Cultivating Empathy: Inspiring Health Professionals to Communicate More Effectively [1 ed.] 9781608059881

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CULTIVATING EMPATHY: Inspiring Health Professionals to Communicate More Effectively Authored By

Kathleen Stephany Full Time Nurse Educator in the Faculty of Health Sciences Douglas College, BC Canada Canada

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DEDICATION To my beloved Aunt Dorothy Barichello. Thank-you for being an amazing role model. This world was made better because of you.

CONTENTS About the Author

i

Forward

ii

Preface

iv

Acknowledgements

v

CHAPTERS 1.

What is Empathy?

3

2.

When the Client/Patient Feels Alone

39

3.

Why Empathy is Sometimes Lacking: The Influence of Environmental Factors

55

4.

What it Feels Like to Experience Empathy

84

5.

How to be Empathetic

99

6.

Dealing with Difficult People and Situations with Empathy and Care

127

7.

Understanding Compassion Fatigue

147

References

167

Glossary

174

Appendix B

182

Index

183

i

About the Author Dr. Kathleen Stephany PhD is a practicing registered nurse, psychologist, teacher and published author. She has extensive clinical experience assisting persons who are in crisis and facilitating conflict resolution. Kathleen is also an ethicist and care theorist. Kathleen obtained her PhD in Counselling Psychology from Breyer State University in Alabama, USA. She also holds a MA in Counselling Psychology from Simon Fraser University (SFU), a BA in Psychology from SFU, a BSN from the University of Victoria and a Diploma in Nursing from the British Columbia Institute of Technology (BCIT). Kathleen is a practicing RN with the College of Registered Nurses in BC (CRNBC), an Associate Member of the Western Northern Region of Canadian Association of Schools of Nursing (WNRCASN), and a Certified Canadian Counsellor with the Canadian Counselling & Psychotherapy Association (CCPA). She is also a Member of The Xia Eta Chapter of Sigma Theta Tau International, Honor Society of Nursing and a Member of the International Association for Suicide Prevention (IASP). Kathleen has experience as a critical care nurse, psychiatric nurse clinician, therapist, researcher and coroner. Kathleen is presently employed full-time as a Nurse Educator in the Bachelor of Science in Nursing (BSN) Program at Douglas College in Coquitlam, BC. She teaches courses in Nursing Ethics, Mental Health, Addictions and Communications simulation. She is also an inspirational speaker. In addition to her passion for reading, writing and teaching, Kathleen is an avid gardener.

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FOREWORD A book of inspiration. The concept of caring in our human existence is a moral and ethical imperative. Our survival as a species depends on the quality of care we give to our fellow human beings. Caring must satisfy certain human needs and the giver should demonstrate some special interpersonal qualities and skills. Empathy is a significant quality which is sometimes misunderstood and is not synonymous with sympathy. This text crystallizes the concept as it is applied to caring. The focus of this foreword is to give assent to the rigour of the current work. Kathleen a creditable clinician and educator with years of experience, has boldly and passionately addressed the importance of empathy. This in-depth work has defined the construct of empathy and moved its comprehension to levels where clinicians, educators and students can appreciate its application. She has demonstrated the complexity and dynamics of empathic caring through theoretical knowledge, models of application and above all, through the lived experience of case studies. The emic view transcends the values, beliefs and assumptions of other individuals. Individuals construct their experiences from perception, personal evaluation and other cognitive brain functioning. This unique and lived experience is what empathy sets out to capture and understand, not only from the individual describing it, but also from the emotions which accompany the experience. When empathy is not experienced by the recipient, mistrust, not being understood and “being alone” is a devastating feeling. Chapter 2 aptly addresses these feelings. On the other hand, chapter 4 highlights the experience of Rebecca when empathy is felt. This is a powerful humanistic and spiritual feeling. Apart from the various levels of empathy such as understanding, acquiring trust and the accurate interpretation of the agony or suffering to the emotional feeling, as you travel with the individual, Kathleen has raised many poignant questions about the nature of empathy. Are humans naturally empathetic? Is it a nature/nurture issue? Can empathy be cultivated? She attempted to answer these questions well with a

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creditable body of theory, research and case experiences. She has recommended many good ideas of how to cultivate empathy in chapter 5. So far, the focus of discussion has been on specific extracts of Kathleen’s brilliant work. Let us briefly turn our attention to the challenging aspects of empathy. Life has many exciting pleasures however; it can be frustrating with anger, disappointments and self destruction. These are difficult situations and experiences to comprehend especially when bias, beliefs and values are considered. She has again, focused on many insights to dealing with difficult situations. Bias, beliefs and values can deter an empathic response to such experiences. Kathleen has approached this with a measured sensitivity and warmth in chapter 6. In conclusion, this text is an exceptional piece of work which addresses the concept of empathy from different perspectives. Its uniqueness lies in the multimodal approaches which is embedded with evidenced informed practice research material. She has synthesized research, education and clinical practice experiences well. Her dedication to care as a moral and ethical imperative is highly commended and, she is wished the best of success in her inspiring work to others in the field.

Michael Miller

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PREFACE “When I have been listened to, when I have been heard, I am able to reperceive my world in a new way and go on.” Carl Rogers, 20th Century Psychologist and Forefather of Humanism I chose to write a book on empathy because I believe that empathy is the foundation for all therapeutic interaction and when it is lacking, our patients and/or clients feel emotionally neglected. For example, when people are faced with a serious life or health challenge, they want knowledgeable and competent practitioners caring for them, but they also long to be understood. Yet, all too often, empathy is not included in the curriculum of many caregivers’ training. Therefore, the intention of this book is to inspire and teach both students and practicing health professionals, how to be more empathetic. I chose the title, Cultivating Empathy, because I am a gardener. Just as a beautiful garden can be cultivated, empathy can also be nurtured. (Note: All of the stories and case study narratives in this book come from real life experiences. However, names and details have been altered significantly enough to preserve confidentiality).

Kathleen Stephany Full Time Nurse Educator in the Faculty of Health Sciences Douglas College, BC Canada Canada E-mail: [email protected]

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ACKNOWLEDGEMENTS This book could not have been written without the many people who willingly shared their heartfelt stories. Thank-you for helping me to understand how important empathy is. I am indebted to my mother for being a living example of empathy and compassion. I am grateful to my beloved husband, Harold, for encouraging me to write about this important topic. To my children, Nathan, Connie, Kent and Kim, thank-you for your love and appreciation. Thank-you Bentham Science for publishing this book. I extend appreciation to my peer reviewers for their insightful suggestions, and I express sincere gratitude to all of my former and present students who forever inspire me. CONFLICT OF INTEREST The author confirms that this ebook contents have no conflict of interest.

Kathleen Stephany Full Time Nurse Educator in the Faculty of Health Sciences Douglas College, BC Canada Canada

Cultivating Empathy, 2014, 3-38

3

CHAPTER 1 What is Empathy? Abstract: The first chapter of this textbook covered what is unique about this particular communications manual. Unlike many other books that focus primarily on communication strategies, this book presents empathy as the foundation for all therapeutic communication and teaches how to be empathic. The chosen methodology for this textbook was the examination of lived experience in conjunction with evidence informed practice. The underlying theoretical premise of this work was the ethic of care. The important connection between the ethic of care and empathy was explained. The concept of empathy was explored from a historical view point and from the perspective of both philosophy and psychology. Terms that are closely aligned with empathy such as benevolence and compassion were carefully delineated. The concept of empathy was further examined through recent evidence derived from social neuroscience. This discussion included: the role of mirror neurons; an explanation of how we come to know what another person is thinking and feeling; what leads us to respond with sensitivity to another’s suffering; and how we are able to differentiate between our own experience and that of the other person. In the case in point subjective perceptions of empathy in practice were shared by different helping professionals. A closing simulation exercise focused on practicing active listening, reflection and watching nonverbal cues, followed by mock scenarios on how to tell the difference between sympathy and empathy. The rules for confidentiality during simulation were introduced along with a sample simulation confidentiality form.

