Cultivating Empathy: Inspiring Health Professionals to Communicate More Effectively (Revised Edition)

By Kathleen Stephany

Research demonstrates that even if empathy – the capacity to perceive or share emotions with other beings or objects – is not part of a person’s communication skill set, it can be taught. Empathy can, therefore be viewed as an acquired communication skill. Cultivating and practicing the skill of empathy among health care providers enhances the quality of care experienced by their patients which, in turn, can even improve work satisfaction for health care providers.
Many communication textbooks or manuals for care giving professions primarily focus on specific communication skills and techniques. Cultivating Empathy takes a different approach; the book sets empathy as the foundation of all therapeutic interactions and teaches the reader to learn the art of empathy by using constructive approaches and research findings from social sciences and neuroscience.
Cultivating Empathy is perfect for any student or practicing health care professional who has felt that there was an absence of rapport when interacting with clients or patients and their families. Real case narratives, dynamic interactive exercises and simulation techniques are also provided in this text to assist helpers to learn how to be more empathetic. Readers will gain awareness about human and emotional aspects of patient care, which will hopefully make a positive contribution to their professional practice.

• Language: English
• Publisher: Bentham Science Publishers
• Release date: May 19, 2003
• ISBN: 9789815036480

Book preview

A Historical Definition of Empathy from the Perspective of Philosophy, Psychology & Neuroscience

Kathleen Stephany

Abstract

This book is unique because it promotes empathy as the foundation of all therapeutic interactions and teaches how to be empathetic. The chosen methodology for this book is Phenomenology. The key method for data collection are narratives and the underlying theoretical premise for data analysis is the ethic of care. The important association between the ethic of care and empathy is explained. The concept of empathy is historically explored from a philosophical, psychological, and Social Neuroscience perspective. Terms that are closely aligned with empathy, such as benevolence and compassion, are carefully delineated. Positive Psychology is introduced as a new and crucial focus that emphasizes positive emotions. It is pointed out that whereas traditional empathy is primarily focused on the identification with troubling feelings with the goal of helping people feel better, positive empathy is a therapeutic response that emphasizes emotions like joy and contentment. Emotional intelligence or the ability to read others’ feelings is deemed necessary for empathy. The intelligence quotient (IQ) and emotional quotient (EQ) are both essential for success. In the Case in Point, subjective perceptions of empathy in practice are shared by different helping professionals. A closing simulation exercise focuses on practicing active listening, reflection and nonverbal cues, followed by mock scenarios on how to tell the difference between sympathy and empathy.

Keywords: Active listening, Behavioural approaches, Benevolence, Code-recode, Compassion fatigue, Compassion, Cultural intelligence, Emotional intelligence, Emotional quotient (EQ), Empathy, Ethic of care, Flourishing, Intelligence Quotient (IQ), Member-check, Methodology, Method, Mirror neurons, Moti-vation, Narratives, Non-verbal communication, Phenomenology, Philosophy, Psychoanalytical theory, Psychology, Person-centred Humanistic Psychology, Positive emotions, Positive empathy, Positive Psychology, Reflection, Reflex-ivity, Self-awareness, Self-awareness, Self-Psychology, Self-regulation, Social intelligence, Social Neuroscience, Social skills, Traditional empathy.

LEARNING GUIDE

After Completing this Chapter, The Reader Should be Able to:

Become aware of why a book on empathy is needed.

Gain an understanding of the rationale concerning the methodology, method and theoretical premise for the research data utilized in this book.

Explore the concept of empathy from a philosophical viewpoint.

Understand the key differences between empathy and sympathy.

Draw a connection between empathy and the ethic of care.

Review how two prominent 20th Century Psychologists influenced empathy.

Be able to identify the similarities and differences between terms that are closely aligned with empathy such as benevolence and compassion.

Be introduced to Positive Psychology and flourishing.

Compare traditional empathy with positive empathy.

Gain an awareness that the intelligence quotient (IQ) and emotional intelligence/ quotient (EQ) are both deemed necessary for success.

