Empathy doesn’t have to be intuitive to be real

Real or acted, does it matter? Empathy by Shutterstock

Empathy is having a moment. Author Roman Krznaric, founding faculty member of The School of Life in London, called for an empathy revolution, arguing that empathy is a transformative force. Organisations like Roots of Empathy run programmes in schools. And those seeking the neuro-scientific manifestations of empathy perform fMRI brain scans with all types of people ranging from troubled adolescents to humans responding to robots.

American novelist and essayist, Leslie Jamison, is also fascinated by empathy: its character, presence and absence and its relationship to pain and suffering. Her collection of essays – The Empathy Exams – is published this week in the UK after much attention in the US. It is a thought-provoking and wide-ranging exploration of empathy, drawing on subjects including illness, travel and female pain.

Healthcare has a complex relationship with empathy. It’s considered fundamental to clinical practice and is constantly encouraged and emphasised. Yet, there are conceptual challenges – what is this thing we value so highly? If, as seems likely, it is an elusive and problematic idea, how do we foster and evaluate it in medical professionals. Does the capacity to act empathically suffice? Or is it possible to be sincerely empathic but lack the facility to demonstrate it?

Perhaps empathy is most knowable in deficiency or perceived absence – the moments when we believe that someone neither knows, nor cares, how someone else is feeling. Several high profile inquiries into failures of care captured memorable vignettes where empathy was apparently lost: moments when no one seemed willing to imagine, still less attend to, the experiences and feelings of a patient or client.

Acting empathy

Speaking to Jamison, it’s clear she’s had ample opportunity to explore both the idea of empathy and its enactment. When writing her second novel she worked part-time job as a standardised patient, playing roles ranging from “girl with seizures” to “pregnant woman with pre-eclampsia”. Most medical schools in the UK and US use standardised patients to help train medical students; they get to practise and have their communication skills evaluated. In The Empathy Exams, Jamison offers a unique insight into the experience of participating in these sessions and examinations, while reflecting on her own experiences of vulnerability as a “real” patient, in relationships and with others.

Role-play allows a safe environment for practice: a chance to experiment, to be clumsy, to try on the professional role without real-life responsibilities. As “the patient”, Jamison identifies power as the distinguishing characteristic:

I felt like I had some kind of power over the medical students — I knew what was wrong with me, and they didn’t … I also knew I’d be evaluating them. As an actual patient, I’m often struck by how powerless I feel. I’m a pretty intelligent person. I’ve got advanced degrees. But when I’m lying in a paper gown on a doctor’s table — much less a surgeon’s table — I feel incredibly ignorant and powerless, afraid that all of my questions are stupid, deeply mortified at the idea of wasting anyone’s time. When you’re an actual patient, you feel vulnerable and full of need — it’s a hard position from which to assert yourself.

Simulation and authenticity

The relationship between simulation and authenticity when it comes to empathy is a recurring theme. Jamison’s take on the problematic question of sincerity in clinical practice is to challenge the idea that emotion must coincide with behaviour or affect. To her surprise, she says, she has “become something of a defender of ‘simulated empathy’”.

What I think of as ‘going through the motions’ while waiting for the mind and heart to catch up. For a large portion of my life, I’ve associated ‘authenticity’ with intuitive response or impulse — feeling something before you do it. But now I think that’s a pretty limited conception of authenticity. We can will ourselves to do things — to spend time with people, to ask questions, to pay attention — which might stimulate those compassionate emotions we think of as empathetic response.

Doctors I’ve spoken to about this also talk about certain feedback loops — physical actions (like smiling) that can actually induce or precipitate certain internal states. There’s no hard line between simulation and feeling.

Jamison is too thoughtful to be unaware that there is a tension between self-preservation and empathy. She was struck by a review of her book which described her facility for being both “flinching and unflinching” in her examination of suffering. She says that it “actually helped me think about what an ideal version of empathy might do: acknowledge the vulnerability of dealing with pain, but also keep looking.”

Provoking productive action

The relationship between resilience and empathy is too rarely considered overtly – the problem of burnout co-exists with calls for more empathy with few joining the conceptual dots. Jamison suggests it is worth exploring the connection “between empathy and stamina, and empathy and action.”

If we want empathy to provoke productive action — action that can actually improve other people’s lives, somehow ameliorate the conditions that are producing the pain that produces the empathy, then what kind of self-preservation or conservation of emotional resources is necessary to make that action possible in the long run?

Her book demonstrates that empathy is also inextricably linked to marginalisation: the willingness to see, hear and respond to those whom others, individually and collectively, overlook, neglect and dismiss. Jamison seeks out those whom others, including the medical profession, find problematic. She spends time with people who have experience of Morgellon’s disease, in which sufferers report intensely itchy and stingy skin with no apparent cause, and the result is a moving meditation on belief and subjectivity in illness.

It’s a theme that is revisited in the essay on women’s pain, in which Jamison captures what it is to be disbelieved. Both essays elucidate the way power shifts in situations of simulation as compared with actual distress. The privilege Jamison enjoys in a role-play where her experience is not merely valued, but prioritised, too often cedes to professional determination when the suffering is genuinely felt. The real patient no longer has jurisdiction over her body and its fragility.

What then has Jamison concluded about empathy? She believes it is “something we are constantly reckoning with and practising (or struggling to practise) in our daily lives, but we don’t always consciously think about what it consists of, so it’s both familiar and mysterious at once.”

Simply put, the willingness to care and be curious about the experiences and wishes of others is “just part of being a person in the world. Or it should.”

Leslie Jamison will be in conversation with Deborah Bowman on 7 July at St. George’s, University of London, part of the free Art of Medicine series.