Psychiatry & Psychotherapy Podcast - How Empathy Works And How To Improve It

Episode Date: January 8, 2019

Empathy is the ability to understand another's state of mind or emotions. It is also is being able to feel, understand and share with someone else in what they are saying, their meaning of life, their motivations and values. In research there are 3 types of empathy that are commonly described: cognitive, affective, and compassionate. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video. Instagram: dr.davidpuder Twitter: @DavidPuder Facebook:DrDavidPuder

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puter, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. Welcome back to the podcast. Today I am going to be going through my next, series on the Therapeutic Alliance. This will be session three. And also really a focus on empathy.

You can start here. You don't have to listen to the first two. It will be a standalone episode, but it will build into the prior first two episodes because empathy is a very important facet of what creates a therapeutic alliance. So first I'm going to start out by defining what empathy is, talking historically about some people what they said, talk about affective versus cognitive empathy and talk about deficits of empathy, psychopathy, autism, spectrum disorder, narcissism, Machavelianism, that kind of stuff and their specific areas of deficits in empathy. We're going to talk about the importance of empathy in physicians and therapists and really all humans. and then we will go into a study in which I'm a P.I. in, a primary investigator regarding on how

empathy is experienced by medical students as they go through wards in regards to their relationship with their supervisors. And then we'll talk about how does one increase empathy? And finally, my conceptualization of different stages of giving empathy. So I think that that's helpful for understanding, you know, how to both improve your empathy and how to think through the proper ways of giving empathy. Okay. So the big ideas. Empathy is the capacity to recognize or understand another state's mind or emotion to put oneself into another's shoes. There's a story that Yalom tells about a person who's driving down a road taking his, daughter to college. And she says, wow, this is the most beautiful river I've ever seen. It's just so glorious and beautiful and shining and those animals are just enjoying it. And the father looks out

his window and he sees this like shriveling mud pond that's kind of an extended ditch river thing. And he's just like, what is she talking about? Right. And, And he says, I don't know, it's not that pretty to me, right? So then on the way home, he's now on the other side of the road looking out his other wind, you know, the window in the other direction, and he sees the river and it is glorious and it is beautiful. And it's kind of an image of, you know, when someone's having an experience, we often reflect on our own experience to sort of understand the other person, but we don't need to do

that. We can start to detach from our own experiences and just try to experience what the person is saying and what they are experiencing without context of our experience. And mirror neurons is how this happens effectively and affective empathy. So mere neurons is, you know, part of your brain lights up the same way as another person. So, you know, one gazelle perks up as an enemy is coming and all the gazelles sort of move in unison. And, you know, as we watch sports, as someone moves on the field, we have that same representation of movement in our brain. And some great athletes can watch someone do a movement and repeat the movement without ever even practicing it. Some great athletes can do that. So it's a way of representing movement and emotions in our brain,

as we watch someone else. It's a way that we learn. Really how kids learn how to speak is to watch other people speak, to hear other people speak. So here we go. Empathy. Thinking, feeling, resonating, sharing in the moment to moment subjective state of another's affect, meanings, motivations, and values. So a couple things in that statement is that it is a subjective state. Everyone has a subjective state. It's the current state that they're in. It's their affects, their meanings, their motivations, what they're valuing. And essentially, we are feeling, we're thinking, and we're resonating and sharing in that state of another.

That is what empathy is. So the German word in philong, I'm probably butchering that, meaning feeling into. Okay. Empathy is the capacity to think and feel oneself into the inner life of another person. Hans Kohut was famous for saying that. An effective response that stems from the apprehension or comprehension of another's emotional state or condition that is similar to what the other person is feeling or would be expected to feel. Empathy involves the inner experience of sharing. in and comprehending the momentary physiological state of another person?

It's the capacity to know emotionally what another person has experienced from within the frame of reference of that other person, the capacity to sample the feelings of another or to put oneself in another's shoes. It means to share, to experience the feeling of another person. Here's a quote by a Weinschwarz, a psychologist. We recognize others as empathic when we feel that they have accurately acted on or somehow acknowledged in stated or unstated fashion our values or motivations, our knowledge and our skills or competence, but especially as they appear to recognize the significance in a manner

that we can tolerate there being recognized. Carl Rogers, here's a quote from him, the state of empathy or being empathic is to perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as if one were the person, but without ever losing the as-if condition.

Thus it means to sense the hurt or play, pleasure of another as he senses it and to perceive the causes thereof as he perceives them, but without ever losing the recognition that it is as if I were hurt or pleased or so forth. If this as if quality is lost, then the state is one of identification. So it's an affective response more appropriate to another's situation than one's own. It's the ability to sample others' affects in order to respond in resonance to them, an inner experience of sharing in and comprehending the psychological state of another person. So I am going to move on to there's two types of empathy that are most sort of differentiating.

