You Have Come by Way of Sorrow: Enhancing Empathy in Clinicians by Using Personal Experiences to Construct Professional Learning Materials

You have come by way of sorrow

You have come by way of tears

But you’ll reach your destiny

Meant to find you all these years

“By way of sorrow” by Julie Miller

Professional clinicians experience and manage life too, so can we use subsequent learning to enhance our and others’ professional work?

Background

I am a registered clinical psychologist (CP) working for a National Health Service (NHS) funded clinical psychology training program in the United Kingdom. The NHS is the UK’s free health-care system employing a wide range of professional clinicians. It has a fundamental value base embodying respect, dignity, and compassion for all (1). Concerningly, studies show lower than expected empathy scores in medical students (2) resulting in a call to emphasize empathy in training (3). Although these studies are non-UK based with non-CP professionals, to ensure quality in care, it is crucial all clinicians take note. Further, there is minimal direct research exploring the relationship between empathy/compassion and improved clinical care. However, exploring the impact of burnout on the caregiving capacity of professionals (4) and quality care by carers (5) implies it is important, especially when working in busy health-care environments (6). In the United Kingdom, CPs train to “reduce psychological distress and to enhance and promote psychological well-being by the systematic application of knowledge derived from psychological theory and research” (7). Empathy is crucial to attain this aim, and learning methods can facilitate this. For example, over the years, my colleague, Erasmo Tacconelli, and I have constructed vignette materials for teaching that simulate typical issues seen in clinical practice—these materials include professional referral letters utilized within Adult Mental Health (AMH) services. Since 2009, within the construction of the materials, we have additionally used music to enhance emotional and social connection within the trainees learning process (8). This current paper explores the potential of using personally inspired creative mediums for a learning vignette which was initially constructed in 2015.

The Learning Materials

An aim in the production of vignette materials was to enhance emotional understanding and connection and, thus, empathy with the people within the vignettes; this particular vignette was used with 2 different learning groups. The first group was a cohort of 15 CP trainees who reviewed the materials in small groups for a 6-week learning task culminating in an assessed university-based presentation in front of peers. The second involved 3 qualified CPs working in NHS clinical practices who received the same materials via the post/e-mail which they then reviewed alone. This group of 3 clinicians subsequently wrote individual reflective pieces on the experience of combining creative mediums with the assessment letters. The analysis highlighted a positive impact the mediums had on the clinicians’ connection with the person within the vignette (Keville et al., 2019).

This particular vignette contained the following parts given chronologically at different timepoints over a 2- to 3-week period:

A General Practitioner referral letter to an AMH service for a mother of 3 children struggling following the sudden loss of her husband. Also included was a KitKat chocolate bar for each CP learner.

A CP assessment letter with more details of the loss, its psychological impact, and background information.

A link to “Boulder to Birmingham” for them to listen to. This is a song about loss written by Emmylou Harris and Bill Danoff.

Another KitKat bar for each clinician, and letters by the 3 children for their Dad on Fathers’ Day. Included was an addendum which their mum had written:

D–I, M and E’s dad—died 2½ years ago. We are not Christians and so when they asked where Daddy had gone we invented a place where he would have all the things he liked: KitKats, Arsenal winning all the time and the PlayStation—it’s called KitKat Land. (Mum)

(* Arsenal are a UK premier league football team)

KitKat’s handed out to the clinicians with part 1 were initially unconnected with the vignette. By part 4, via the music, letters, and KitKats, the hope was deeper; empathic connections would occur toward the person within the vignette.

Bridging the Personal Professional Divide

As a trainer, I believe modeling the navigation of the personal professional boundary creates safety for learners and enables them to leap courageously into emotionally uncertain places; if I can be professional yet open, so can they. I also believe it was my personal connection with the material which enabled me to enhance nuances by utilizing real material; through this I believe the learning process was enhanced for my colleagues in both learning groups as demonstrated in the reflections produced (Keville et al., 2019) and my reflections below on the group-learning task in 2015. It is in this spirit of openness that I share my personal story behind the materials.