Keywords: Active listening, behavioural approaches, benevolence, compassion, compassion fatigue, empathy, epistemology, ethics, evidence informed practice, knowledge, metaphysics, mirror neurons, non-verbal communication, personcentered humanistic psychology, phenomenology, philosophy, politics. esthetics, psychoanaly-tical theory, psychology, reflection, science, self-awareness, selfpsychology, social neuroscience, sympathy, the ethic of care. LEARNING GUIDE After Completing this Chapter, the Reader Should be Able to *

Define empathy.

*

Define the ethic of care and understand its relevance to empathy.

*

Explore the development of the concept of empathy from a philosophical viewpoint. Kathleen Stephany All rights reserved-© 2014 Bentham Science Publishers

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Kathleen Stephany

*

Understand the key differences between empathy and sympathy.

*

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.

*

Define social neuroscience.

*

Appreciate what recent research in social neuroscience tells us about empathy.

1) the role of mirror neurons. 2) how we come to know what another person is thinking and feeling. 3) what leads us to respond with sensitivity to the suffering of other people. 4) how we are able to differentiate between our own experience and that of the other person. *

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

*

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

*

Gain an understanding of the importance of confidentiality during simulation.

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 chose rather to share our pain and touch our wounds with a warm and tender hand.” Henri Nouwen, Author of the Road to Daybreak: A Spiritual Journey

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Many communication textbooks or manuals for the helping professions primarily focus on specific communication skills and techniques. This book takes a different approach. It promotes empathy as the foundation of all therapeutic interactions and teaches how to be empathetic. Empathy, described in the most simplistic form, is the ability to identifying with, and/or to understand, what another person is truly experiencing (Shafir, 2008). As illustrated in Fig. 1, even Primates have the capacity to be empathetic to each other.

Figure 1: Mother Primate demonstrating empathy to her offspring. Source: Freestock Photos http://www.rgbstock.com/.

However, there is considerable data to indicate that some nurses and physicians act in ways that are not empathetic. Kuhl (2003) points out that, although there are many physicians who are excellent communicators, there are also “many more who – without being aware of it – cause people to suffer by not communicating in a compassionate manner” (p. 44). Other studies indicate that some health care professionals, including both doctors and nurses, sometimes just do not know how to be empathetic (Hague & Waytz, 2011). Research evidence also suggests that some

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nurses may even be inclined to avoid the use of empathy as a form of self preservation (Marino, 1998). Many nurses are negatively impacted on a cumulative basis by all of the suffering that they witness daily, which may result in the development of compassion fatigue. Compassion fatigue occurs when the caregiver distances themselves emotionally and stops being empathetic as a result of being continuously exposed to too much pain in their work setting (Figley, 2002). In order to address this important issue, the last chapter of this book specifically focuses on recognition of the symptoms of compassion fatigue and how to heal from it. Other research reveals that empathy can be taught, that it can improve work satisfaction for the health care provider, and even enhance the quality of care experienced by the patient (Palese et al., 2011; Klitzman, 2008; Goleman, 2006). Hague and Waytz (2011) explain that strategies that promote clinician awareness of the human and emotional aspects of patient care, help to teach them about what it means to be empathetic. This book provides the reader with constructive ways to learn and practice the art of empathy. It is therefore, perfect for any student or practicing health professional who has felt that there was an absence of rapport when interacting with clients/patients and their families. Real case narratives, dynamic interactive exercises and simulation techniques are used to assist helpers to learn how to be more empathetic. METHODOLOGY According to McLeod (2001) when seeking to understand human behaviour, the study of lived experience, when combined with existing knowledge derived from other sources, enriches what we know about the subject in question. For this reason, the methodology that was chosen for this book was to examine the lived experiences of people who have either felt empathy or a lack there of, in conjunction with evidence informed practice material. THE ETHIC OF CARE AS THE UNDERLYING THEORY The underlying theoretical premise of this textbook is the ethic of care. The ethic of care is a special proponent of applied nursing ethics that emphasizes the relational or contextual aspects of care within the context of ethical decision

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making (Stephany, 2012). The ethic of care is also the moral imperative to act justly (Stephany). It is concerned with the interconnectedness between people and with the purposeful pursuit of ending discrimination against all minorities. The reasons why I chose the ethic of care as the underlying theory for this work, is due in part because I am strong follower of the ethic of care, but more importantly because the literature offers supporting evidence for the close alignment between empathy and the ethic of care, which will be demonstrated in the ensuing discussion. The ethic of care was derived from the work of Gilligan on the subject matter of ethical actions and the practice of nursing (1982). Gilligan proposed that nurses should address ethical decision making in practice based on caring relationships, connectedness to one another and context. Gilligan also insisted that nurses oppose all action that causes unnecessary suffering or the exploitation of others. Current day nurses who practice under the premise of the ethic of care, are also encouraged to be involved in client or patient advocacy, and to be the voice for the voiceless (Stephany, 2012). Caring action in the practice of the ethic of care is seen as the means of going beyond the ego self through developing and sustaining a helping, trusting, caring relationship, as a way of connecting oneself more deeply with the experiences of the person being cared for (Noddings, 1984). Caring is also acted upon through experiencing the world as the other experiences it by viewing it in the “eyes of the cared for” (Noddings, p. 13). In other words, empathy and the ethic of care are both seen as an active means to cultivate a form of motivated sensitivity to the experience of others. As highlighted in Fig. 2, here-in lays one key bond between the ethic of care and empathy.

Empathy and the ethic of care are both seen as an active  means to cultivate a form of motivated sensitivity to the  experience of others. Figure 2: Diagram demonstrating a key connection between empathy and the ethic of care. Source: Noddings, 1984; Stephany, 2012.

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Slote (2007), Watson (2008) and Stephany (2012) also draw attention to empathy in relationship to the moral action of caring. However, before proceeding with the important discussion of morality, empathy and the ethic of care, it is imperative that the distinction between morality and ethics be made clear. Although both moral and ethical behaviour are “concerned with the same questions of doing what is right and good... unlike morality, ethics makes no claim regarding its assumptions being based on divine inspiration or intention” (Rychlak, 1973, p. 822). Within the practice of the ethic of care, caring is also viewed as an “ethical-moralphilosophical values guided foundation that denounces the notion of separateness and replaces it with the importance of relationship” (Watson, 2008, p. 29). In this context, empathy is viewed as action orientated behaviour that consists of intentionally putting oneself into the situation experienced by the other person because they are a part of the greater whole and if they suffer so do we (Watson; Stephany, 2012). The present day philosopher, Michael Slote (2007) in his book entitled, The Ethics of Care and Empathy, connects care ethics and empathy with the earlier work of philosophy and current 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 empathy and empathic caring is crucial to moral motivation. He argues that empathy is a key component of morality and a necessary personality trait of moral agents. He even offers a general criteria of what he would consider right or wrong action based on the idea of empathic caring or concern for others. Slote uses the example that one must show concern for those both near and dear to us but also be concerned for the plight of distant others. As effective and caring moral agents we must not exclude those that we do not know or those that live in distant places. Our caring must instead be for all who suffer. This is in keeping with the notion of the ethic of care that condemns exploitation and works toward ending the suffering of all people (Gilligan, 1982; Stephany 2012). Fig. 3 emphasizes the important connection of both the ethic of care and empathy in relation to the moral action of caring.

