In a previous Communication Tip (Can Fam Physician 2007;53:640–1), we discussed empathy. It would be more accurate though to speak of the “empathic process” or “empathy cycle,” for it is a phenomenon that can spread over many exchanges and be expressed in different ways.1 In this article, we show how simple reflection plays a part in every empathic process.
Suchman et al2 pointed out that, in most medical interviews, patients express emotions indirectly. Rather than voice emotions explicitly, patients provide clues to how they feel. To practise empathy, physicians must first clarify the emotions at which patients are hinting. They might decide, however, not to explore all the clues they observe, and, even when patients express emotions clearly, physicians must decide whether or not to stay on particular emotional tracks with them. Depending on the relationship that has been established with a patient, the doctor might already know the emotions the patient is experiencing and decide not to revisit the subject. Alternatively, the physician might have perceived the emotions at play but decided that the time was not yet right to deal with them. Once a physician broaches the subject, an empathic process (or empathy cycle) begins.1
Stages of the empathic process
Figure 1 illustrates the stages of the empathic process, both when emotions are explicitly stated and when they are expressed indirectly. Following the terminology proposed by Suchman et al,2 a straightforward expression of emotion by a patient presents an “empathy opportunity.” If a physician does not follow up on it, he or she is said to have blocked the empathic process. If patients insist on talking about their feelings, however, physicians are well advised to take up the matter with them; such insistence can signal an emergency. Intense emotions on the part of a patient might also hamper the transfer of information. Consequently, if patients persist in wanting to discuss their feelings, it is better to comply, pursue the subject, and return to other more cognitive issues afterward.
The empathic process
For the empathic process to begin, a physician must recognize that a patient has expressed an (often negative) emotion. If the physician decides to venture into emotional terrain with the patient, the first step simply consists of identifying the emotion, thus allowing for the beginning of a dialogue, the purpose of which is to clarify and, if need be, qualify the emotion (Empathy 1 in Figure 1). By identifying the emotion, physicians indicate to patients that they have understood them and check that the understanding is correct. Physicians can then use a form of empathy that Hammond et al3 call “reciprocal empathy,” in which physicians merely reflect the emotional content of patients’ speech without delving below the surface of what has been said. Reciprocal empathy is set in motion by the use of fairly standard phrases, such as the following:
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“What you’re saying is ...”
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“If I understand you correctly, you ...”
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“It’s as though you were saying ...”
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“You feel ...”
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“You often feel that ...”
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“You seem to me like ...”
Empathy in action
A 35-year-old man is seeing his physician about stress at work. We join the consultation as the physician begins to explore the patient’s work situation.
Physician: “How are things at work?”
Patient: “In general, I’d say they’re okay. But lately it seems I’ve lost my motivation. My responsibilities have changed and I now have to report to someone who used to be a colleague. Last Friday, it reached the point where I just wanted to quit and walk away. I’ve been thinking of quitting for a while. My boss and I have talked about it. He knows it’s not easy for me. Still, nothing changes.”
This indirect expression of emotion is a “potential empathy opportunity.”
Physician: “So, even though you talk about it with your boss, your work situation isn’t getting any better. You feel so frustrated that sometimes you fantasize about quitting.”
In this exchange, the physician illustrates a form of reciprocal empathy as he reflects the patient’s words without substantially adding anything to or subtracting anything process from them. He verbalizes the emotion somewhat differently; he changes things slightly by speaking about the patient’s frustration rather than his lack of motivation, but retains the general sense. If the patient wants to, he can pursue the topic.
A physician might decide to keep up the dialogue after having named the emotion and verified his or her understanding with the patient by resorting to what Hammond et al3 call “additive empathy” (Empathy 2 in Figure 1). The physician infers the causes of the emotion or suggests feelings associated with what has been explicitly voiced, completing what the patient says. The transition to additive empathy can be made by using such phrases as the following:
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“What you’re saying suggests to me that ...”
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“I wonder if you don’t mean that ...”
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“Perhaps ...”
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“I have the impression that ...”
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“Do you have the impression that ...?”
Returning to our example, after a few encounters during which the man regularly returns to the subject of his job dissatisfaction, the physician begins to discern more of the implicit content of his statements.
Patient: “Yes, it’s hard for me. What’s the point of talking to my boss if nothing changes? I feel my job is useless now. It can’t go on like this forever. I’ve got my needs. Something’s got to change soon. And it won’t just be talk.”
The patient begins to explore his emotions, confirming his frustration. He also gives notice that he is ready to do something about it.
Physician: “I sense this is very disturbing for you. Don’t you think there might be something more going on than just your frustration with your boss? I sense that your job isn’t as challenging as it was before all these changes.”
Here the physician goes beyond what the patient has said and suggests an underlying reason for the frustration. It follows that his frustrations are not entirely due to his boss. The patient must face up to the physician’s hypothesis, which forces him to begin to think about the matter.
In itself, empathic reflection is a mild form of challenge; being made to consider one’s own behaviour amounts to being asked to justify what one says. The challenge, though, becomes more serious when hypotheses on the causes of or underlying reasons for emotions are put forward. It is therefore inadvisable to use additive empathy before the relationship is well established, as the patient might feel rejected or insulted.
When to use the empathic
Empathy is useful when physicians think that emotions expressed or hinted at might interfere with patients’ therapy. The appropriateness of using empathy will vary depending on the precise circumstances. For instance, emergency room visits are generally not ideal for engaging patients in reflective processes about their emotions. On the other hand, when monitoring patients with chronic diseases, it is rather important to explore how they feel about their illnesses. Chronic diseases entail a redefinition of patients’ self-images and have important long-term consequences for them and their families.
In common medical parlance, empathy has become synonymous with support. In fact, as we have seen, empathy is only a weak form of support. There are more direct forms, such as expressions of sympathy, which, though not recommended in psychotherapeutic relationships, are entirely acceptable in medical consultations.
Acknowledgment
This article in the series “Communication Tips” has been adapted from an article that originally appeared in the French-language journal L’Omnipraticien. We thank Merck Frosst Canada for covering the costs of adaptation and translation.
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