I'll talk about a third as well. There's cognitive empathy and affective empathy. and cognitive empathy is sometimes referred to as perspective taking and it can help a team understand each other's perspective experience. Cognitive empathy can lead to altruism and decrease interpersonal aggression. When taking perspective of someone else, we're more likely to see someone's behavior as similar to our own and is a significant step towards de-biasing personal stereotypes about others. The cognitive component of empathy is one's understanding of another person's experience and can be further divided into a fast, intuitive versus a pursued.

The fast is more of the mimicry and the resonance, and the later is more of the information gathering perspective taking. And through these facets, one is able to, put to words what another person might be thinking or feeling. So that is contrasted with affective empathy, which is a shared emotional experience. It uses the mirror neuron system. Also occurs through mimicry of another facial,

another person's facial expressions. And it can be used by the attending to, feel the resident's emotions and help them navigate back into a connected mode. It's powerful in forming a shared state. So, you know, you can normally tell if someone is sharing some of your emotion, you know. And we can also tell if someone is, you know, as we share something, just completely not feeling what we're feeling. and this is the affective empathy it's that sort of leaking of the actual emotion into another whereas cognitive empathy is more of the knowing and cognitive empathy i think more of in terms of

are you accurately um watching them watching their body language watching their their micro expressions watching their facial expressions and and coming to thoughts about the meanings behind what they're saying. So interestingly, they did a study of Asperger's syndrome, and they show that they had a lower cognitive empathy, but not effective empathy. And autism spectrum disorder is DSM-4. Now it's kind of grouped into, I mean, Asperger's is DSM-4. Now it's Autism Spectrum Disorder in DSM-5. So Asperger's is more, was more of like the high-functioning, autism spectrum disorder person and the lower cognitive empathy is important to sort of register because it means that they're not they're not paying attention and able to put to words

what is going on in another person's state but they still have the affective component which is means that they can feel what the other person is feeling and that's really important to sort of understand autism spectrum disorder. Whereas in high aggression, boys that were highly aggressive had one half of the affective empathy, but the same level as cognitive empathy as a control group. So they check these adolescent boys, a large group of them, and the ones that were highly aggressive had one half the affective empathy. we'll come back to that a little bit but first the third form is compassionate empathy the way that

I think of this is like empathic motivation pro-social concerns sympathy it's the empathy of the first two leads to this it's kind of like a um a motivating force so it's when you you use the energy that's occurring through your empathy to do something that's pro-sufficiency social that helps the other person. So those are the three types of empathy. Now on to the dark triad. I haven't spoken about the dark triad before. So in short, the dark triad is the three personality types that are Machavelianism, which is kind of a, you know, comes from the book where, you know, they're talking about politically how to navigate and gain power and thwart others. And it's about exploiting others' weakness and using interpersonal strategies for manipulation.

They're highly cynical. They lack usually emotional attachment and they hide their own weaknesses. A second part of the dark triad is psychopathy, which are highly impulsive and inclined towards recklessness. inappropriate, immoral, violence, and there's no remorse or guilt. They use charm or manipulation for personal gain, regardless of the cost of others, and they display destructive interpersonal behaviors. And I had a whole episode on psychopathy, which, if you haven't listened to, it's really good. I interviewed Dr. Cummings, who's a psychopathy expert. The third part of the dark trad is narcissism, in which they have,

people have an exaggerated self-worth and they're very self-centered. They exploit others, exploit relationships, arrogant, view others as a means to an end. So in short, there was a study, Way 2012, in which they looked at the dark triad characteristics that were found in people and looked at empathy. And they found that people who had a deficit in affective empathy were the primary psychopathy people. And people with primary psychopathy are the cold-blooded killers. They're the people that don't have any remorse for what they do. They have low guilt. They're, physiologically do not get aroused to stimulus like fear. And they execute behaviors with a lack of

morality, whereas a secondary psychopathy is more of a, of their responding to negative emotions when they harm others. So they get very angry and then they harm others. But the people with primary psychopathy, they're very cool and calculated. And they do have kind of a abnormal response to negative emotion. They, they have like positive expressions. on their face when looking at sad, angry, or fearful images. It's very odd. It's like a, it's like there's a mismatch there, right? And so people who were in the primary psychopathy had a low affective empathy. And also the prior study showed that high aggression boys had a low affective empathy. And, you know, narcissism and Machavelianism had had lower empathy,

but actually after you controlled for the primary psychopathy, which is also fairly prevalent in these populations, they were pretty much the same as controls. So it's really the primary psychopathy, which has the low affective empathy. So what do you do with that? Well, I think, first of all, it's good to know that not everyone has empathy as much as other people. There are people who have less empathy on a bell curve. The people with the lowest affective empathy are probably in more of the psychopathy range. They're pro-social and, you know, people who do things that are good for society that have primary psychopathy.