Compare & contrast emotional intelligence, social intelligence and cultural int-elligence.

Establish the relationship between emotional intelligence and positive Psychology.

Appreciate what recent research in Social Neuroscience tells us about empathy.

Review the Case in Point: Subjective perceptions of empathy in practice.

Enact the Simulation Role Play: Mrs. Jones experiences a recent loss.

INTRODUCTION

When we honestly ask ourselves which person in our lives mean the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen to rather share our pain and touch our wounds with a warm and tender hand. Henri Nouwen, author of The Road to Daybreak: A Spiritual Journey.

This book is unique and different from many other communications manuals because it promotes empathy as the foundation of all therapeutic interactions and teaches health professionals how to be empathetic. This introductory Chapter forms the foundation for the rest of the book. The chosen methodology is Phenomenology, the key method for data collection are narratives, and the ethic of care is the underlying theoretical premise for data analysis. The crucial association between the ethic of care and empathy is established, followed by a discussion of how empathy evolved historically. Terms that are closely aligned with empathy are compared. The link between empathy, positive Psychology and emotional intelligence is identified along with recent research evidence from Social Neuroscience. Subjective perceptions of empathy in practice are reviewed in the Case in Point and a simulation role play focuses on caring for a client who has experienced a recent loss. Mock scenario exercises are also recommended to differentiate between statements that are sympathetic versus empathetic.

WHY A BOOK ON EMPATHY IS NEEDED

Empathy, described in the most simplistic form, is the ability to identify with and understand what another person is truly experiencing (Shafir, 2008) (Fig. 1.1). A book on empathy is needed because although empathy has been determined to be crucial in establishing trust in the therapeutic relationship between health professional and client, there is considerable data to indicate that some health professionals act in ways that are not empathetic (Palese et al., 2011; Riess, 2018). Kuhl (2003) points out that although there are many physicians who are excellent communicators, some do not communicate in a compassionate manner. Other studies indicate that many doctors and nurses just do not know how to be empathetic (Hague & Waytz, 2011; Riess, 2018). Additional evidence suggests that many nurses may be inclined to avoid the use of empathy over the course of time as a form of emotional self-preservation (Mathieu & Cameron, 2007). Physicians have also been traditionally taught to detach themselves emotionally in order to sustain an attitude of objectivity and to protect them from over exposure to human loss and anguish (Decety et al., 2014). Being cautious has its benefits in that it can ward off compassion fatigue. Compassion fatigue occurs as a result of being continuously exposed to human suffering which causes the caregiver to distance themselves emotionally (Mathieu & Cameron, 2007). Chapter Eight explores the important topic of compassion fatigue and offers strategies to prevent and treat it when it occurs.

Fig. (1.1))

Do you understand me? Source: www.pixabay.com.

The good news is that research reveals that empathy can be taught and that it can improve work satisfaction for the health care provider (Palese et al., 2011). When a practitioner consistently acts in empathetic ways, study results indicate a decreased incidence of physician burnout; reduced personal distress, anxiety and depression; and increased life satisfaction (Decety et al., 2014; Goleman, 2006; Hague & Waytz, 2011; Klitzman, 2008). Being the recipient of empathy also improves the quality of care experienced by the patient (Palese et al., 2011). They have more favorable health outcomes, are more likely to follow health advice, and are less likely to complain or take legal action for suspected malpractice (Decety et al., 2014).

PHENOMENOLOGY AS METHODOLOGY

Methodology

in research consists of identifying the approach for gathering data best suited to address a theoretical question or problem in practice (Jackson et al., 2007). The methodology chosen to study empathy in this book is a form of qualitative research called Phenomenology. Qualitative research conducted by social scientists is chiefly concerned with gaining an understanding of human beings’ experiences through humanistic and interpretive means. Their goal is to get to the truth of the phenomena under study and then describe those experiences as best as they can (Jackson et al., 2007; Jobin & Turale, 2019). In qualitative research, it is assumed that reality is not fixed but is a construction of the human mind, and a person’s truth is a combination of varying interpretations of reality (Loiselle & Profetto-McGrath, 2011).

