Empathy in the narrow sense

Empathy has been defined as a ‘complex imaginative process in which an observer (the ‘empathiser’) simulates another person's (the ‘target’) situated psychological states while maintaining a clear self–other differentiation’ (Coplan Reference Coplan, Coplan and Goldie2011: p. 5). This definition entails three components: first, affective matching, where the empathiser feels a qualitatively similar emotion to the target's emotion, for example matching anger with anger, as opposed to feeling, for example, fear in response to the target's anger; second, by taking the target's perspective, the empathiser imagines being the target and having the target's experience, as opposed to imagining being themselves having the target's experience; third, maintaining always a clear self–other differentiation during the process, i.e. the empathiser maintains a clear awareness of the fact that the emotions and perspective adopted are those of the target and not of themselves (Coplan Reference Coplan, Coplan and Goldie2011: pp. 6–15). This definition sets empathy as an effortful skill that requires high-order cognitive resources such as controlled processing, active imagination and the ability to keep psychological boundaries from emotionally charged subjective experiences. Thus, this definition distinguishes it from concepts such as sympathy, compassion, kindness and concern for the other.

Sympathy

The notion of sympathy has changed in its meaning over time. In the 18th century, the Scottish philosopher David Hume defined it as the inclination to sense the feelings of others, whereas his compatriot Adam Smith described it as the tendency to feel compassion for others, to care about their feelings; more recently it has come to be understood as a feeling of sorrow or concern for someone based on that person's negative emotional state or condition from the perspective of somebody who cares for the other person's well-being (Gerdes Reference Gerdes2011). Stueber (Reference Stueber2019) stresses that the relation between empathy and sympathy is a contingent one, as sympathy does not necessarily require feeling any kind of congruent emotions on the part of the observer, so a detached recognition that the other is in need or suffers might be sufficient. Conversely, empathy can lead to empathic distress, compassion fatigue or mere personal distress, which can prevent a sympathetic response (Stueber Reference Stueber2019).

Compassion

Distinguishing compassion from empathy is important for, although conceptually different, in medical parlance they are often used synonymously. As Bloom indicates, compassion is caring for others, wanting them to thrive, a discrete emotional experience characterised by a state of concern for the suffering or the unmet needs of another (Bloom Reference Bloom2016: p. 138). Bloom distinguishes compassion from empathy, emphasising that compassion is always necessary for any supportive human encounter and that it is unlikely to have negative effects on the target of the emotional experience who, in clinical contexts, would be the patient, whereas empathy is not essential for supporting human encounters and it can certainly have negative effects. Compassion is also distinct from empathy in terms of its scope, since, in empathy, people perceive and mirror a variety of emotions (e.g. delight, pride, or anger), whereas in compassion there is an emotional response to suffering that involves wanting to do something to reduce another's suffering. In mental healthcare, it is unlikely that compassion could have negative consequences, whereas empathy can certainly have negative consequences for the patient, as will be discussed below.

Empathy in the broad sense

A broader definition of empathy seeks to have face validity for clinicians, patients and the wider public. Clinical empathy has been defined as ‘attempting, as far as possible, to understand another person's situation, feelings and perspective, recognizing the difficulties in putting oneself in another's shoes; communicating that understanding, checking its accuracy; and acting on that understanding in a helpful way’ (Mercer Reference Mercer, Maxwell and Heaney2004). The communicative component is necessary to ascertain whether the empathiser's understanding is correct and to respond appropriately to that new knowledge. Thus, this definition includes communication skills, communication of compassion, optimism and promotion of autonomy, as reflected in the influential Consultation and Relational Empathy (CARE) instrument (Mercer Reference Mercer, Maxwell and Heaney2004) (Box 1).

Socioeconomic factors

Empathy it is likely to be influenced by the conditions in which the patient–clinician interaction occurs and it is possible that the more unequal the socioeconomic background of clinician and patient, the more difficult it will be for empathy in the broad sense to emerge because, as indicated above, it involves communicating the clinician's understanding of the patient's situation and feelings as well as acting on that understanding in a helpful way. In this regard, a systematic review (Willems Reference Willems, De Maesschalck and Deveugele2005) found that patients from lower social background received significantly fewer positive socioemotional utterances, a more directive and less participatory consulting style, more biomedical talk and more physical examinations. Similarly, the communication between patients from a lower social class and doctors is often characterised by less questioning, less opinion-giving, less affective expressiveness and a less involving behaviour from the doctor (Willems Reference Willems, De Maesschalck and Deveugele2005). In a qualitative study of 80 American patients, most participants perceived that the treatment provided by their physicians and the relationship they had with their health provider was affected by their socioeconomic status, although they often avoided saying so directly (Arpey Reference Arpey, Gaglioti and Rosenbaum2017).