They're, you know, as we talked about in the psychopathy lecture, they could be a part of the military, special forces. They could be, you know, doing good things for society. They will not be doing it with as much fear. so that, you know, people who may go into a place where there's a bomb and take apart the bomb, you know, you don't want a lot of fear in that situation. So having a little bit less empathy can be actually good. Okay, so why empathy?

Why do we care about empathy? Well, in one study of 20,000 patients, primary care providers with high empathy had a lower rate of metabolic complications with their patients who had diabetes. If they were in the high empathy group, the top third empathy group compared to the bottom two-thirds of the empathy group. So if the primary care physician was higher in empathy, they would have less metabolic complications. So that's not something we normally think about when we think about just treating diabetes. is empathy important for the treatment of diabetes? I would say it's probably important for more diseases than we realize

because empathy allows us to see into another person's world. And just that human capacity allows us to create a bond, create that therapeutic alliance, which allows us to long-term give the treatment needed or actually be part of the treatment itself. So one study has shown that physicians can increase their empathy skills. That's good news. And I would also say that empathy declines in the third year of medical school,

both in men and women, but it looked as if in this one study, and I'll post this, Hojat 2009, women have a higher baseline empathy. And the reason for that is they're, are probably, well, they are higher in one of the big five personality types called agreeableness, which there's a sub-domain of agreeableness called friendliness, and women score higher than men, and friendliness has a high correlation with empathy. So that's important to kind of understand that, one, that, you know, high trait agreeableness, higher empathy. Number two, women are

slightly more empathic than men. And three, that empathy can decline at different parts of our life. One example is during the third year of medical school. Now, interestingly, third year of medical school is when, you know, most people go onto the wards and start seeing patients, you would expect empathy to increase. But what I've found is that actually training is necessary to improve one's ability to empathize. It's not the amount of year, or the experience, really, it's how good the experience is. And if you're not paying attention, and if you have bad role models, you could actually have lower empathy than you started out with.

Different surveys have explored both cognitive and affective empathy, showing long-term results for high and low empathy in patient care. And this is why this is important to look at. Studies have shown that we can more accurately diagnose depression and anxiety if we're higher in empathy. We more accurately gauge interactions, which leads to better outcomes. You have increased therapeutic alliance. Therapeutic alliance in one study was, I think, about 0.8 correlated or 0.7.8.

So it's pretty highly correlated with empathy. You have increased patient satisfaction with higher empathy. you had a more, a higher likelihood that your patients will take medications. So I'm going to digress a little bit into something called Therapist Effect. And I think this is a really important area that I am going to probably spend a whole, a whole lecture and come back to over and over again. So Therapist Effect is that, is that there is a variance between outcomes of different therapists. So some therapists are better than other therapists.

And in different studies, the variance of outcomes is 5 to 12%, which is actually pretty big. That's a pretty big variance. One study of 91 therapists over 2.5 years, the best therapist showed a change of 10 times the average mean. So the average rate of change, they were 10 times higher. than that. And the worst therapist showed an average increase in symptoms. High interpersonal skills have been linked to better outcomes when studying therapist's effect. And how they actually measured this in Anderson, 2009, is they had the therapists respond to video clips of difficult patient

situations, and then they graded their response. So they pretended they were having that patient in front of them and the patient said something and then they were supposed to come up with the response to how they would sort of deal with that situation and then those responses were videotaped and graded and there was a link between the higher interpersonal skilled therapists and the outcomes. One of the interpersonal skills, of course, is empathy. So higher empathy therapists had a higher success rate regardless of theoretical orientation in another study. And lower empathy therapists linked to higher dropout rates, relapse rates, weaker therapeutic

alliance, empathy was shown to have an effect size of 1.22 to 1.43 when independent observers rated empathy for substance use outcomes. That was Moyers 2013. In a big study of therapist's effect, so this was another study. 69 therapists, 4,500 patients, they found that years of experience, gender, age, profession, highest qualifications, case load, degree of theoretical orientation, did not predict outcomes. Okay, so all those things I just listed had nothing to do with how good the therapists were. the amount of time spent targeting improving specific skills and reviewing therapy recordings predicted client outcomes. So it's the therapist that continued to want to improve their skills and continued to sort of attack skills, you know, in particular, either by watching videos, going to conferences that

were sort of oriented, but in general, it seemed like the therapists who were more motivated and had sort of a lifelong learning pattern of like, I'm going to continue to improve specific skills. So just kind of a thought that comes to my mind as I sort of reflect upon all this stuff. Right. So it seems like empathy is important. And when we do continuous case conference at my at the program where I teach some psychotherapy, we review video of third and fourth year psychiatry residents giving psychotherapy. And when we review that with the group, we look specifically at can we judge if accurate empathy is going on?

