EMPATHY and compassion are multifaceted, dynamic concepts that are often confused with each other as they are etymologically related. This perceived similarity and interchangeability is perhaps because their definitions have evolved differently depending on which disciplines (medicine, philosophy, psychology, counselling etc) refer to them, and is clearly demonstrated in the proposed umbrella term “compassionate empathy”.
However, differentiating between these distinctive concepts is imperative if we want to ensure our health care providers can offer better mindful “compassionate care” to their patients, and ultimately avoid the risk of drifting into emotional empathic distress and subsequent burnout. For the purpose of this article and for simplicity’s sake, both notions will be voluntarily differentiated between the ability — or not — to distance ourselves from another person’s suffering, and the impact of sustained emotional empathy versus compassion from a medical standpoint will be explored.
What is empathy?
The etymology of the word “empathy” comes from the Ancient Greek empatheia (from em- “in” + pathos “feeling”), later translated to English in the early 20th century from the German word Einfühlung, meaning “the ability to understand and share the feelings of another” or “the ability to feel the other from within”.
In other words, and according to Theodor Lipps, it entails the capacity to place oneself in another’s position (fusion state) and unreservedly experience the feelings of that person. This concept also refers to unconscious emotional (or affective) empathy or empathic (identical) resonance.
When we become too empathic to patients’ personal stories of suffering, we allow their narratives to become a part of us and we therefore start experiencing their suffering as ours. This means we lose differentiation between ourselves as health care providers and our patients. These assimilated emotions may be further magnified if the situation triggers unresolved personal feelings or trauma in our own lives.
To summarise, empathy means “I suffer when you suffer”, which in a medical context means a health care provider might need to take care of their own deeply stressful personal feelings first before being able to help their patients.
What is compassion?
In comparison, the word “compassion” is derived from the Latin compati (from com- “together” + pati “to suffer”), literally meaning “to suffer with” and currently defined in the Oxford dictionary as “a strong feeling of sympathy for people who are suffering and a desire to help them”.
Chochinov describes it as a deep awareness of the suffering of another, coupled with the desire to relieve it. It implies a strong feeling of sympathy, caring concern, and even sorrow for the sufferings or misfortunes of others, but from a slightly greater emotional distance. Empathy is a precursor to the most evolved and nurturing stage of shared compassion, a conscious affective separation (or non-fusion) state that represents the health care provider’s lifeline against gradual mental or physical exhaustion and burnout.
We should bear in mind that compassion does not affect the ability to experience genuine heartfelt desires to alleviate pain and suffering by showing kindness, care and willingness to help. Furthermore, compassion offers a more durable positive emotional connection between health care providers and patients, with an improved moral capacity to understand and adequately respond to others’ suffering.
Our neocortex is the neural basis of empathy and compassion and was one of our most important developmental tools as a species, enabling us to survive despite many dangers and predators through the emotional bonds and connections formed with others.
The social foundations of empathy reflect the capacity to experience the emotional feelings of another human being, and identical (affective) resonance is therefore crucial to our relationships with our loved ones, especially our children, siblings, family and close friends. Automatic activation of our psychological “mirror neuron” system helps us, inter alia, explain how we learn through mimicry in childhood and are able to create lasting relationships crucial to the survival of our own species. But in the relationship between patients and health care providers, resonance should be consciously detached from our own feelings, as we don’t want to experience every patient’s pain (identical resonance) or trauma every single day of the week. This would be unreasonable, psychologically taxing, and likely autodestructive over time. Indeed, the greater and longer the exposure to traumatic situations, the more serious the risk of experiencing vicarious trauma.
What is an effective deterrent to self-inflicted and often emotionally confronting empathic feelings that could randomly arise from interactions with some of our patients?
Becoming more aware and mindful of our own deeper feelings, potential weaknesses and limitations, and aiming at progressing to the next stage of conscious affective compassion and kindness. This implies recognition of and “reactive resonance” to stressful situations, where health care providers are able to distance themselves and only experience a positive emotion, such as loving care, in response to the patient’s pain.
Paul Ekman outlines the importance of making such distinction, especially when working in a highly stressful, demanding and psychologically draining environment such as the emergency ward or the intensive care unit, as excessive oblivious empathy (or identical resonance) felt every single day of the week will eventually lead to emotional exhaustion, depersonalisation and burnout. Conversely, reactive resonance implies that while not experiencing mirrored feelings, we are still able to distance ourselves from our patients, recognise their own suffering, and adequately respond, in a nurturing way, by offering love and healing compassion. It is therefore important to recognise and understand the subtle but quite significant differences between the terms “empathy”, which may lead to empathic distress if not cognitively processed, and mindful “compassion”, which doesn’t.