Phenomenology

is the study of the essence of consciousness as experienced by a person (Smith, 2006). The key aim of this type of research is to gain an understanding of a person’s lived experiences and emotions to create detailed descriptions of the phenomenon under investigation (Yuksel & Yildirim, 2015). Phenomenology is concerned with making the invisible visible, a kind of seeing that brings what seems hidden to the forefront (Groenewald, 2004; Stanghellini, 2011). McLeod (2001) explains that when we seek to understand human behaviour, the study of lived experiences when combined with existing knowledge from other sources, enriches what we know about the subject. A strength of Phenomenology is that it has the potential to assist health professionals in gaining valuable knowledge that informs practice (Loiselle & Profetto-McGrath, 2011; Neubauer et al., 2019).

Narratives as Method

Although methodology is concerned with utilizing the best approach to address a particular problem, method refers to how that data is collected and by what means (Jackson et al., 2007). In this textbook, the specific method to collect data mostly consisted of narratives. According to Stanghellini (2011), narratives are personal accounts of a person’s actions, experiences and beliefs that have meaning for them. When someone tells their story, they bring us into their world and help us see as they see and feel what they feel (Stanghellini, 2011). Consequently, narratives offer helping professions a compelling way to study the constructs of care and empathy.

Ensuring Research Rigor in Qualitative Inquiry

Even the most optimistic scholar is aware that it is virtually impossible to grasp all aspects of a social phenomenon, inquiry or question. They do, however, most often advise that their research is conducted with objectivity, ethical attentiveness, and accuracy (Jackson et al., 2007). There are specific ways to ensure that research rigor occurs in qualitative research. The standard of trustworthiness in data collection for this textbook was ensured through member-checking, code-recode, and reflexivity. Note that although member checking could not occur with a Coroner’s case it was still applicable with the other means of inquiry.

Member-checking

is a way to validate qualitative research findings by sharing the themes and descriptions with participants to confirm that they are accurate (Jackson et al., 2007). With code-recode the data that is gathered is analyzed and then after a period of at least two weeks, it is re-analyzed to ensure that it accurately represents the first analysis (Krefting, 1991). Reflexivity is concerned with the degree of intentional or unintentional influence that the researcher has on the research results (Jootun et al., 2008). It involves a process of ongoing reflection in order to gain an understanding of one’s own values and beliefs that may influence findings. Once aware of biases, the researcher resorts to alternative means to analyze the data to reduce predispositions (Jootun et al., 2008). In this work, a journal was maintained on an ongoing basis to assess for personal bias.

THE ETHIC OF CARE AS THE THEORETICAL PREMISE

Every qualitative researcher brings their own worldview and theory base into their work that, in turn informs their social inquiry (Jobin & Turale, 2019). For this book, I chose the ethic of care as the theoretical premise to analyze data. The ethic of care is a special proponent of applied nursing ethics. It is the moral imperative to act justly, emphasizes the relational or contextual aspects of care and is concerned with the interconnectedness between people (Stephany, 2020).

Leget et al. (2019) point out that although care ethics has developed over the past 35 years, what has consistently remained is the focus on the experiences of real people and the meaning derived from those encounters. The ethic of care was derived from the work of Gilligan (1982) and her world renown book, In a Different Voice: Psychological Theory and Women’s Development. In her work, Gilligan studied the differences in the moral development of women versus men. She discovered that a woman’s caring ways were often interpreted as weakness and they were, therefore, subsequently excluded from psychological research and critical moral discourse (Stephany, 2020). In her preliminary studies, Gilligan pointed out that the way people talk about their life experiences and the words that they use to describe those experiences is important, and that they highly value their connections with other people (Stephany, 2020). Gilligan subsequently concluded that being aware and sensing the needs of others was as important as being able to use universalized maxims in ethical decision-making (Stephany, 2020). Gilligan specifically defined care as a web of connection. Being conscious of the needs of others and responding to those needs was deemed crucial to the act of caring. Gilligan also openly condemned the exploitation of other people (Stephany, 2020).