And within, you know, the first couple minutes, I would desire to be able to see that the resident is reflecting, in such a way that shows the patient that they're listening, that they're paying attention, and that they've noticed distress. It's not always the distress that the patient brings into the room verbally, right? I have a couple of patients who will talk verbally about distress, but then they will show no distress on their face or their tone of the voice. They may share pride actually as they are really sharing a story of overcoming.

And so the empathy might be towards, wow, that's amazing that you were able to overcome that rather than connecting with something that's not there. So the question that I often ask them is, where's the distress? and can you put to words why the distress is there? What is the meaning of the stress? What are the emotions linked to the distress? And what actually is in the room right now? More on that in the future.

I want to jump to some studies that I've been doing on empathy. I've been studying connection in trainees, whether residents or medical students. and this is unpublished stuff that is going to be published. And basically I had a connection index created in which we looked at questions that gauge the amount of connection and disconnection between the resident or the medical student and the supervisor. And within the connection index, we have three questions that are empathy related. And interestingly, the empathy questions,

are very, very related statistically to questions that are about feedback, that are about gratitude, that are about psychological safety. But specifically, I want to mention the three questions that I put in, the final survey, which is I felt heard and understood. I felt understood and heard based on this person's body language, nonverbal cues and facial expressions. and this person was in touch with my perceptions and concerns. So these three questions were asked to a group of medical students. And then the medical students talked about reasons why they responded the way they did.

And we had them grade their most connected and their least connected supervisor. and they came up with, you know, little stories that happened in the most distressing situations with the most disconnected supervisor they had. And they came up with stories about, you know, this was the most connected supervisor I had. So I thought I would read through this. And I will give credit to my research team for all the labors that they did. I would not have been able to do this work with. them. So in the most connected supervisor, the medical student said the senior was receptive to the

student speaking and would respond appropriately. Senior was very honest and open-minded with the student's concerns and took time to genuinely listen. Senior was aware and understanding of the students' emotions. With an emotionally difficult case, student cried around senior. So it shows like You know, the student felt comfortable enough doing that. Senior was relaxed, lighthearted, encouraging, optimistic, and overall in a good mood. So a student was less worried about upsetting them. Senior introduced themselves by their first name and talked to students one-on-one to see where the students, you know, what they were doing.

They would go down to the student's level, you know. Senior wasn't rushed during presentations. He wasn't just tolerating me verbally and was actually. trying to understand rather than just move on to the next thing. Senior wanted to get to know the student as a person, learn about their passions, etc., and the student felt invested in as a learner and as an individual. Interestingly, there's also the,

and these were just these three empathy questions, by the way, and we're still talking about the most connected supervisor. So with body language, the senior would make eye contact and smile, nod his head, have thoughtful facial expressions. A senior was not looking at the computer, paper, or phone while the student was talking. Senior would stop whatever they were doing and fully turned to face the student, letting the student speak without interruption. Senior listened attentively, repeating back to students' words and giving verbal acknowledgments

like, um and um. Senior didn't cross his arms unless calls. cold and would cross legs towards the students or lean towards the student when talking to the student. So the body language represented that they were really listening to the student. They would lean towards the student. The senior was relaxed when talking to the student. So it wasn't like an aggressive posture. Senior would greet the student in the morning and make the student feel welcomed. And then there's a teaching category. This all came from the interviews with the medical students. So in teaching,

the senior was very easy to talk to and validated students' questions. Even if they were simply saying, I didn't know that when I was in medical school either. So there was kind of a normalization that occurred here, right? So they normalized this student by saying, oh, I wouldn't have known that either when I was in medical school, right? If the medical student didn't know something.

Senior proactively answered students' questions and helped the student reason through situations. questions were clearly understood and clearly answered. Senior understood medical students' level of knowledge and once aware of what students would find valuable and what they cared about learning. This is an important piece here because empathy allows for the assessment of where the person that you're talking to is at.