Organisational factors

The organisational context of clinical encounters is also likely to influence empathy. In low- and middle-income countries, a significant proportion of the population either do not have access to mental healthcare or, if they do, they access a precarious service where resources and respect for patients’ human rights may suffer (Fearon Reference Fearon2014). If access to private mental healthcare is dependent on payment, potential distortions in the deployment of empathy may occur. Moudatsou et al (Reference Moudatsou, Stavropoulou and Philalithis2020) report that empathy is negatively influenced by, among other factors, a high number of patients that professionals must manage and the lack of adequate time to see them. Empathetic clinicians can have a positive effect on medical care in a range of areas. A meta-analysis found that empathetic consultations reduced patients’ pain and anxiety and improved satisfaction by a small amount and were not associated with any harm (Howick Reference Howick, Moscrop and Mebius2018). Sadly, patients suffer when organisational problems coincide with poor standards of care, as documented in the public inquiry into the Mid Staffordshire NHS Foundation Trust: ‘a culture of habituation and passivity in the face of issues which may indicate real suffering [ … ] would be unlikely to be persisted in if those adopting it were constantly to place an empathy for the predicament of patients at the forefront of their mind’ (Francis Reference Francis2013: para. 78).

Clinical empathy in psychiatry

A qualitative study identified that, for psychiatrists, empathy is an important component of the therapeutic alliance (Ross Reference Ross and Watling2017). Another qualitative study, on patients’ views on what constitutes good psychiatric care, found that the quality of the therapeutic encounter with staff, as well as the feeling of being understood by staff, were the most important aspects of care; the perception of staff allocating time to the patient was also important (Johansson Reference Johansson and Eklund2003). An important question is whether patients and psychiatrists agree on which psychiatrists are perceived as empathetic by their respective patients. An important although rather small study addressed this question. Ten out-patient psychiatrists and five of their patients completed a questionnaire rating the psychiatrists’ empathetic skills. Crucially, no significant correlation was found between psychiatrists’ self-perception of empathy and patients’ perception of their psychiatrist's empathy. Furthermore, psychiatrists’ self-assessed empathy was significantly higher than the patients’ ratings of their psychiatrists’ empathy, a difference that reached significance between male psychiatrists and female patients, i.e. female patients rated their male psychiatrists as less empathetic than their male psychiatrists rated themselves (Aggarwal Reference Aggarwal2007). It is worth noticing that there are no data pertaining to the impact of empathy, in psychiatry, on outcomes such as hospital admissions, relapse, medication adherence and engagement with community services. The factors specifically influencing empathy in psychiatry are rather limited and will be summarised next.

Socioeconomic factors, ethnicity, religion and empathy

Regarding socioeconomic status, very low-income patients reported experiencing poor communication and poor provider satisfaction in a retrospective study of 68 447 patient-reported experiences, which included measures of provider responsiveness, patient–provider communication, shared decision-making and patient satisfaction (Okunrintemi Reference Okunrintemi, Khera and Spatz2019). Regarding ethnicity, a systematic review and meta-analysis is underway exploring whether racial and socioeconomic status influence patient-reported experience of clinicians’ empathy (Roberts Reference Roberts, Trzeciak and Puri2020). Regarding religion, in a study of 100 out-patients with non-affective psychosis, 16 participants had psychotic symptoms reflecting aspects of their religious beliefs and the majority of participants reported that religion was an important aspect of their lives. However, only one-third had raised it with their clinicians and, in half of the cases, the clinicians’ perceptions of patients’ religious involvement were inaccurate (Huguelet Reference Huguelet, Mohr and Borras2006).

Working environment

Some factors related to the work environment have been linked to lower empathy. A survey of 63 physicians (Ahrweiler Reference Ahrweiler, Neumann and Goldblatt2014) found that they reported that stress at work and being overworked had a negative impact on their empathy, with specific comments on time pressure, clinical workload and time away from direct patient care (e.g. because of paperwork and administration). Specific settings can be particularly difficult. For example, mental health professionals working in in-patient environments in Latin America (Santamaría-García Reference Santamaría-García, Baez and García2017) reported lower levels of empathy. A survey of English mental health teams found high emotional exhaustion among acute ward and community mental health team staff and social workers and greater emotional strain related, among other factors, to a highly demanding job, low autonomy, and limited support from managers and colleagues (Johnson Reference Johnson, Osborn and Araya2012). Thus, it is possible to hypothesise that different management styles would affect psychiatrists’ empathy; undoubtedly, research is needed in this area.