Noddings (1984) described the ethic of care as a way to venture beyond the ego self through developing and sustaining a helping, trusting, and caring relationship. Noddings proposed that caring was a way to experience the world as another person experiences it and see with their eyes. In other words, the ethic of care and empathy are both viewed as an active means to cultivate a form of motivated sensitivity to the experience of others. Lachman (2012) reminds us that caring and empathy are synonymous with making an intentional connection with the people who we are looking after.

The Moral Connection Between Care Ethics & Empathy

The Philosopher, Michael Slote (2007), connects care ethics and empathy with the earlier work of Philosophy and Psychology (Noddings, 2010). Slote explains how people can sometimes have a caring attitude toward certain persons and possess an absence of caring or even malice toward others. Slote makes the assertion that empathic caring is crucial to ethical motivation and a necessary personality trait of moral agents. He even offers general criteria of what he would consider right or wrong action based on the idea of empathic concern for others. Slote uses the example that one must show concern for those both near and dear to us but also for the plight of distant others. As effective and caring moral agents, we must not exclude anyone. Slote asserts that we are ethically obligated to care for everyone who suffers. This is in keeping with the notion of the ethic of care that condemns the exploitation of all people and promotes advocacy to end suffering (Gilligan, 1982; Stephany 2020).

THE PHILOSOPHICAL UNDERPINNINGS OF EMPATHY

Philosophy is the study of the fundamental nature of knowledge, reality and existence (Rand, 1982). It is the goal of this discussion to give a historical account of the philosophical development of the concept of empathy. (Fig. 1.2). Philosophical underpinnings are succinctly reviewed to demonstrate how the term has evolved over time.

Fig. (1.2))

Philosopher. Source: www.pixabay.com.

The word empathy, was first introduced from the German language into English early in the first part of the 20th century by Titchner, a Cornell University Professor. The term was derived from the German word, Einfuhlung, which when translated means feeling one’s way into (Hunsdahl, 1967). However, although the specific word, empathy, had not been used in North America prior to that point in history, it does not mean that awareness of empathic action did not already exist. In fact, the philosophers David Hume and Adam Smith were well acquainted with the application of what we now refer to as empathy as long ago as the 18th century. However, they called it sympathy (Hume, 1739; Smith, 1759). Both terms, sympathy and empathy were derived from the Greek word, pathos which means to suffer or endure (Merriam-Webster Dictionary, n.d.). Today we see sympathy as different from empathy. Presently, sympathy takes on the form of feeling sorry or pity for another person’s situation. Yet empathy is seen as a way of trying to understand the actual experiences of others, which may or may not include feeling their pain (Adler et al., 2012). Slote (2007) points out that a person can feel sorry for another person who experiences pain and also wish them well. This is a form of pity or sympathy for them. The following example assists us in better understanding how the two terms differ in action.

Consider the difference between sympathizing and empathizing with a homeless person. When you sympathize, it’s the other person’s confusion, joy or pain. When you empathize, the experience becomes your own, at least for the moment. It’s one thing to feel bad (or good) for someone – sympathy – but it is more profound to feel bad (or good) with someone – empathy (Adler et al., 2012, p. 79).

Hume (1739) used the term sympathy to describe how one uses their imagination to take in the perspective of the other person and/or their situation. Smith (1759) also believed that trying to understand the experiences of others was a necessary social construct for morality. Morality is a somewhat multifaceted term but, in its most fundamental form, refers to a code of conduct that is put forward by any group in society which may or may not include religion, law or etiquette (Stanford Encyclopedia of Philosophy, n.d.). Rychlak (1973) asserts that morality is concerned with behavioral decisions that could be made by a supreme being or God. Smith claimed that sympathy arose from an inherent desire to understand the emotions of others in order to ultimately enhance the greater good of society. Both Hume and Smith referred to this phenomenon as emotional contagion which is the capacity to feel the emotions of other people through coming into contact with their pain. The word contagion is related to the word contagious, and it is as if one catches the other person’s emotional experience in the same manner as you would catch a physical cold. Slote (2007) explains that it is as if their pain becomes our pain. Today we would call that sort of action, empathy or compassion. The relationship between empathy and compassion will be discussed more fully a bit later on in this Chapter.