And so if you change, if you're saying the same, thing to every person you meet. You're not gauging the person you're talking to. You're not aware and sensing them. Senior had students develop their own assessments plans daily and took student notes home to give feedback the next day. Senior was clearly paying attention to the student's presentation and gave specific and helpful feedback. Senior advocated for the patient and was invested in prioritizing good patient care, which showed the student what good medicine looked like. Senior new student's name and didn't refer to them as medical student.

So that was the most connected supervisor. Now we will talk about the least connected. And, you know, just let you know that this is, you know, the least connected of all the person. So you may, you may, you may interact with like 100 supervisors through your third and fourth year of medical school. And this is at multiple different rotations. You're rotating at many different medical centers all across the U.S. You know, you're doing interview rotations. And so you, once in a while you come up against a pretty frustrating situation. And so this is kind of, you know, You come up against situations where you feel ignored, indifferent,

and you feel invisible and worthless. So during the empathy questions, as they ranked these people fairly low, you know, they did not feel hurt and understood, they did not feel that a person was in touch with their perceptions and concerns, and they said these things about why they answered those questions low. student had minimal interaction with the senior because the senior only directly spoke to residence and had the attitude that the medical student was not important.

A student did not feel a part of the team. Senior tolerated the student's experience but didn't intentionally interact with or encourage them. Senior was never engaged, never engaged the student's perspective. A student had to work to be noticed at all. Senior was not in touch with student concerns, time, or well-being. Senior did not appear to think about students at all and never asked for feedback. Senior did not acknowledge students unless student made a mistake and did not notice if they were caring for patients or not.

Senior did not let students speak. Senior was very hierarchical and only discussed patient care. student would not bring concerns to senior only resident. Student felt judged unheard and not understood, unvalidated and unimportant, and a little bit objectified, and undervalued as a person. Senior favored specific students and gave them special treatment. The senior was on their phone or computer looking at a list, talking to someone else during the student presentations, would face the student

be talking to other people or just bored when the student was talking. Senior had a flat facial expression in response to this student. Senior was very stoic, deadpan, excessively logical. So that's kind of coming back to the still face experiment with me,

tronic still face experiment of just like, just a flat-faced person looking at you. Senior had a look at disgust if they thought something was stupid, and if the senior was smiling, it's sarcastic because they're laughing at you. Senior would purposely avoid eye contact with the student and didn't look directly at the student. Senior did not say hello or acknowledge the student. Student felt senior was waiting for them to make a mistake. Student felt so fearful that I'm doing something wrong, fearful of that pressure that I'm doing something wrong.

student felt anxious because they would try so hard to get the senior's attention. Senior wanted to move very quickly. Senior's goal was to get work done and wasn't concerned with how residents or students were doing, feeling, learning. There was no purposeful connection. Student presented patients during rounds, but didn't have any discussion with the senior outside of that setting. Student felt tense around the person and felt the senior's attitude. was I'm doing my thing. You gave me your crappy little presentation,

and I'll blow you off now. Senior did not know this student's name. So these are all different, really horrible interactions of, you know, in the end, not feeling heard, seen, feeling invisible, feeling worthless. And unfortunately,

this happens even in medical education. And we know from research that it's the bad role models that make medical students depressed and burned out, not the difficult patient situations, you know, the traumatic situations, the life or death situations. So much of it is the mentors. So this is something I'm really passionate about. I really want us who are in medical education, and I think if you're a doctor or in that

journey, you should consider teaching the next generation of doctors. and I think although it takes more energy to, you know, establish a meaningful relationship, to look at someone, to get their name, to understand a bit about them, to have them present, to have you share their thoughts and their reasoning behind how they view, you know, a situation, these things these things are so important and a little bit of attention goes a long ways attention is actually I think hugely similar to empathy like you have to give someone attention to feel into their experience so where does that leave us so we're going to transition now into things that may improve your ability to empathize

Number one, optimize Sensorium. I give a little series on Sensorium. And Sensorium is total brain function. It's the fluctuating function of the brain. So if you're super tired and you're listening to this, it's not going to be as registering as much as if it's first thing in the morning and you just had a cup of coffee. Regression is universal. And it's caused by sleep deprivation.

distress, illness, intense loss. And we really want to try to optimize our sensorium, whether that is getting off of certain medications that lower sensorium, or developing a good exercise and diet regimen that optimizes our sensorium. And of course, sleep. Number two, try to understand the person's emotions. So just paying attention. to someone's emotions, increases the amount of mimicry that goes on on your face.

That was a study that they looked at that specifically, and that's what they found to be true. So when you are paying attention to someone's emotions, when that part of your attention is being drawn there, you will mimic their emotions more, and that will increase your affective empathy. And thinking about their emotions will increase your cognitive empathy as well. But, you know, the mirror neuron response tends to increase when you're actually focused on it. Reading fiction and allowing yourself to be transported into the book, into the time frame.