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Empathy and the ethic of care are both involved in the moral  action of caring for, and about, the plight of others, especially their  suffering, either individually or globally. Figure 3: Diagram demonstrating the connection between the ethic of care, empathy and moral action. Source: Watson, 2008; Stephany, 2012.

Noddings (2010), in making reference to Slote ’s work on the ethics of care and empathy explains that we need to train children to identify with the needs of others and that the act of empathy should assist us in recognizing and helping to relieve the pain experienced by others, even if we had no part in causing them to suffer. “Moral sensitivity is not merely a matter of not causing pain, it should lead us to relieve pain whatever its cause” (Noddings, p. 7). Slote (2007) also encourages us to act with a larger and perhaps even global sense of commitment to the welfare of others. If we (as individuals, as societies, as a species) haven’t in fact yet made our best efforts to stimulate and educate our empathic capacities for concern with people we don’t know, then we presumably don’t know how far those capacities can or eventually will take us (Slote, 2007, p. 33). My interpretation of what Slote (2007) was saying in the above quote, is that our capacity for empathetic care can extend beyond what we are accustomed to, and if we dare to care beyond what we have chosen to do in the past, we may succeed in connecting and helping others on a much bigger, perhaps even on a global scale. WHAT IS EMPATHY? Chapter one defines empathy from a philosophical and psychological perspective and offers a historical glimpse of how the concept of empathy evolved over time. The key differences between empathy and sympathy as we currently understand them, is presented. Terms that are closely aligned with empathy such as benevolence and compassion are carefully delineated. Toward the end of the chapter, what we now know about empathy from social neuroscience research will be presented.

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Knowledge from Science and Philosophy Before proceeding with a concise overview of some of the philosophical historical influences on the concept of empathy, it is first necessary to briefly define knowledge. Knowledge that is derived from science will be compared with knowledge that originates from philosophy. Knowledge is concerned with all that is known about a specific subject matter and, this “spectrum of knowledge ranges from very broad statements to very precise statements” (Fawcett & Garity, 2009, p. 4). Although there are many different ways to obtain knowledge, this discussion will only focus on knowledge that is derived from science and philosophy, but will not cover this subject matter extensively. Rather, science and philosophy will be introduced as the backdrop for further discussions about the concept of empathy. Science consists of a methodical endeavour to build on existing knowledge through rigorous means of testing explanations and predictions. The scientific method consists of a set of orderly, systematic and controlled methods for acquiring empirical data that can be either quantitative or qualitative in nature (Oxford Dictionary, 2012; Loiselle & Profetto-McGrath, 2011). Quantitative research designs are most often “used to test descriptive, explanatory, and predictive middle-range theories, (and) are most simply characterized by data that are numbers” (Fawcett & Garity, 2009, p. 98). In quantitative studies, the researcher typically uses large numbers of subjects and acts as an objective observer. In contrast, in qualitative inquiry, reality is viewed from the research participants’ perspective and typically, smaller numbers of subjects are used. The qualitative approach is holistic and often occurs in natural settings, and the data that is collected is in the form of words or themes rather than numbers (Fawcett & Garity). Philosophy is the study of the fundamental nature of knowledge, reality and existence (Rand, 1982). Rand does a great job of poetically referring to the interconnectedness of knowledge that is derived from both science and philosophy. She refers to science as the trees of a forest, but notes that philosophy is the soil which makes the forest possible. Therefore, although scientific knowledge is a crucial part of gaining understanding through evidence,

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philosophy offers us the background to more comprehensively understand how that knowledge relates to living a moral or good life (Durant, 1961). Philosophy consists of five key subcategories: metaphysics, epistemology, ethics, politics and esthetics (Oxford Dictionary, 2012; Landauer & Rowland, 2001). Metaphysics questions existence or asks the question, “What is out there?” Epistemology is the study of knowledge or, “How do I know what I know?” Ethics examines right action or, “What is the right thing to do?” Politics studies force or what actions are permissible or how people should act in a proper society, while aesthetics is concerned with scrutinizing the art or beauty of life (Landauer & Rowland; Durant, 1961). THE PHILOSOPHICAL UNDERPINNINGS OF EMPATHY

Figure 4: Historical monument. Source: Freestock Photos http://www.rgbstock.com/.

Fig. 4 depicts a historical monument and is symbolic of the fact that the study of empathy has changed over the course of time. However, it is not the goal of this discussion to give an extensive historical account of the philosophical development of the concept of empathy. Rather, some philosophical

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underpinnings are succinctly reviewed to help you to understand that the term has indeed evolved. 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 what empathic action entails 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, but 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 to endure (Internet Encyclopedia of Philosophy (IEP), 2012). Today we see sympathy as different from empathy. Presently, sympathy takes on the form of feeling sorry for, or feeling 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, Rolls & Proctor II, 2012). Slote (2007) points out that, a person “can feel sorry for, or bad for, the person who is in pain and positively wish them well. This amounts, as we say, to sympathy for them, and it can happen even if we aren’t feeling their pain” (p. 13). 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.

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Morality was previously discussed in relation to the ethic of care, empathy and concern for the plight of others. Here the relationship between morality and empathy will be reviewed from a philosophical and historical viewpoint. Morality is a somewhat multifaceted term but in a most fundamental form it 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 (Gert, 2012). Rychlak (1973) asserts that morality directs behavioral decisions made in keeping with what a, “(S)upreme Being would have chosen had he made the affirmation” (p. 822). 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. “It is as if their pain invades us” (Slote, 2007, p. 13). 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. For example, Theodor Lipps (German philosopher) viewed empathy as aesthetic sympathy which occurs through the process of humanizing objects by feeling ourselves into them (Depew, 2005). For Lipps the example of a willow tree weeping (crying) has nothing to do with the actual function of the tree, but 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 tears (Depew). Walker (1995) points out that, others like, Karl Jaspers, (German psychiatrist and philosopher), and Max Weber, (German sociologist and philosopher), believed that phenomenology, or the philosophical study of subjective experience, was an important tradition of empathy. The goal of phenomenology is to produce a thorough description of the essential or pure nature of the thing that is being studied. In order to be able to feel the very essence of what another experiences

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one must fully immerse oneself into the situation as it is lived by the person (McLeod, 2001). Others like Wilheim Dilthey, (German psychologist, sociologist and philosopher) and George Simmel (German sociologist and philosopher) also emphasized that gaining an intimate and personally felt understanding of another’s experience was important (Walker). 20TH CENTURY PSYCHOLOGY AND EMPATHY

Figure 5: Historical Reference text. Source: Freestock Photos http://www.rgbstock.com/.