You Have Come by Way of Sorrow

In 2008, a group of friends lost a beloved member. We were at university together in the early 90s; first with degrees then doctorates, PhDs, university jobs, or visiting partners. “I” and “D” were one of the first to get married and the first to have children. I have vivid memories of finding out the news of “D”s death, of going to the funeral with 2 young children, of seeing the silent courage of friends carrying “D” into the service, of “I” and “D”s 3 young children saying their goodbyes, and of “I” confiding with me after the service about her pregnancy with their fourth child. We were all in shock and at the funeral we indulged in KitKats. My daughter and I wore *Arsenal scarves; I saw “D”s father, on an otherwise heartbreaking day, responding with a semblance of joy in seeing us honoring his son’s passion for the team. From then on, I wept whenever I heard the song “Boulder to Birmingham” by Emmylou Harris. In 2011, enabling her children to express their grief beyond her own, “I” shared letters her children had sent to a newspaper on Father’s Day; again, I wept: I felt the grief. It took 6 years to gain enough emotional control to manage the impact the music and letters had on me. In 2015, Erasmo and I sought permission to use the materials in a learning vignette; the only real-life parts used were the letters, music, KitKats, love, and resilience. I facilitated a learning group involving 5 trainee CPs. I recall the reluctance for some group members to hear the song—perhaps suspecting it might trigger unwanted connections—and me taking the opportunity to play it as we sat in my office. On the side of my filing cabinet was “D”s obituary unbeknownst to all but me; it is still there as it has been since he died. Whilst hearing the song, I managed to keep my tears locked inside (8); and when the group presented to their cohort, I sat away to contain my emotion quietly wiping the tears away. The group worked well in empathically connecting with the personhood within the vignette, with each other and with me; afterward enveloping us all in a group hug. At that time, no one was aware that the day was also the anniversary of my own father’s death, another day filled with deep shock.

I believe we should embrace and learn from these personal stories to further shift a mind-set that can exist in health care perpetuating a them and us stance between patient and professional (9). As taught by my parents, it is here we listen and reach beyond words to a world of unconditional understanding, tolerance, acceptance, and compassion; understanding we all have unexpressed experiences and stories. It is in that spirit we can empathize with people we do not know; a level of understanding we might have for a family member, partner, or close friend, to help them through a life struggle requiring support from strangers qualified as CPs. It is in that spirit that we might courageously open up to the emotional world of another, even if it triggers our own internal experiences.

Continuing to Connect and Care

On receipt of initial referral and assessment letters, it is common for CPs and trainee clinicians to go into a default mode—at times thinking intellectually with minimal or no emotional connection to the distress that might be present. I have noticed in these learning vignettes when music is subsequently used it is often after listening to the song where CPs realize they may have initially been emotionally disconnected. For example, in the long-distance learning task, 1 of the 3 qualified CPs stated:

I generally consider myself caring and human, but my perspective and connection with the client in the referral letter was anything but. (Keville et al., 2019)

We noted that it was on hearing the music that a deeper emotional connection was unlocked with 1 clinician being “moved to tears” and another stating “the music enabled connection by enabling feeling” (Keville et al., 2019).

The themes elicited through an analysis of the reflective pieces further highlighted this process. These themes were “Empathy may not always be emotionally connected”; “Becoming human: The connective power of music: transporting to memories and emotion”; “The need for protection: Shutting out the emotional world music opens up”; and “Being an effective, congruent and humane practitioner” (Keville et al., 2019).

Ultimately, this particular vignette enabled practitioners to reconnect with underlying values, a deeper empathic level of connection with the referral and a greater understanding of their propensities to avoid when feeling overwhelmed (Keville et al., 2019).

Concluding Comments

Reflecting at the end of the long-distance learning task another CP wrote:

The use of letters, KitKat, and naming a special place of rest made me appreciate the power of using different mediums that engage the senses in my clinical practice. I am grateful that this exercise has strengthened the importance to stand back from labels and allow the space to work creatively with the people in front of me. (Keville et al, 2019)

Humans can have a natural tendency to avoid overwhelming emotional experiences; avoidance strategies used pervasively can become unhelpful and are a known maintainer and intensifier of distress (10); impacting on learning (11). Although CPs enable people to connect with, and process, emotional distress, they are human too, with personal life histories. It is crucial we enable connection within others and ourselves, otherwise, we may indirectly shut down emotional expression—exacerbating rather than improving our own, and others’ well-being.

If we are to enhance empathy/compassion in clinical practice, training across all disciplines should enable practitioners to build emotional depth and honesty to experiences that evoke distress for themselves and for others. Perhaps this can be facilitated through personal openness and reflection; experiential learning methods within and outside of classrooms; and regular reflective spaces supported by the wider organizations people work in (6).