There were other serious philosophers and thinkers that lived in the late 19th Century and early 20th Century who were interested in empathy. Theodor Lipps (German philosopher) viewed empathy as aesthetic sympathy which occurs through the process of humanizing objects by feeling ourselves into them (Nelson, 2005). For Lipps, the example of a willow tree weeping or crying has nothing to do with the actual function of the tree. It is concerned with us placing our feelings of sadness into the image of the way in which the willow tree branches and leaves seem to resemble a streaming flow of tears (Nelson, 2005).

Two prominent German Psychiatrists and Philosophers, Karl Jaspers and Max Weber believed that Phenomenology was an important tradition of empathy (Walker, 1995). Other German Psychiatrists and Philosophers like Wilheim Dilthey and George Simmel also emphasized that gaining an intimate and personally felt understanding of another’s experience was important (Walker, 1995).

20th CENTURY PSYCHOLOGY AND EMPATHY

Historical descriptions of the definition of empathy will now be presented from the perspective of 20th Century Psychology. Psychology involves the science of control and prediction of behaviour which includes but is not limited to predicting people’s behaviour from test scores, during experiments and manipulating human behaviour during psychotherapy (Rychlak, 1973). It also involves the study of human emotions (Fig. 1.3).

Fig. (1.3))

The study of human emotions. www.pixabay.com.

It is not the goal of this discussion to give an extensive historical account of the development of the concept of empathy in Psychology. Rather, empathy will primarily be reviewed through the lens of two prominent 20th Century Psychologists, Heinz Kohut (Self-Psychologist) and Carl Rogers (Person-centered Humanistic Psychologist). The contributions of Kohut and Rogers to the subject matter of empathy in practice has been well respected in the psychological academic community (Kahn, 1985; Tobin, 1991). Both Kohut and Rogers asserted that humans had a universal need for empathic responses throughout their life-time (Kahn, 1985). Although they differed in many ideas because of their different theoretical viewpoints, what Kohut and Rogers implicitly agreed upon was the phenomenological emphasis of empathy as the basis of the therapeutic relationship between the therapist and the client (Tobin, 1991).

Heinz Kohut & Self-Psychology

Kohut (1985) was an Austrian-born American Psychologist known for his development of Self-Psychology. According to Banai et al. (2005), Self-Psychology is a comprehensive theory consisting of developmental and clinical models for consultation and therapy. In Self-Psychology the progression toward a healthy personality is most likely to occur when individuals unite their talents, ambitions and desires for success with the support of significant others (self-objects), who provide them with empathic mirroring while they are growing up (Carducci, 2009). Empathic mirroring is a process where parents offer attention and praise when a child tries to assert their own sense of self by taking risks and trying new things (Carducci, 2009). On the other hand, psychopathology or arrested personality development is thought to occur due to interrupted or unmet developmental needs (Banai et al., 2005). For instance, the adult who did not experience empathic mirroring when growing up loses their capacity to maintain healthy self-esteem, formulate realistic goals and empathize with others (Carducci, 2009). In Self-Psychology the therapist’s goal is to provide the somewhat troubled adult client with an atmosphere of acceptance and understanding. Only after experiencing empathy emanating from their therapist, are they able to feel safe and free to express their inner desires, ones that may have been unmet due to a lack of parental empathic mirroring.

Kohut (1985) also expressed frustration by what he considered to be many misinterpretations of empathy and wanted others to understand what it does and does not mean. He believed that endeavours to understand and know what another’s experience is like should occur without the therapist losing their own objectivity (Kohut, 1985). For instance, the therapist must be understanding without becoming drawn into the client’s actual emotional suffering. In this manner, the therapist is able to understand what the person is going through and act in a supportive role but still remain somewhat separate and maintain professional boundaries (Kohut, 1985). Professional boundaries refer to limitations that restrict the extent and nature of a professional’s involvement with their clients/patients (Oberle & Bouchal, 2009).