Historical descriptions of the definition of empathy will now be presented from the perspective of 20th Century psychology. Fig. 5 is a picture of a reference textbook and illustrates the importance of prior knowledge informing what we know today. 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 also manipulating human behaviour during psychotherapy (Rychlak, 1973). 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 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 are 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

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basis of the therapeutic relationship between the therapist and the client (Tobin, 1991). Kohut ’s ideas on empathy are presented fist. Heinz Kohut & Self-Psychology Kohut (1985) was an Austrian born American psychologist known for his development of Self-psychology. According to Banai, Mikulincer & Shaver (2005) Self-psychology “is a comprehensive theory consisting of both a developmental model and a model for clinical consultation and therapy” (p. 224). 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). 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 a healthy self-esteem, formulate realistic goals and empathize with others (Carducci). Therefore, in Self-psychology, the therapist’s goal is to provide the somewhat troubled adult client with an atmosphere of empathy. 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 means to be empathetic and what is does not mean. For example, he believed that endeavours to understand and to know what another’s experience is like, should occur without the therapist losing their own objectivity (Kohut). 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 by maintaining professional boundaries (Kohut). Professional boundaries refer to limitations that restrict the extent and nature of a professional’s involvement with their clients/patients (Oberle & Bouchal, 2009).

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Psychoanalytical Theory and Behaviouralism as a Prelude to Humanism Person-centered Humanistic psychology appeared in the 1950s as an alternative to psychoanalytical and behavioural theories (Rogers, 1961; Monte, 1995). Before exploring person-centered humanism and its contributions to empathy, let us briefly explore and contrast the theoretical premise of these other psychological approaches. Psychoanalytical theory that began with Sigmund Freud, was founded on the principles of psychic determinism, which is the belief that behaviour can be caused from factors hidden in the unconscious. Human behaviour is thought to be “determined by impulses, desires, motives, and conflicts that are intrapsychic (within the mind) and often out of awareness” (Nietzel, Bernstein & Milich, 1998, p. 38). The basis of behaviours are thought to be determined in childhood through either the satisfaction of, or frustration of, a series of basic needs or psychosexual stages of development (Nietzel et al.). Unlike psychoanalytical theory that emphasizes, intrapsychic conflicts and unconscious motivations, Behavioural approaches 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). Person-centered Humanistic Psychology appeared in the 1950s as an alternative to psychoanalytical and behavioural theories (Rogers, 1961; Monte, 1995). In contrast to both Psychoanalytical and Behavioural approaches, in person-centered humanistic psychology mental and psychological problems are thought to develop in childhood, as a consequence of being regularly judged by a primary care giver as inadequate or less than good enough (Rogers, 1961). The fundamentals of Person-centered Humanistic psychology is 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 “within themselves vast resources for self-understanding and for altering their self-concepts, basic attitudes, and self-directed behaviour” (Rogers, 1980, p. 115). Person-centered Humanistic psychology also focuses on each person’s inherent capacity to self-actualize, as long as the right conditions exist (Nietzel et al.,

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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 achievements (Nietzel, et al.). Furthermore, if someone did not receive loving acceptance and approval from their parents when growing up, they could heal from the past and still (eventually) progress toward their highest potential, if they received the right type of support in the form of unconditional positive regard, emanating from their therapist (Rogers, 1980). Carl Rogers, Person-centered Humanistic Psychology & Empathy Research Carl Rogers was an American born, Person-centered Humanistic psychologist and was, and still is, regarded with tremendous respect within the community of clinical and counseling psychologists (Haggbloom, 2002). In my opinion, the contributions made by Rogers to the study of empathy, was unprecedented prior to his time. It would, therefore, not be appropriate to exclude the important contribution of Rogers to the notion 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 emphasized through his research that empathy, or accurately “understanding the feelings and personal meanings that a client is experiencing... communicates this understanding to the client” (Rogers, 1980, p. 116). Rogers pointed out that a therapist who listens sensitively and actively to what the client is saying and for hidden meanings, may truly facilitate within the client, a willingness to “develop a more caring attitude toward themselves” (p. 116). The Three Key Components to Change in Client-Centered Therapy According to Rogers (1961) three key components must be present during clientcentered therapy in order to help clients change in a positive way. Those essential factors are illustrated in Fig. 6 and consist of: unconditional positive regard, congruence and empathy (Rogers, 1961; Nietzel, et al., 1998). Rogers (1942) substantiated through his own research, that when these elements are evident and being expressed by the therapist, clients are assisted in becoming more self-aware, self-accepting and increasingly more comfortable and less defensive in their

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peersonal relattionships (N Nietzel, et all.). They aree also less llikely to be “rigid in th heir thinking g and more reliant r on seelf-evaluatioon than on evaluations bby others” (N Nietzel, et all., p. 298).

uncconditional  positive regard d

co ongruence

eempathy

Fiigure 6: Diagrram demonstraating the connection betweenn core concepts. Source: Roogers, 1961; Nietzel, N et al., 1998.

Uncondition U al Positive Regard R conssists of an ennvironment oof caring whhich is not po ossessive, an nd which deemands no personal grattification. It is an atmospphere that siimply demonstrates “I care c ”; not “I care for you if you behave thuss and so” (R Rogers, 1961, p. 283). In I this mann ner there aree no conditiions that I ddemand of yo ou in order for me to caare about you u. You are nnot judged aand you feel cared for ev ven when yo ou think thatt you may haave behaved badly (Rogeers; Stephanny, 2012). Congruence C is concerned d with the th herapist beinng aware of ttheir own feeelings and beeing genuin ne and real with their clients. In this manneer trust is ddeveloped beetween the client c and th he therapist because b the therapist’s aactions and w words are co onsistent, ho onest and autthentic (Rog gers, 1961). Empathy E waas considered d by Rogers to be one off the three m most importaant factors in n client healiing within th he venue of therapy. t Acttive listeningg, reflection,, and nonveerbal comm munication were w all ideentified as ccrucial com mponents of empathy.

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These constructs are employed as a means for the therapist to communicate their desire for emotional understanding, as well as to make their client more aware of their own feelings (Nietzel, et al., 1998). Active listening consists of being fully present and listening wholeheartedly and with your full attention to what is said while observing your client/patient’s body language. The purpose of reflection is to focus on the underlying feelings of the person rather than just the content or the factual details of what they are talking about. Therefore, reflection is much more than repetition or paraphrasing. It entails repeating what you think the client intended to say, including mirroring back their feelings (Nietzel, et al.; Adler et al., 2012). Brammer and MacDonald (1999) point out that, “skillful use of reflecting depends on the helper’s ability to identify feelings and cues for feelings, from body cues as well as words” (p. 80). Therefore, nonverbal communication is another extremely important component of communication. Nonverbal communication “is defined as messages expressed by other than linguistic means which includes messages transmitted by vocal cues.... body language, gestures, facial expressions and other actions (Adler et al., pp. 145-146). If a person’s body language is not congruent with their verbal responses, chances are their body language is actually more accurate than what is being said (Riley, 2008). For instance, if you ask your patient how they are feeling and they respond with, “Just Great,” but they are crying and looking downcast, chances are they are not being truthful with you about their feelings. Their nonverbal cues paint the true picture. Similarly, the helper must also be aware of how they are coming across when they are trying to be empathetic. If they raise their voice or express a grimace while listening to their client/patient’s story, they will come across as non-genuine (Riley). (Note: the subject matter of non-verbal communication skills is merely being introduced at this time. Chapter five will deal with this important topic in more considerable detail). As demonstrated in Fig. 7, active listening, reflection and assessing nonverbal communication cues, are all employed as a means for the therapist and/or another helping professional to communicate their desire for emotional understanding, as well as to make their client more aware of their own feelings (Nietzel, et al., 1998).

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According to Rogers

active  listening

reflection

empathy

Figure 7: Demonstrates how active listening and reflection equal empathy. Source: Nietzel, 1998.