Table 1: Differentiation between two empathic reactions to the suffering of others: empathic distress and compassion
|Ability to recognise other’s suffering||YES||YES|
|Inner state||Emotional||Emotional & Cognitive (allowing distance)|
|Affective state||Unconscious (emotional empathy)||Conscious affective separation (sympathy)|
|Becoming part of other’s suffering||Fusion||Non-fusion (separation)|
|Ability to distance ourselves||NO (struggle with boundaries)||YES|
|Resonance||Identical (affective) resonance||Reactive resonance|
|May trigger unresolved personal trauma||YES||NO|
|Risk of (self-related) distress||YES||NO|
|Risk of emotional exhaustion||YES||NO|
|Risk of burnout||YES||NO|
Emotional exhaustion among health care providers exposed to patients’ suffering is a critical matter, especially as it may also lead to impaired patient care, inability to offer emotional support to others (decreasing empathy), depression, substance misuse and, on some occasions, suicide. This emotional burnout may be the result of an intense and repetitive empathic state of mind (empathic distress), defined by an affective resonance with someone else’s suffering; in other words, resonating empathically with that suffering to a point where it becomes intolerable for the health care provider.
Perfectionists, who tend to feel guilty if they don’t perform as well as they would like to, are also at higher risk of burnout. Hojat and colleagues use the term “cognitive empathy”, which involves an understanding of experiences, concerns and perspectives of another person, combined with the ability to communicate this understanding, as an essential component of harmonious relationships between health care providers and patients. Cognitive empathy is a necessary step to compassion, as we must become consciously aware of others’ suffering without being emotionally bound by it (separation), and thus respond adequately, in a non-confronting way, with a heartfelt desire to help and alleviate pain and suffering. This capacity to develop cognitive empathy is therefore crucial in medical education if we want to establish suitable interpersonal relationships and a healthy social life.
Compassionate engagement in patient clinical care has been shown to provide increased treatment compliance and effectiveness, improved satisfaction index and clinical outcome, as well as reducing the risk of medical errors and malpractice litigation (here, here and here).
Hanson describes compassion as warm-hearted sensitivity to suffering, which should be applied to our own suffering first in order to make us more resilient and help us build up self-worth and inner strength. This is the preliminary step before appropriately giving compassion to others, which in turn may lower stress and have a calming effect on our body and mind.
Mindfulness practice through breathing exercises and meditation is a powerful tool for mental strengthening, inner peace, happiness and healing. The eminent Vietnamese Zen-Buddhist and Master Thích Nhât Hanh was instrumental in bringing this practice to the West several decades ago.
This has contributed to the development of new psychological tools such as mindfulness-based stress reduction (MBSR), defined by Dr J Kabat-Zinn in 1979, and mindfulness-based cognitive therapy (MBCT), subsequently developed by Segal ZV and colleagues, to help prevent downward spirals of empathic distress, emotional exhaustion, depression and burnout. Both techniques, which incorporate mindfulness group therapy practices, also include meditation, yoga and breathing exercises to promote relaxation through non-judgemental self-awareness. Their goals are to empower health care providers to adequately respond to potentially stressful situations, consciously rather than automatically, helping them break away from negative thought patterns and replacing them by positive ones.
Two recent systematic reviews looking at the positive effects of MBSR and MBCT on various aspects of employees’ mental health confirmed that both meditation techniques were associated with significant improvements in psychological distress, anxiety, emotional exhaustion, depression and burnout (here and here). Those examples of successful mindfulness-based programs, or alternatively being able to offer easy access to structured supervision or counselling sessions with professional therapists, should be readily available in every medical health service, especially in those with a highly stressful, demanding and psychologically draining environment, such as emergency wards, neonatal units, oncology and intensive care units.
In summary, the risk of developing empathic distress is a concerning health problem for health care providers working in psychologically demanding and stressful environments. It may have potentially devastating consequences. It is therefore vital to remain mindful and distance ourselves from our natural empathic feelings towards others, in a more compassionate way, and accept it as a form of non-confronting emotion regulation. This will allow us to experience our empathic feelings with a nonjudgmental attitude and help us overcome the tendency to simply avoid them. Keeping a positive mindful attitude among health care providers is therefore essential and could be further strengthened by offering regular structured supervision, counselling sessions, or alternative meditation techniques. These may help reduce the risk of drifting into emotional confusion, feeling psychologically drained over time, and eventually burnout.
Conjoint Professor Christophe Berney is a specialist laparoscopic gastrointestinal and hernia surgeon in private practice and teaches at UNSW Clinical School.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.