my genuine efforts toward the patient, helping him through a crisis on multiple occasions. My family sponsored a trip to Australia further to enhance my understanding of personality disorders and substance use.

My third patient, a woman in her 40s who had multiple doctor visits, various specialists, and alternative practitioners over seven to eight years, had almost all the investigations done and, being normal, had somatoform disorder. She continued to insist that the symptoms were due to physical causes and the need for tests. First, a few visits were extremely challenging. What helped me most was a good therapeutic relationship, active and reflective listening involving the family members, and addressing their concerns. Empathy had been the keystone in forging the difficult tasks. The component of a good outcome was that the patient was living satisfied with the feeling of being fully heard. I did exhibit genuine concern about her health problems. Judicious pharmacotherapy combined with Support sessions continued, and after about six months, the patient felt relieved and continued to be regular in her follow-ups to date.

My fourth experience has been a couple—husband, businessman, and wife graduate homemaker married for two years and conflicts between them due to lack of quality time spent, low intimacy, and yearning for an independent job for wife which met with resistance from family. In the initial sessions, the major challenge was to overcome negative beliefs of life toward the therapist and be persuasive enough to instruct the husband to yield to her wishes actively. What helped was a non-judgmental stance, non-confrontational approach, empathetic listening, and use of non-verbal empathy in sessions.

Empathy in Medical School

Effective education requires empathy, and when it is missing, concepts become restricted, compassion dwindles, and the relationship between the instructor, family, and child becomes less positive. This sums up why it is close to my heart, even as an undergraduate and postgraduate teacher. I believe empathy has to be instilled in our future doctors so that we do not reduce them to high-functioning artificially intelligent machines equipped with the best technology but unable to take perspectives and understand fellow human beings.

Steps to Develop Empathy and How These Can Be Inculcated

The following are the steps to develop empathy: (a) Listening. (b) Understanding. (c) Internalizing. (d) Projecting. (e) Planning. (f) Intervening.

The above steps can be used to teach empathy to medical students. The steps can be further divided to teach the values of compassion and the importance of the doctor-patient relationship.

The first two steps—listening and understanding—constitute awareness: Students must first pay attention to others and then take the time to learn what is being said and how (and for more mature students, perceiving what is not being said).

Goleman, ⁹ observes that empathy begins with listening and understanding. It basically refers to understanding another person’s point of view cognitively. The hardest part of training learners to become empathic may be getting them to “internalize” what they have learned. It is important to put oneself in other people’s situations and feel what they are feeling. Once students can envision their reactions in a certain scenario, they go on to the next phase, which is projecting. In order to understand how simple or difficult it could be for the other person, they might also try to comprehend how others see the views they hold. Through “planning,” students are able to organize their reaction to a specific circumstance based on empathy; this response may begin with talks aimed at reaching a mutual understanding with attempts to change the situation or both. Finally, plan “intervening” in real-world scenarios, either in role plays or demonstrating empathy in clinical interviews.

These steps can be planned either in direct interviewing of patients and families, where a specific task is given to demonstrate empathy (verbal and nonverbal, body language, etc.) or through Structured role-play. The AETCOM model has also stressed the same in undergraduate students.

Disadvantages of not Having Empathy

Let us briefly see the disadvantages of not having empathy; lack of empathy dehumanizes patients and shifts the physician’s focus from the whole person to the target organ and test results. This can make doctors focus mostly on disease-centric and investigative-driven approaches rather than a more holistic recovery-centric approach. Lack of empathy leads to poor quality of care and poor medical outcomes in adequate time. Poor therapeutic alliance would lead to a lack of trust, increased litigations, and hostility due to unrealistic expectations, as witnessed by rising violence against doctors. It would also lead to burnout and lower job satisfaction. Practice becomes a mechanical chore, and hence, there is no sense of joy or contentment. Compassion fatigue leads to poor quality of life among doctors, resulting in substance abuse and suicide.

Pitfalls of Empathy

One needs to know that there are definite pitfalls of empathy. A type of tension or stress known as “compassion fatigue” is brought on by often interacting with traumatized individuals. It results in us being fixated on their misery or pain. Compassion fatigue has two elements: burnout and secondary traumatic stress. When we are unable to alleviate someone else’s suffering, and we get upset and fixated on their misery, this is known as secondary traumatic stress. Secondary trauma symptoms might resemble those of post-traumatic stress disorder quite a bit. Burnout is a phenomenon that can occur after prolonged periods of stress-induced physical, mental, and emotional weariness. Burnout progressively intensifies and sets in. Although secondary traumatic stress is usually quickly experienced, burnout may result from it. ⁸

So, how do we overcome these two? In order to overcome compassion fatigue, it is crucial to take care of oneself, create emotional boundaries, lighten one’s workload, be honest with coworkers about one’s struggles, and consider getting professional assistance. ⁸

Technology: A Disrupter of Empathy

Technology is a definitive disruptor of empathy. Modern social and virtual distances have created an anomaly in human beings, though it is one we now consider to be the norm. This separation mutes empathy, absent with altruism falters.

Conclusion

To conclude, empathy is IKIGAI in Medicine, more so in psychiatry. Empathy can be a gift of nature to certain individuals. However, it is an important trait all of us need to develop for a fulfilling life. Empathy has to be cultivated in budding doctors through interviews, OSCEs, and role plays. Optimal use of technology has to be emphasized from early childhood. It is a must-have trait for joyous practice and a good quality of life.