HOW ARE BENEVOLENCE AND COMPASSION SIMILAR AND DIFFERENT FROM EMPATHY? We will now turn our focus away from the work of Kohut and Rogers and empathy, and instead  focus on the similarities and differences of terms that are closely related to empathy, such as benevolence and compassion. Benevolence consists of emotions regarding other people with the intention of good will or wanting what is best for them (Jackson, 2006). Compassion is identification with the suffering of other people, where their pain, becomes our pain (Chopra, 2005). Empathy is concerned with identification with, or experiencing all of the feelings of another person, either good or bad (Collis & Nolan, 2005). How are compassion and benevolence specifically similar yet different from empathy? All three notions are about caring for others and experiencing emotions. However, benevolence is emotion that you have about other people and the desire to make their situation better. It is as though you are standing outside of their circumstances as a concerned observer. Yet empathy is emotions that are felt with other people, as though you and they are having the same affective, lived experience. Compassion is only concerned with identification of another’s suffering, whereas empathy is about identification with both the positive and negative feelings of others. Slote (2007) even asserts that empathy is central to, and the primary mechanism of, all caring, including benevolence and compassion. Fig. 8 demonstrates how each of these three concepts are different, yet related.

What W is Empathyy?

Inspiriing Health Profes essionals to Comm municate More E Effectively 21

Let L us look at how theese three notions n mayy actually pplay out in real life. Hypotheticall H ly, let’s assu ume that you u come acrooss a person who looks distressed on n the street, appearing hungry, h cold and crying. If you are aacting in a bbenevolent manner, m you will want to o do somethiing that willl benefit them m and their situation. You Y might giive them a blanket b or something to eeat, and mayybe even gett involved in n causes to end e homelesssness. But you y will nott necessarilyy become em motionally in nvolved in their plight. If you aree moved w with compasssion, you ppersonally id dentify with the person’s suffering and want too end it. Thiis could stilll result in acctions that are a helpful, like noted above, a but, uunlike benevvolence, youu become qu uite emotion nally investeed. Howeverr, if you are experiencinng empathy, you want to o understand d what it trully feels like to be in thiss person’s sittuation. Youu desire to feeel everythin ng that they are feeling so that youu can undersstand them bbetter and want w to help. Although, you might identify witth their pligght and painn and also giive them a blanket b and something to eat, you ar are also interrested in heaaring their whole w story, which inclu udes the goo od times as w well as the not so goodd ones. In su ummary, wh hat benevolence, compasssion and em mpathy havee in commonn is caring fo or others an nd emotions,, yet they arre also som mewhat differrent and em mpathy, or ex xperiencing what the other is ex xperiencing, is viewedd as centrall to both beenevolence and a compasssion (Slote, 2007). 2

benevole ence: emotionss regarding  wanting tto do good tto  others. e mpathy: co ompassion: identifying wiith  he suffering of  th otthers

dentifying w with the  id feeelings and lived  experiences o of others,  w which includes ( +) and (  ‐) emotionss

Fiigure 8: Diagrram demonstraating the differeences between benevolence, compassion annd empathy. So ource: Jackson n, 2006; Chopraa, 2005; Collis & Nolan, 20005.

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WHAT DOES SOCIAL NEUROSCIENCE TEACH US ABOUT EMPATHY? Although empathy has received a great deal of attention in the 19th and 20th Centuries by both philosophy and psychology, empathy has only been more closely examined from a social neuroscience perspective in the recent past, namely in the last 10 – 15 years (Decety & Lamm, 2006). Therefore, I will now examine some of the evidence that has been made available through social neuroscience research into empathy. However, note that this overview will not be in depth, but offers the reader foundational knowledge for understanding what we now know about social neuroscience and empathy. It will specifically cover the topics of the role of mirror neurons; how we know what another is thinking or feeling; what causes us to respond with sensitivity to others; and how we can differentiate our experiences from that of the other person. According to the Society for Social Neuroscience (2013), the nervous system of a human being is now viewed as intimately connected with the social environment where people live. Social neuroscience is therefore defined, as, “the interdisciplinary academic field devoted to understanding how biological systems implement social structures and processes and behaviours, and how these social structures and processes impact the brain and biology” (Society for Social Neuroscience, p. 1). Empathy research is now a multidisciplinary field of inquiry and the social neuroscience of empathy studies empathy from the perspective of biological, cognitive and social perspectives (Decety & Lamm, 2006). 1) What are Mirror Neurons and What Do They Tell Us About Empathy? What are mirror neurons? Mirror neurons are smart cells in our brains that help us to understand others (Iacoboni, 2008). The Parma experiments in Italy were performed on monkeys through brain imagining research and neurophysiology. Note that there is strong evidence that the human fronto-parietal circuit of the brain is similar to that of a monkey (Rizzolatti & Destro, 2008). Brain imaging studies utilized the following tools: electroencephalography (EEG), magnetoencephalography (MEG) and transcranial magnetic stimulation (TMS). Neurophysiology studies relied on positron emission tomography (PET) and

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functional magnetic resonance imaging (fMRI) (Rizzolatti & Destro). Brain Imaging and neurophysiology studies revealed that cortical mirror neurons are formed by two main areas of the brain, the ventral pre-motor cortex and the rostral part of the inferior parietal lobule (Rizzolatti & Destro). (Fig. 9 shows an abstract picture of the human brain followed by a brief explanation of a variety of brain imaging and neurophysiology tests).

Figure 9: The human brain. Source: Freestock Photos http://www.rgbstock.com/.

Brain Imaging & Neurophysiology Tests (As adapted from Penny & Frison, 2007; Carter & Velae, 2009) Electroencephalography (EEG) is a test that records electrical activity along the scalp of the skull and measures the electrical activity of the brain. Magnetoencephalography (MEG) is a non-invasive method to measure magnetic fields produced by the electrical currents of small brain neurons. Transcranial Magnetic Stimulation (TMS) is a non-invasive method that causes either depolarization or hyper-polarization of the neurons of the brain. Positron Emission Tomography (PET) is an imaging test that can reveal how different tissues and organs in the body are functioning, including the brain.

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Functional Magnetic Resonance Imaging (fMRI) is a technique for measuring brain activity by detecting changes in blood oxygen flow. Neuroscience uses “sophisticated brain imaging equipment to confirm what many have suspected for years; that when we see another person’s actions (for example pain, laughing or crying), our bodies respond as if we feel a degree of that action too.” (Gerdes & Segal, 2009, p.117). It turns out that monkeys and humans imitate whatever activity they observe, which in turn helps them to understand the actions of other people that they are watching. However, imitation is not the only function of mirror neurons, they also have related roles in action understanding, intention, language and empathy (Rizzolatti & Destro, 2008; Iacobani, 2008). (Please refer to Fig. 10).

imitation

action languange

understanding Mirror  neurons

intention

empathy

Figure 10: Demonstrates the sub-categories of mirror neurons in the human brain. Source: Rizzolatti & Destro, 2008; Iacobani, 2008.