Psychoanalytical Theory & Behaviouralism as a Prelude to Humanism

Psychoanalytical theory began with Sigmund Freud and was founded on the principles of psychic determinism. Psychic determinism is the belief that behaviour is determined by a person’s mostly unconscious urges, yearnings, motives and conflicts that occur in the mind (Nietzel et al., 1998). The basis of behaviour is thought to be determined in childhood through either the satisfaction

or frustration of a series of basic needs or psychosexual stages of development (Nietzel et al., 1998).

Although Psychoanalytical theory emphasizes intrapsychic conflicts and unconscious motivations, Behavioural approaches are quite different. They are based on the assumption that persons are born as blank slates and that their personality develops as a result of learning that occurs in a social setting (Monte, 1995). In this manner, behaviour is learned and molded through the person’s environment and the situations that they encounter while growing up (Monte, 1995).

Person-centered Humanistic Psychology

Person-centered Humanistic Psychology appeared in the 1950s as an alternative to psychoanalytical and behavioural theories (Monte, 1995; Rogers, 1961). The fundamentals of Person-centered Humanistic Psychology are founded on the belief that people are inherently good and that they have the potential to grow into something more (Rogers, 1980). Humanism professes that people have the ability for self-awareness and are capable of changing their self-concept, attitudes and behaviour (Rogers, 1980).

Person-centred Humanistic Psychology also focuses on each person’s inherent capacity to self-actualize as long as the right conditions exist (Nietzel et al., 1998). Self-actualization is concerned with a person reaching for and achieving their highest potential during the course of their life-time, not in the form of material possessions, but in terms of personal character development and achievements (Nietzel et al., 1998). Rogers (1980) asserted that if someone did not receive loving acceptance and approval from their parents when growing up, they could heal and eventually progress toward their highest potential but only if they received support in the form of unconditional positive regard emanating from their therapist. In contrast to both Psychoanalytical and Behavioural approaches, in Person-centred Humanistic Psychology, mental and psychological problems are thought to develop in childhood as a consequence of being regularly judged by a primary caregiver as inadequate or less than good enough (Rogers, 1961).

Carl Rogers & Empathy Research

Carl Rogers was an American born, Person-centered Humanistic Psychologist and is regarded with tremendous respect within the community of clinical and counselling Psychologists (Haggbloom, 2002). The contributions made by Rogers to the study of empathy were unprecedented in the field of Psychology prior to his time. It would, therefore, be inappropriate to exclude Rogers in a discussion of the historical evolution of the concept of empathy.

This book proposes that empathy is vital to all therapeutic communication and it was Carl Rogers who empirically proved the importance of empathy in therapy. Rogers (1980) emphasized through his research that empathy or the ability to really understand the feelings and personal meaning of another’s experience actually communicates to them that you genuinely care. He pointed out that a therapist who listens sensitively and actively to what the client is saying may truly facilitate within the client a willingness to become more caring toward themselves (Rogers, 1980). Rogers believed that the ability to care for oneself forms the foundation for personal change (Fig. 1.4).

Fig. (1.4))

Self-acceptance. Source: www.bodhicircle.blogspot.com.

Unconditional Positive Regard, Congruence & Empathy: Key Components of Change

According to Rogers (1961), three key components must be present during client-centered therapy to help clients change in a positive way, unconditional positive regard, congruence, and empathy (Rogers, 1961; Nietzel et al., 1998) (Fig. 1.5). Rogers (1942) substantiated through his own research that when these elements are expressed by the therapist, clients are inclined to become more self-aware, self-accepting, and less defensive in their personal relationships (Nietzel et al., 1998). They are also likely to base their self-concept more on self-evaluation and less on the opinions by others (Nietzel et al., 1998).