Honing Empathy as a Therapy Tool

My first real encounter with compassionate care occurred during the “observation hours” each PT school applicant is required to log. I did my outpatient hours over the summer in an orthopedic clinic, each therapist seeing 4 patients every hour, with most patients passed off to the therapy tech (or to me – the volunteer) for their exercises. That fall, I created an independent study through my college to get credits for observing the PT at the state psychiatric hospital right next to the school. Unsurprisingly, therapy at this hospital looked completely different from therapy in outpatient orthopedics, in about every possible way. But, most strikingly, this therapist’s approach to creating a therapeutic relationship was also completely opposite.

In outpatient, the therapists had big personalities and were almost cavalier in the way that they doled out rote treatment plans. They were busy and used joking around to create a sense of camaraderie in the clinic, but there was really not much discussion of how a patient felt, individualization of plan of care, or analysis of whether the prescribed treatment plan was working. In this state psychiatric hospital, the therapist was quiet and reserved. She spent a long time in conversation with prospective patients, learning their personalities, the way their diagnoses manifested in their behaviors, and functional difficulties. She consulted with nurses and with physicians, as well as the security staff stationed in each unit to figure out each patient’s triggers, whether they had been violent recently, and what their particular health concerns were. Then, after all this prep work, she engaged with the patient in exactly the manner required to enlist the patient’s participation. She followed all the steps for compassion listed in the previous post: made a meaningful relationship, believed the patient did not need to be suffering, and believed she could alleviate some of the patient’s current suffering. I was amazed by her ability to be calm in the face of some rather unpredictable patients and to communicate loving kindness to people who could be a little scary.

In her book Atlas of the Heart, emotions researcher Dr. Brene Brown teaches that empathy is the most powerful tool for compassion, defining it as “an emotional skill set that allows us to understand what someone is experiencing and to reflect back that understanding”. I watched and learned as this therapist recruited a patient, who believed himself to be a prophet, to stand and do strengthening exercises not by lecturing him about the health benefits of participation, but by reading aloud his favorite scriptures and listening intently to his thoughts about them while he worked. She offered words of strength and encouragement, rather than words of criticism or admonition, to a patient who declined to participate in therapy because she believed herself to be in labor having twins (she was in her 70s). When a patient cried about not having the right clothes to wear, rather than assuring the patient she was dressed appropriately, this therapist took her to the patient’s own closet in order to perform standing balance while “shopping” and choosing the perfect outfit. This is definition of empathy resonates with what I witnessed, but did not have the language to describe.

So if we use the 3 steps from my last post to reflect and change our own attitudes to engage in compassionate action, how do we hone empathy to use as a tool of compassion? Angus Fletcher, a writer with dual degrees in neuroscience and literature, has done research that illustrates the neural evolution of empathy as an antidote to the human’s brain’s preference for justice and fairness. In his book Wonderworks, he presents the idea that ancient humans used the apology as a mechanism to increase empathy – it alters the perspective-taking network deep in the brain that allows us to consider the apologizer’s point of view. He also demonstrates that reading literature which contains characters who show remorse can strengthen our empathy “muscles” by giving us additional practice viewing situations from a point of view other than our own. This shift in perspective allows us to move from justice/judgment and into empathy. The more we practice understanding view points that are not our own, the more we will be able to hone our empathy skills.

During that independent study experience, the most important thing I learned is that people will not participate or engage with people who don’t meet them where they are. Therapists who work in pediatrics or who work with patients with cognitive disorders often know this intrinsically. If the patient doesn’t feel empathy from you, the therapist, they are going to shut down and refuse to do anything, because what they actually feel is some form of judgment. Neurotypical patients are less overt about this, but genuine connection is not less important. One systematic review compiled research about therapeutic alliance (which we know from previous posts cannot be created without compassion) with patients of various diagnoses and cognitive abilities[1]. In studies including patients with traumatic brain injury, stronger therapeutic alliance was associated with improved adherence to treatment plans, higher post-injury employment, decreased depression, and overall success with therapy. In studies including patients with general musculoskeletal complaints (such as chronic pain), stronger therapeutic alliance was associated with perceived success of treatment, decreased pain, improved physical function, decreased depression, and improvement in general health status. Patients with cardiac conditions demonstrated increased adherence to treatment protocols, and geriatric patients with functional deficits demonstrated increased function and decreased depression.

This systematic review contains a wide range of cognitive statuses and physical capabilities, and it’s striking that building a strong therapeutic alliance - with tools like active listening, empathy, and compassion - creates such wide spread positive effects for patients. The directive for therapists is simple, but difficult. Believe patients when they tell you their point of view. If that patient’s perspective doesn’t seem to make sense, then ask more questions and actively listen to (and believe!) their answers. Read literature (or even the news), and practice exploring perspectives that are not your own, without judging them to be right or wrong. Think of some of the most difficult people you know, patients or otherwise, and imagine things in their life that they may not have shared that affect their attitudes and behaviors. We can hone these abilities for the benefit of our own personal development, as well as for the benefit of our patients.

[1] The Influence of the Therapist-Patient Relationship on Treatment Outcome in Physical Rehabilitation: A Systematic Review. https://academic.oup.com/ptj/article/90/8/1099/2737932?login=true