Nina Ann, a colleague and cancer patient once said to me, “I never was properly empathic until I had peripheral neuropathy (PN).” She had undergone many treatments for breast cancer for nine years. She said it was now difficult to button her shirt and she experienced shooting pains in her hands and feet, hallmark symptoms of PN. This was the first I heard her self-criticism. I knew her to be a very empathic person. She had been active organizing support groups and volunteered to speak to patients who wanted a veteran cancer patient’s point of view. I asked her to tell me what she meant. She had heard patients talk about PN but it was only when she experienced it herself that she really “got it.” I subsequently have had many conversations with patients, colleagues, and oncology health care providers about empathy and the prerequisites for achieving a state of empathic connection with another. The implication of Nina Ann’s observation is that it is necessary to have a problem before we can empathize with it. Is she correct?
What is empathy?
Empathy is the act of understanding another person’s thoughts, feelings, and experience, by imagining oneself into their situation. The empathizer apprehends the other’s experience as if it were their own. It is “walking a mile in their shoes.” The English word “empathy” emerged over a century ago as the translation for the German psychological term “Einfuhlung,” meaning “feeling into.” Its origin is found in the Greek, “em” in + “pathos” feeling = empatheia.
Empathy differs from sympathy with regard to the emotional component. Simply stated, empathy is feeling with and sympathy is feeling for. Nina Ann criticized herself because she did not feel properly empathic until after experiencing peripheral neuropathy. She concluded she needed to have PN in order to empathize properly. If this conclusion is valid, we have little capacity for going beyond our own experience. However, the essence of empathy is the capacity to imagine ourselves into another’s situation without experiencing it. While it is not necessary to have PN to empathize with it, it may be important to have experience with some unpleasant physical sensation to “get it” about suffering. In fact, sharing a similar experience, e.g., chemotherapy treatment, can mislead a person into thinking “this is how chemotherapy is for everyone,” which is far from accurate. There are many different types of chemotherapy treatment and countless variations on individuals’ responses.
There are three components to empathy and its expression: cognitive—the ability to grasp what the person thinks, to see things from their perspective; affective—the ability to discern another’s feelings; and importantly, the ability to act in such a way as to convey understanding to the other, sometimes referred to as compassionate empathy. It is a complex cognitive and affective process as well as a social behavior, which can be facilitated by direct or indirect experience. Reading literary fiction is an indirect, vicarious experience; it can enhance empathic capacity. Stories inform our capacity to understand other people. However, it is not enough to understand the person’s thinking and feeling, which is largely an internal process; it is necessary to translate that understanding into compassionate action. The behavior of the listener creates the empathic connection, through body language and words well spoken.
Empathy is best thought of as an interpersonal process. In a conversation, being empathic means putting aside our agenda in order to see the others point of view and take account of their emotions. It involves listening with the heart as well as the ears and eyes and communicating that listening/understanding to the person. Empathy expressed effectively results in the other feeling cared for and heard. The empathic healthcare provider may even affect the course of illness.
Are the effects of empathy always positive?
We assume the effects of empathy are positive but there can be a downside. For example, a highly empathic caregiver may feel the suffering of their loved one to the extent that they develop compassion fatigue. In this case, while empathy facilitates caregiving behavior and closeness, it can be at the expense of the self. Professional healthcare providers, during this time of pandemic, have been especially vulnerable to compassion fatigue, a result of the constant experience of empathic connection with suffering patients.
There is also evidence that empathy for our own group is wired in neurologically and can result in unconscious bias. The practical implication of this discovery in neuroscience is that being properly empathic with people who are not in our own group may be more challenging for healthcare providers.
However, the majority of research on empathy reports positive outcomes. For example, high empathy capacity is associated with more prosocial behaviors and stronger relationships with others. In healthcare, we think of empathy as a skill used to connect with suffering which is largely true. However, being properly empathic can also connect us with people sharing positive experiences and humor, a healing elixir in any setting.
Can empathy be taught and learned?
Empathy is both a skill and a quality of the heart. The skill can be learned and the quality can be nurtured. Some people are natural “empaths” and need little training, just as some people are natural athletes. Clinicians in medical settings have studied the important elements of communication training and identified empathy as key to promoting patient involvement in care. Excellent written and internet/video resources are now available. At Atrium Health Wake Forest Baptist Medical Center, a training program to enhance relationship-centered communication is available to all employees. Finally, teaching empathy was the topic of a study on a medical student lecture and practice session at the 2021 American Psychosocial Oncology Society Virtual Conference (see “Facilitating Empathy in medical students with art: An exercise in focused attention, T46”). Variations on these programs are available at other institutions and websites for professional caregivers. They have one important element in common: recognition of empathy as a key component in helpful communication with patients.
Nurturing the qualities that energize empathy, e.g., deep listening, energy, kindness, compassion etc., may be more challenging. A weary professional caregiver burdened with an overload of very sick patients may find little emotional reserve to be empathic when on the front lines of care. Fortunately, there is the recognition that both institutional and individual factors are important in maintaining healthcare providers who can be both competent and empathic in their work.
The empathy exams
Nina Ann felt she failed her own version of “The Empathy Exams,” a phrase used to describe the training some medical schools employ in assessing the effectiveness of Dr-patient relationship skills. I felt her self-rated failure to understand PN was overly critical. Nina Ann was a very empathic person. Her self-reflection was evidence of her sensitivity to others. Developing peripheral neuropathy gave her improved ability to gauge her level of pain relative to others and in so doing, more deeply understanding the other, a form of useful social comparison. It is likely we all have an internal “rating scale” for another’s experience and use it to judge suffering which in turn can activate a certain level of empathic response. Nina Ann established a new threshold for her empathy after her personal encounter with peripheral neuropathy. Her self-observation of deficiency was a testament to her flexibility and openness, both skills useful in developing an empathic connection.
What does it take to be “properly empathic”? An open heart and mind that can imagine the experience of the other and express that connection verbally and nonverbally. Simply stated, becoming properly empathic means listening carefully and responding thoughtfully.