I have been reading a series on the formation of England, and I'm so transported into that time period that I think I can feel what it would be like to some, agree to live in that time period, you know, without electricity, where there was constant threats of death, of disease, of, you know, being completely necessary to go to war and go to war frequently, like what that would be like. And by sort of immersing yourself into a book, you can start to create representations that are not of your own brain. And you can have empathy for other people's circumstances. And it can be an important piece in that. Interestingly, violent video games do the opposite.

They take you away from empathy. And that was a study that looked at that Anderson, 2010. Okay, number four, working through our countertransference. So countertransference is your reaction to the patient, your complete reaction, based both on the hearing, here and now situation of the patient and also your past situations in life, maybe your parents or your role models or your mentors or people that the patient reminds you of. Some of them negative, some of them positive, but countertransference is that total reaction you'll have to a patient.

And working through that can be important for having continued empathy. So how to work through countertransference? You really can't do this by reading a book only. You can't read it by just listening to a podcast. You have to actually have a good supervisor. Talk through difficult situations. Things that get stirred up for you, things about your past. You need to talk about those.

Put them to words. Process them through with someone who also has empathy for you and your situation. I was talking to a friend recently about, you know, his kids are four right now, one of his kids is four. And he remembers back to when he was four and the distress of his childhood. And I think it's a common situation. As our children go through certain age and certain developmental time periods, we get transported back into what it was like to be that age.

did you feel just ignored? Did you feel alone? Did you feel attacked for different ways that you were? So it can be important to, you know, not just with, as patients stir up our sort of experiences from the past, but also as life stirs up those periods from the past, can we continually work through, make sense of, bring, draw meaning to understand herself deeper.

I think all of those things allow us to then be more present with another person. And here's what I see often is when there's too much countertransference, you're too much in your own experience. And when you're too much in your own experience, it's hard to enter into another person's experience. And so by working through any emotional reactions you have to other patients, you can start to be more present with them. patients have different ways of relating and it helps to see those ways of relating as adaptive.

If we can put it into an adaptive perspective, it can be easier to empathize. For example, some patients will be passive and acquiescing. How is it helpful for them to be passive and acquiescing in their life? some people will be afraid of intimacy well how is that helpful for them at some place in their life how is that adaptive if someone is challenging or suspicious to you how is that helpful for them at some time in their life if they want to maintain a sense of themselves they may attack they may um you know push away and coming to grips with, okay, how is that useful for them to act in those certain ways? How is that adaptive?

That can be helpful. I've looked at what are the difficult patients that doctors experience? And the difficult patients, and you know, you have different doctors, and there's been studies where they rate which patients are the most difficult. And, you know, then you can generalize like, okay. okay, these are a difficult group of people that we will see. Then how can we understand them better? And if we can understand them and see how their diseases or the way that they're

interacting is adaptive, then maybe we can tolerate them better and be less distressed and then be more present with their distress. So, for example, one thing that's near due to my heart is, patients with unexplained physical illness or others uncontrollable factors. So if a patient comes in with a lot of distress and it's really hard for us as physicians to know why they have that distress, then it can be, it can make us feel helpless. And sometimes that helplessness that we feel is actually just a mere neuron empathic response to the patient's feeling of helplessness.

So sometimes even just putting that to words can be helpful. Like, you know, I'm wondering if you feel fairly helpless in this situation. Yeah, Doc, that's it. I feel very helpless. Oh, wow. Well, I can understand. It would be really a big struggle. Well, here's the steps we can take to helping you.

And I think this is what's going to be, you know, important. You know, sometimes it'll be, you know, I think you need to start working out or I think you need to start setting some boundaries around your sleep, stuff like that. Stimple stuff. stuff that's not like necessarily, you know, invasive and, you know, lab tests or stuff like that. And other difficult patients are, you know, when we sense that they're manipulative, demanding, or have a hidden agenda. So it can be important to just put words to it, you know, like, hey, like, what's, what are you hoping to get out of this meeting? If you were to get one thing out of this meeting, what would it be?

And, you know, other patients that are difficult, they may be drug-seeking. And I would say if they are drug-seeking, what is helpful about taking the substances that they're taking? You know, if you feel like they're taking it for non-medical purposes, you know, like, what is the purpose? Maybe there is a psychological purpose. Opiates, I had a patient who was going through some severe attachment issues, issues where, like, just, she was in a five-day-a-week. program and just the weekend was so distressing that she found that she could go on Friday and get some opiates from an ER and then take them Saturday as well. And she could usually get through Sunday. But the opiates helped her with her in very intense attachment issues and being away from

the therapist and this treatment team. And we had to address that and of course, you know, work on developing coping strategies to help her so that she didn't need the opiates, right? Some like something else to give her, to help her soothe the angst of being separated. So I can't not mention that they're also difficult doctors. So there are doctors that are, that often rate patients as being more difficult. And so they've kind of reversed the research study and show that physicians who are younger have evidence of anxiety or depression, have longer work hours, often perceive patients to be more difficult.