Medical education

Some of the problems seen among psychiatrist may have started developing at medical school. A systematic review (Neumann Reference Neumann, Edelhäuser and Tauschel2011) found that self-perceived empathy declines significantly during medical school and medical residency, particularly following the clinical phase of training, which could be the result of two factors: the ‘hidden curriculum’ (e.g. harassment, belittlement, discrimination, human suffering and death, shifts of focus on to technology and objectivity, high workload) and the ‘informal curriculum’ (e.g. fragmented patient–physician relationships with no time for learning from and with the patient, few bedside interactions and inadequate role models) (Neumann Reference Neumann, Edelhäuser and Tauschel2011). Another systematic review of interventions to enhance empathy in medical students (Batt-Rawden Reference Batt-Rawden, Chisolm and Anton2013), which included patient narrative and creative arts, writing, drama, communication skills training, interprofessional skills training, experiential learning and empathy-focused training, found that 15 out of 18 studies reported significant increases in empathy.

Psychiatric training

The UK's curriculum for specialist core training in psychiatry (Royal College of Psychiatrists 2020) mentions empathy when taking a clinical history: during a consultation, trainees must ‘demonstrate interviewing skills, including [ … ] the establishment of rapport, the appropriate use of open ended and closed questions, [ … ] the appropriate use of facilitation, empathy, clarification, confrontation, reassurance, silence and summary statements’ (p. 53) as well as ‘demonstrate respect, empathy, responsiveness, and concern for patients, their problems and personal characteristics’ (p. 55). The RCPsych's ‘Silver Guide’ to psychiatric training in the UK (Royal College of Psychiatrists 2022) states that ‘At core training, trainees are expected to undertake a short and long-case in psychotherapy under the governance of a Medical psychotherapy tutor. Trainees will participate in Balint or case-based discussion groups to reflect on their psychotherapeutic training and are encouraged to continue to participate in these groups in higher psychiatric training’ (p. 8). Regular participation in a series of Balint groups can help trainees to develop their empathy skills.

There is little research on whether empathy and compassion should be explicitly assessed at the point of applying for psychiatric training and how training encourages empathy skills. A qualitative in-depth interview with 21 psychiatry trainees in London (Appleton Reference Appleton, Singh and Eady2012) found that one factor influencing their choice of psychiatry had been positive role models, including being approachable and people centred, and that trainees had been particularly influenced by consultants who took personal interest in them and their development. Furthermore, many respondents valued the opportunity to have more time with patients and the psychosocial aspects of care, as well as having to develop the skill to establish a rapport with psychiatric patients (Appleton Reference Appleton, Singh and Eady2012). A survey of 359 psychiatry trainees (Barras Reference Barras and Harris2012) found that those considering leaving UK psychiatry training mentioned as reasons spending too much time on paperwork, feeling that clinical priorities took second place to managerial objectives and not having enough time to see their patients.

A research study into understanding career choices in psychiatry, describing the experiences of 159 trainees on the RCPsych's training programme in 2019, indicated that they enjoyed patient interaction: 89.3% said that they met ‘fascinating patients with complex and interesting conditions’, 82.4% liked having more time to be with and get to know patients than in other specialties, and 74.4% found their clinical work intellectually comprehensive, with a holistic, biopsychosocial, ‘whole patient’ approach (Medisauskaite Reference Medisauskaite, Rich and Silkens2020: p. 3). On the other hand, reported challenges included under-resourcing (66%), systemic changes and constraints (e.g. reforms, target culture, long waiting lists) (66%), feeling that psychiatrists were held accountable for adverse patient outcomes more than in other specialties (46.5%), verbal or physical abuse from patients (28.3%), high stress and workload and burnout (37.7%) (Medisauskaite Reference Medisauskaite, Rich and Silkens2020: p. 3). Given that a recent systematic review found a negative association between burnout and empathy (Wilkinson Reference Wilkinson, Whittington and Perry2017), it is reasonable to assume that a significant proportion of psychiatry trainees find it difficult being empathetic clinicians (Box 2).

Clinician's beliefs about the causes of mental disorders

Clinician's beliefs in this area may be related to their level of empathy towards patients. The reactions of psychiatrists, social workers and psychologists to clinical vignettes emphasising either biological or psychosocial explanations indicated that vignettes portraying a stronger biological explanation yielded lower empathy in all professionals, a phenomenon even more significant among psychiatrists (Matthew Reference Matthew and Ahn2014). A meta-analysis found that people who tend to explain psychiatric conditions as brain diseases or chemical imbalances may be especially likely to see patients as more dangerous and less likely to recover and more likely to distance themselves from patients than those who do not endorse those explanations (Loughman Reference Loughman and Haslam2018). Given the correlational nature of these studies, it is difficult to establish a causal relationship. However, a causal role of knowledge and training on empathy is supported by the finding that information about treatability, service provision, training and policy went a long way to change attitudes, including empathy, towards people with borderline personality disorder (Day Reference Day, Hunt and Cortis-Jones2018).