Evidence indicates how the mirror mechanism in the brain is related to empathy or the ability to feel the same emotion as the other one feels (Rizzolatti & Destro, 2008). For example, in a fMRI experiment, when a subject was exposed to a foul odor and made a facial grimace, the observer, who was not exposed to the smell

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also made a facial grimace (Wicker et al., 2003; Carr et al., 2003). Similar results occurred in an experiment where a painful situation experienced by one individual, that was observed by someone with an emotional bond to the one having the pain, resulted in the observer feeling the same degree of discomfort (Singer, 2006). Iacoboni (2008) conducted several experiments that revealed that there is a pathway connecting mirror neuron areas and limbic (feeling) areas of the brain, a pathway, that indicates that “we understand the emotions of other people thanks to our own mirror neurons, which are activated by the sight of someone else’s smiling or frowning face” (p. 117). Iacoboni demonstrated that mirroring is such a powerful mechanism for understanding the emotions experienced by others through studying the large amount of mirroring that occurs between parents and their children, even newborns. “Newborns are instinctively imitating movements from their first hours. Infants as young as ten weeks old spontaneously imitate some of the rudimentary features of happy and angry expressions” (Iacoboni, p. 126). Infants and very young children often display empathic connections to each other and even imitate the distress that they see in other children (Peirce, 2009; Iacobani; Goleman, 2006). For instance, when another child hurts her fingers and puts her fingers in her mouth, the child who is watching puts her fingers in her mouth. Similarly, a toddler gives another small child who is crying, a toy to soothe him and also lovingly caresses his head (Peirce; & Goleman). 2) How Can We Know What Another Person is Thinking and Feeling? How are humans able to come to know what another person is thinking or feeling? Cognitive-affective neuroscience has demonstrated that “in the domain of emotion processing and empathic understanding, people use the same neural circuits for themselves and others” (Decety & Jackson, 2006, p. 57). Iacoboni (2008) explains that we come to understand the emotions of another person by a form of inner imitation. Our neurons fire when we see others expressing their emotions. It is “as if we were making those facial expressions ourselves. By means of this firing, the neurons also send signals to emotional brain centers in the limbic system to make us feel what other people feel” (Iacobani, p. 119).. This process “involves actual involuntary, physiological experience in the observer....

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It is largely an unconscious and automatic experience” (Gerdes & Segal, 2009, p. 117). 3) What Leads a Person to Respond with Sensitivity and Care to the Suffering of Another? Researchers in the field of social neuroscience have also been trying to understand what leads a person to respond with sensitivity and care to the suffering of another (Batson, 2011). Mirror neurons demonstrate that we are not alone in our experience but that we are biologically and evolutionarily designed to be deeply interconnected with each other (Iacoboni, 2008). Stern (1987) and Szalavitz and Perry (2010) illustrate that caring for the other is learned behaviour that originates from early experience with one’s primary caregiver. Repeated moments of either validation or rejection, of having ones needs met or ignored, form the basis of either confidence or insecurity (Stern). The child who is soothed and loved is more likely to be able to identify with the feelings of the other (Szalavitz & Perry). (D)uring the course of normal infant development, mother and child become attached to each other in a reciprocal connection that links pleasure with soothing each other and happiness with making each other happy. Here’s how it works: when a mom runs to soothe her crying baby, she is actually tapping into a set of memories from her own childhood. If the mother was cared for in a loving way, her brain made associations between her own mother’s touch, gaze, smile, and other characteristics and pleasure. So now, many years later when she calms her own child, these actions stimulate a set of key neurotransmitter networks in her brain (Szalavitz & Perry, 2010, p. 29). Other ways that we gain understanding of another’s suffering is by intentionally adopting the subjective experience of other people by putting ourselves into that person’s shoes and imaging how it would feel to be them. This occurs by tapping into neural mechanisms that underpin emotional processing (Decety & Jackson, 2006). But whether the tendency to care for the other person’s suffering is the result of learned behaviour in early childhood or intentional means, all such caring

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behaviour activates the same neural pathways (Goleman, 2006). In fact, empathy begins with self-awareness (Goleman). Self-awareness is being aware of one’s own emotions and also aware of how you impact others. It is concerned with the ability to be self-monitoring in relationship to how others perceive you to be (London, 2002). The more open we are to our own emotions, the more skilled we will be in reading the feelings of others (Stern, 1987). 4) Differentiating Between One’s Own Experience and the Experience of the Other However, there is also strong evidence from recent functional-imaging studies that a person’s ability to monitor and regulate cognitive and emotional processes are also important in preventing confusion between the self and other (Decety & Jackson, 2006). Although it is beneficial to feel what the other person is feeling, especially when one is wanting to gain an understanding of the other’s experience, it is also crucial that one not become confused about the boundaries between self and other (Decety & Jackson). It appears that self-awareness prevents confusion between self and other from occurring (Decety & Moriguchi, 2007). The ability to be able to differentiate one’s own experience from the experience of the other, especially their pain or anguish, is precisely what the psychologist, Kohut (1985) asserted when he pointed out the importance of setting professional boundaries as a crucial role of an empathic therapist. CASE IN POINT: SUBJECTIVE PERCEPTIONS OF EMPATHY IN PRACTICE “Could a greater miracle take place than for us to look through each other’s eye for an instant?” Henry David Thoreau, American author, poet & philosopher In my earlier work I described empathy as “the identification with and understanding of, another’s situation, motives and feelings. It concerns imagining what it would be like to be that person and be in their predicament” (Stephany, 2012, p. 14). Your intention is to know what the other person is going through so you can better understand them (Stephany). Sometimes health professionals do not necessarily consciously think about the specific parameters of the term,

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empathy, but they can describe what it means to be empathetic. For instance, during an informal focus group for helping professionals, I asked those in attendance to tell the other members of the group what they thought empathy was. Some felt they were pretty good at showing empathy, but others admitted that they purposely avoided getting too emotionally involved. Hospital Social Worker: Empathy is me trying to imagine, just for a moment what it might be like to be in my patient’s predicament, like having no money for food or living on the street. But, because I haven’t experienced what they are going through, I sometimes can’t really feel what it would be like to be them. But I try my best to imagine how much of a struggle it must be. Psychiatric Nurse: Empathy is one of those things that you have a hard time to describe. It needs to be felt. I have learned and watched how many of my psychotic mental health patients have been so distressed because they hear and see things that aren’t real, but that they can’t stop the hallucinations from happening either. I try to understand how frustrating it must be to hear voices inside of your head and still try and concentrate on what you are doing or saying. I can’t even listen to music when I am reading so I can’t imagine how awful it must be for them to hear voices and still try to do other things. That helps me to be more understanding and less judgmental. That is when I feel like I am practicing empathy. Family Physician: I don’t like to think about it too much, but for me I feel I am most empathetic when I try to sense how my patient is feeling, especially when I give them particularly bad news. I also try and sit beside a patient who is a hospital bed so I can be on their same level and not be talking over them. One of my colleagues told me that this was a better way to connect with patients and I think it works. Operating Room Nurse: I don’t worry about empathy too much because for the most part, my patients are either asleep, except for those who have a spinal. The ones who are awake seem anxious but most often we keep a drape between them and the surgery to protect them from seeing too much unless they insist on seeing what is going on. Mostly it is the pre-operative and post-operative nurses who

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deal with their anxiety and pain. That is more their role than mine. That is one of the reasons why I think I am still doing okay and that I still like my job. I don’t have to deal with the sadness that people feel when they are sick. I know friends of mine who I trained with who have gotten burned out by all of the human suffering that they have to deal with on a daily basis. I know from experience that that is not the case for most of the Operating Room (OR) Nurses that I work with. We love working in the OR because it is fast paced and always moving and we are still helping people. Maybe it is even safer emotionally. Psychiatrist: I don’t think about empathy because it is just what we are supposed to do. I try to do my best to care for my patients with a sense of what their struggles might be but without getting overly involved. You know you have to be careful not to get patients to be too attached to you, especially ones that are very needy. You can’t rescue them or have them become emotionally dependent. I see my role as facilitating their healing but not fixing all of their problems. Counsellor: I think that empathy is what we do but sometimes it is hard to imagine living the client’s reality. It helps if you have suffered some on your own. I was so young when I became a counsellor and even though I wanted to help I don’t think I had enough life skills back then to consistently act in empathetic ways. I think getting older and gaining more life experience helped me to be more understanding. Questions Pertaining to the Case in Point 1.