And patients with psychosocial problems and substance abuse were more likely to be seen as frustrating by this group. So there is a process in developing and in becoming more tolerant of difficult patients. and I would say that this is, if there is a particular type of person that is more distressing to you to interact with, and if you're capable of working with a supervisor on discussing what it is about that person that really sets you off, I think that can be very valuable work. Often in my, I'll run group supervision for the residents where I'll have a group of like 10 residents talking. And I want to find these situations, the patients that are really,

getting under their skin. And then I try to use the whole group to sort of both normalize and empathize with that person who's going through that, but also kind of like, can we stimulate a discussion and all grow together to become more tolerant of this type of situation? So the next thing on my list of things that you can do to improve your ability to empathize is to learn to read emotions and body language more accurately. I have three episodes on microexpression, which I will point you towards here, and an app emotion connection, which providers can learn how to read microexpression. And I hope to really help people improve their ability to learn how to read emotions in other people

and understand what those emotions actually mean. And you can actually improve your ability to empathize, by learning to observe people more accurately, even if you are a little bit more effectively empathy or affective empathy challenged. And what I've found, though, is that when you learn how to read someone's emotions more accurately, then you can tune that mere neuron experience

that's happening simultaneously because you'll know what you felt and what you saw. And so you can start to tune your instrument. Okay. the next point is to learn to accept feedback from your, from your patients. So feedback is very helpful, even negative feedback, because it allows us to know when we were not empathizing accurately and when we were empathizing accurately. And so if someone feels unheard, then that's a very important piece of feedback. And we should not be defensive to it, but rather see it as an opportunity to recalibrate

to re sort of engage in an empathic listening way. Calming your own hyper arousal. So if you have situations in which you get overly stimulated, it may be important to learn how to sort of calm that, how to self-regulate. And I think there are some breathing techniques, mindfulness that have been shown to be helpful in this. I personally have used a biofeedback device

to learn how to breathe, to bring my self-in-R-SA, respiratory sinus arrhythmia. And in certain situations with patients, when I feel, especially the patient starts to dissociate or starts to feel lightheaded or disconnected from reality, it can be helpful for me to ground myself in my chair, in my, you know, in my body. and with breathing and with feeling myself in my chair and feeling my hands and feeling my feet on the ground. The next one is noticing when connection or disconnection is occurring. So even within a 15-minute encounter, there may be moments where the person does not feel hurt and understood. There may be moments where they feel very hurt and understood.

And so noticing the ebb and flow of connection and disconnection, can be important for empathy and sort of understanding where you are in the moment with a particular person. Practice empathy towards viewpoints that are not your own is my last one. And specifically become, put yourself in situations that you would normally not, and with people you would normally not, and practice the ability to listen to them, not for the sake of increasing your ability to do this, but for the sake of understanding a person and connecting with a person.

I think that should always be the primary motivation. And in the midst of that, become mindful of the emotion, the distress, the meaning behind the distress. And I think this is at its height of difficulty in our political day and age that we're in. And I often see families where they've stopped talking. talking to each other because of differences in political viewpoints. And, you know, maybe there's a limit to your own tolerance to empathize with someone else. But nevertheless, if you want to improve your ability to empathize, I would say specifically putting yourself in a situation that would allow you to listen to someone and to listen to their

full thought process without necessarily, you know, needing to be right or needing to prove your point. But just for the sake of practicing this skill of listening to someone else, someone else's distress. So finally, to the levels of empathy. So I think that there are three levels that I'm going to talk about. One is the first, the first level is the flashes of emotion. So when you listen to someone, there are flashes of emotion that across their face and there are changes in body posture and, you know, there are micro moments of emotion. And within these micro moments of emotion, you might ask, what are you feeling while you're listening to them? What are they feeling?

And you could ask them to tell you what they might be feeling. You know, you could suggest, you know, perhaps you are feeling frustrated as you tell me this. Use their own words. You could repeat you. You could use their own words to repeat back to them. I hear you feel tired and sad all the time. If maybe they use those words, you can match the, the rhythm of their voice, the tonality, the emotionality.

So, you know, sometimes I'll be in a very happy mood. I'll have a patient come in and right off the base. They're telling me a very sad story. And I'll kind of have to readjust the way that my face is, the way that I'm feeling to sort of match or resonate with them a little bit. This is kind of the first stage. And I think this is something that's so, so very important. It's where is the distress?

what's the actual emotion that you're seeing and what might the meaning of the emotion be? So that goes into phase or sort of the second level of empathy as I am defining it. The second level of empathy is looking at the meaning of the emotion and the distress in the context of their lives. So it's not the first stage is just recognizing the emotion and maybe the, the very acute surrounding distress. The second stage is looking at the broader context of their lives. So there's a flash of anger. And then you know, you asked them like, hey, when you were saying that, what came to your mind?

And they said, well, I just feel like I hate myself. And then you could say, well, maybe as you're listening to them, you could say, well, it'd be really hard to hate yourself, to feel that frustration towards yourself. So that would be like kind of the phase one, right? Because you've identified the emotion and the acute situation of the emotion. And then sort of the context of their life is what they've previously told you, what you know of them, and connecting it with how they are currently in that situation.

So, for example, in this example, they have anger towards themselves. And you could point out to them like, hey, you know, like, when you were growing up, you told me that when you would get angry, you know, you would basically get beat up. And maybe it's harder for you to express your anger towards anything other than yourself because, you know, it was adaptive and strengthening of you. or it was life preserving for you to sort of point that anger at yourself and to not attack back, to keep that sort of under wraps. And so maybe that's where you're feeling it. So that's the context. It's the life story, right?

So people feel emotions. and often the emotions are linked. The dreams that they have are linked to the past. And so if we can kind of identify and observe and then resonate and then help them understand the context of where it comes from, it's actually a deeper sense of, understanding of the person. And so I would say that's sort of the second level of empathy.

And the third level is the meaning of their emotions and distress in the context of their relationship with you. So within your relationship with them, as they feel some of the anger, the anger actually may start to be directed at you. And that anger that's directed at you may, you know, like especially with someone who's only turned that anger inwards, and so they have no representation of the anger to something outside of them. And so then it gets directed at you,

and now you're in the here and now with them, experiencing their anger at you and you're feeling that and if you can put words to that it is um it's it can be powerful it can also be a little bit dangerous right it can be interpersonal feedback is the most difficult to give um because because it can be so easily misrepresented so saying something like it could be it could be challenging to share if you were frustrated you were frustrated frustrated at me, but I want to let you know if you do have any frustration towards me, it would make sense, and it would be helpful for us to explore that. So by saying that, I'm not necessarily telling someone what they feel towards me or pointing it out

directly, but you're giving space, and even though you saw the flash of anger directed and that the direction was at you, they made a snide remark or something that allowed you to know that there was some passive aggressiveness towards you. It's hard to know what the aggression towards you is. Maybe it's a competitiveness. Maybe it's maybe you did do something that was wrong. And so it's hard to know what the meaning of it is always, right, unless they tell you. But we can start to put out that it's okay for them to express what they're feeling in the here and now.

and in the relationship. So it's about the relationship that you're having with them in the here and now and the context of that that gives that third level of empathy. So here's a quote from Dr. Tar in sort of this sort of how he opens up patients to give him feedback. I very much want to hear your positive and negative feelings, particularly about me, particularly negative ones. It will be helpful for you to share any feelings of disappointment, feelings of not being understood, feelings of not being responded to or criticized, or mannerisms or things I say that affect you

undesirably. I hope you can understand that this is not a usual social situation where you don't tell people negative thoughts. here I hope you can have the courage to say them out loud. So let me repeat that. I hope you can understand that this is not a usual social situation where you don't tell people negative thoughts. Here I hope you have the courage to say them out loud.

It will be helpful to say as it is happening. We can learn much more than if it comes out later. We know it will be hard. but it's kind of a laboratory where we discover what goes on between us. So there's a quote by Dr. Tar. With that, I will wrap up the session. If you found this helpful, I will be posting this on my social medias. You can comment there.

You can also comment on the website, psychiatrypodcast.com. if you would like to get CMEE for this episode, you can follow the show notes to get CME for it. For every hour of a podcast, you can get one unit of CMEE, and I have gone through the painstaking steps to get CME subscription available to the people who listen and professionals.

So I hope that's helpful for you. I hope this episode, was helpful for you and I hope to coach people to increase their empathy and so I will have practical tips throughout all of my podcasts I hope in order to better equip people to be more empathic and if there are certain areas that you think I could emphasize more for you I would love to do that you can correspond with me through my my website or through my social medias, all of which I will link in the show notes. Have a great day.