Can you identify with any of the professionals’ experience?

2.

Did it seem normal or counter intuitive for some of them to create professional boundaries? Reflect on why you think you felt the way that you did.

REFLECTING BACK Summary of Key Points Covered in Chapter 1 *

This chapter pointed out that empathy is the foundation for all therapeutic communication. However, research has demonstrated that not all health care professionals know how to be empathetic.

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*

Empathy was defined in the most simplistic form as the ability to identifying with, and/or to understand, what another person is experiencing.

*

The chosen methodology for this textbook was acknowledged as the examination of lived experience in conjunction with evidence informed practice.

*

The underlying theoretical premise of this work was identified as the ethic of care.

*

The ethic of care focuses on addressing ethical decision making in nursing practice based on caring relationships, connectedness to one another, and context. It is also concerned with the moral imperative to act justly.

*

The connection between empathy and the ethic of care was explained. For example, empathy and the ethic of care are both seen as an active means to cultivate a form of motivated sensitivity to the experience of others. Furthermore, like the act of empathy, the ethic of care was viewed as a moral action of caring for, and about, the plight of others, especially their suffering, either individually or globally.

*

The way in which we came to understand empathy has evolved over the course of time.

*

Initially empathy was deemed by 18th Century philosophers to be similar to sympathy or feeling sorry for another person. (Note: Currently we view sympathy as feeling pity for someone and empathy as a way to identify with the other person’s feelings).

*

Philosophers like Hume and Smith claimed that sympathy arose from an inherent desire to understand the emotions of another in order to enhance the greater good of society. They referred to this term as emotional contagion, which is the capacity to feel the emotions of others by getting in touch with their pain.

What is Empathy?

Inspiring Health Professionals to Communicate More Effectively 31

*

Other philosophers, like Karl Jaspers and Max Weber believed that phenomenology, or the philosophical study of subjective experience, was an important practice in the study of empathy.

*

Historical descriptions of empathy were presented from the view point of 20th Century psychologists like Kohut and Rogers.

*

Heinz Kohut was an Austrian born American who was a Selfpsychologist. Self-psychology proposes that people develop their selfesteem (good or bad) through their relationships with their parents in their early years.

*

Kohut believed that people develop a sense of good self-esteem by the empathic mirroring that they receive from their parents. Empathic mirroring consists of praising children for doing a good job, which in turn builds self-confidence and makes them more willing to step out of their comfort zone in order to learn and grow.

*

Kohut also proposed that therapists learn to be understanding with those in their care without becoming drawn into their client’s emotional suffering.

*

Carl Rogers an American born, Person-Centered Humanistic psychologist also made tremendous contributions to the study of empathy.

*

Person-centered Humanistic Psychology views people as inherently good and capable of developing better personal characteristics over time.

*

Rogers proposed that these three key components are necessary to facilitate change in client-centered therapy: unconditional positive regard, congruence and empathy.

*

Rogers also asserted that active listening, reflection and being observant of the other person’s non-verbal cues, were all necessary for the therapist to fully understand what their client is experiencing.

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*

Although Kohut and Rogers differed somewhat in their ideas, they agreed that the phenomenological emphasis on the experience of empathy was the basis of the therapeutic relationship between the client and their therapist.

*

The similarities and differences between the emotional expression of benevolence, compassion and empathy were explained. Benevolence is an emotion that a person has about another, and includes the feeling of wanting to do good to others. Compassions consists of identify with the suffering of others. Empathy entails identifying with all of the feelings of others, which includes positive and negative experiences.

*

Social neuroscience consists of an interdisciplinary academic field of inquiry from the perspective of biology, cognition and sociology. Recent contributions of social neuroscience to the study of empathy was presented.

*

Caring for others was identified as a learned behaviour that originates from our early childhood experiences with our primary caregivers.

*

We were made aware that we are not alone in our experience but that our brains are hardwired to interconnect with each other.

*

Mirror neurons in our brain were specifically identified as the smart cells that help us to understand others.

*

The Parma experiments in Italy were performed on monkeys through the use of brain imaging research and neurophysiology. These studies revealed that mirror neurons are located in two key areas of the brain, the ventral pre-motor cortex and part of the inferior parietal lobe.

*

Sophisticated brain imaging confirmed that when we see another person’s actions, we respond as if we feel what they are feeling.

*

Regardless of whether the tendency to identify with what another person is feeling is the result of learned behaviour in childhood or

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intentional later on in life, all empathetic caring behaviours activate the same neural pathways in the brain. *

It was pointed out that self-awareness helps us to differentiate between our own experiences and the experiences of others.

SOMETHING TO PONDER 1.

What does the concept of empathy mean to you personally?

2.

Is the evidence from social neuroscience that attests that our capacity to be empathetic is hardwired in both monkeys and humans convincing or is it confusing to you?

3.

What about the assertion that empathy is learned in early childhood. What implications does this have, if any, on the development of insensitivity to the suffering of others?

GROUP EXERCISES Focus Group Exercise 1.

Form your own focus group with other members from the helping professions and discuss how you try to act in empathic ways with clients/patients. Pay attention to the similarities and differences. Ask yourself, “What can I learn from other professionals’ ways of being?”

SIMULATION ROLE PLAY: MRS. JONES EXPERIENCES A RECENT LOSS The Importance of Simulation Confidentiality: What is said and done in a simulation session needs to stay in this setting and not be shared with persons outside of the learning environment. The key here is to use simulation as a safe place for mistakes to be made and for maximum learning to take place without causing any harm to an actual patient in the clinical setting. For example, Grossman (2009) points out that, “Student satisfaction with their learning increases if they are able to carry out the skills involved in a safe, simulated

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setting prior to performing these same skills on real patients” (p. 89). The instructor may want to consider having the participants sign a confidentiality form. (A sample confidentiality form is attached at the end of chapter one). Student Preparation for the Simulation Review the definitions of active listening, reflection and non-verbal communication. Active listening consists of being fully present and listening wholeheartedly and with your full attention to what is said while observing your client/patient’s body language. The purpose of reflection is to focus on the underlying feelings of the person rather than just the content or the factual details of what they are talking about. Reflection is much more than repetition or paraphrasing. It entails repeating what you think the client intended to say, including mirroring back their feelings (Adler et al., 2012). Nonverbal communication consist of messages expressed by other than linguistic means which includes vocal cues, body language, gestures, facial expressions and other non-verbal actions (Adler et al., 2012). Objective Learning how not to be: Observe verbal and non-verbal actions performed by a doctor who fails to be empathetic while listening to a story of a patient who has experienced a recent loss. Scenario Participants Needed You will require two actors for this simulation. One person will act in the role of the patient (Mrs. Jones). The second individual will act in the role of Dr. Smith, a family physician. The role of the observers and/or class participants is to do intense observation, which will include recording what is said by each of the two actors as well as descriptions of observed body language and other forms of nonverbal communication.

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Setting the Scene The scene takes place in a doctor’s office examination room. A Doctor is dressed in a white coat, has a stethoscope around their neck and is holding a clip board, prescription pad and pen. Mrs. Jones is dressed as an old lady and is all alone sitting on the office chair. Action The scenario starts when Dr. Smith enters the physician office examining room where Mrs. Jones is sitting on a chair crying. Mrs. Jones is very despondent and although Dr. Smith tries to be caring, the doctor is uncomfortable with her display of emotion and wants to down play Mrs. Jones’ emotional outburst. Subsequently, the physician acts with insensitivity and his body language is cold. The doctor simply writes on the clip board and avoids eye contact at all costs. The doctor does not sit down, but stands a few feet away from Mrs. Jones, looking down at her. Dr. Smith asks the question, “Mrs. Jones tell me about what is upsetting you.” Mrs. Jones tells her story expressing a great deal of emotion. “I just loss my husband to a heart attack three weeks ago. I have been crying everyday and I have lost my appetite. I can’t sleep and I don’t want to go on anymore. My only daughter is living in Ontario and doesn’t have any time for her mother anymore.” Mrs. Jones starts crying even louder than before. Dr. Smith attempts to practice active listening and reflection techniques. “You sound very upset and like you are at the end of your rope, is that correct?” Mrs Jones: “You don’t understand how terrible I feel. I want to die. I want you to give me something to end it all. You can’t possibly know what I am going through.” Dr. Smith: is very uncomfortable with what the patient has just disclosed and tries to minimize the seriousness of it. “I am sure you will feel better in time. How about if I write you a prescription for something to help you sleep better?” Dr.

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Smith hurriedly hands Mrs. Jones a prescription for sedation and then walks out of the room. Mrs. Jones just sits there looking shocked and continues to cry. (You can end the scene here or you can improvise and create a longer dialogue. Don’t be afraid to be creative). De-Brief & Learn Allow at least 15 – 20 minutes to de-brief and for discussion. The instructor or facilitator may choose to de-brief the actors and observers either individually and/or as a group. De-Brief Questions 1.

Provide an opportunity for the two people acting as Mrs. Jones and Dr. Smith to openly share what if felt like to be in their respective roles.

2.

Allow the other observing members to offer feedback on what they heard and/or observed. Ask the question: Did the actors’ body language seem to be in agreement with what was being said?

3.

What specific communication techniques were used? Include those that were intended as a part of the simulation as well as any others that were utilized.

4.

Did anything that was said, or any non-verbal cues that were exhibited, appear awkward? If yes, describe what it was that seemed troubling?

5.

Did anything seem counter intuitive?

6.

Did any action by Dr. Smith appear to invalidate what Mrs. Jones was feeling?

7.

How could Dr. Smith have acted differently to better convey empathy and care to Mrs. Jones?

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ON YOUR OWN: PRACTICING THE DIFFERENCES BETWEEN SYMPATHY & EMPATHY * Review the definitions of sympathy and empathy. Sympathy takes on the form of feeling sorry for, or feeling pity for, another person’s situation. Empathy is seen as a way of trying to understand the actual experiences of others, which may and may not include feeling their pain. *

Do the following exercises to differentiate between responding with sympathy and responding with empathy. 1) A good friend of yours phones to tells you that their beloved cat has just died at the age of fifteen. They are very upset about their loss. Respond with sympathy: Respond with empathy: 2) A friend just informed you that he is very depressed about recently being fired from a job that he loved. Respond with sympathy: Respond with empathy: 3) Your sister is visiting and she tells you that she and her husband are getting divorced after 15 years of marriage. Respond with sympathy: Respond with empathy:

 

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APPENDIX B SAMPLE Confidentiality Agreement for Simulation (As adapted from Douglas College Faculty of Health Sciences Simulations Lab, November 2013). Welcome to our Faculty of Health Sciences Simulation Centre. The simulation lab is a learning environment whereby students and faculty actively engage in simulated clinical scenarios to enhance psychomotor, assessment, communication and critical thinking skills pertinent to clinical practice. The simulation lab is a learning environment which promotes professionalism and an expectation that all students and faculty adhere to professional practice. This includes treating everyone with respect, valuing the opinions of others, and fostering a collegial and supportive learning environment. It is also an expectation that all simulation experiences be kept confidential with respect to scenario information, student performance, and debriefing discussions. All students are to adhere to confidentiality by ensuring that no discussions of students actions are to take place outside the simulation lab, this includes any information shared during debriefing sessions. This confidentiality agreement is in keeping with our school of Nursing’s Policy, which expects academic integrity, honesty and ethical conduct of all students. As a student participating within the simulation lab, I understand that the information and shared experiences of all students be kept confidential and that any violation of confidentiality is unethical and may result in disciplinary action according to our school’s Academic Honesty policy. Student Signature: _______________________ Month ___________ Day ____ Year _________

Cultivating Empathy, 2014, 39-54

39

CHAPTER 2 When the Client/Patient Feels Alone Abstract: In this chapter narrative accounts were shared by persons who experienced or witnessed a lack of empathy. These stories were not intended to place blame on helpers. The goal was to assist practitioners with a better understanding of what it feels like to be treated with a lack of empathy and care in order to ultimately inform practice. In the case in point a nurse told her story of what it felt like to be a patient who was treated with indifference. At the end of the chapter reflective journaling was encouraged as a means to begin to increase self-awareness.

Keywords: Empathy, self-awareness, narratives, stories, objectification, detached concern, indifference, coroner’s investigation, psychological autopsy, hopelessness.

Figure 1: Picture depicting human despair. Source: Freestock Photos http://www.rgbstock.com/.

LEARNING GUIDE After Completing this Chapter, the Reader Should be Able to *

Understand that communication is a two-way process.

*

See the importance of helping practitioners becoming more selfaware.

*

Describe how narratives inform practice. Kathleen Stephany All rights reserved-© 2014 Bentham Science Publishers

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*

Explain what objectification is.

*

Have a deeper understanding of others’ experiences of a lack of empathy and care by reading their stories.

*

Review the Case in point: When a nurse becomes the patient.

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Make use of reflective journaling as a means to begin to increase selfawareness.

WHAT DOES IT FEEL LIKE TO BE TREATED WITH A LACK OF EMPATHY AND CARE? “When dealing with people, remember you are not dealing with creatures of logic, but creatures of emotion.” Dale Carnegie, American Writer, Lecturer and Developer of Courses in Self-Improvement They say that a picture is worth a thousand words. Fig. 1 depicts a person feeling despair and sets the stage for the subject of discussion in this current chapter. Narrative accounts are presented by persons who either experienced or witnessed a lack of empathy. Empathy is the ability to identify with, and/or to understand what another person is experiencing. It is concerned with trying to imagine, even for just a moment, what it would be like to be in the person’s situation (Shafir, 2008). However, even if a helper’s intentions are noble, sometimes their actions can still be perceived by others as insensitive and lacking in empathy (London, 2002; Riess, 2010). Research has demonstrated that nursing caring behaviours have been deemed to be an important element in contributing to positive patient experiences (Watson, 2008; Cook & Cullen, 2003). Yet, the opposite is also true. Patient satisfaction with the care provided is diminished if nurses come across as insensitive, impersonal or lacking in understanding (Wagner & Bear, 2008; Hobbs & Burant, 2004). For example, a recent extensive study conducted in six European countries (Cyprus, Czech Republic, Greece, Finland, Hungary and Italy) examined 1,565 surgical patients’ perceptions of caring behaviour by nurses (Palese et al., 2011). The results indicated that although nurses appeared to have

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the necessary knowledge to provide competent care, they did not necessarily seem to be connected to their patients in a meaningful way which resulted in decreased patient satisfaction. All correlations on this finding were statistically significant (p