Clinicians know how important it is to establish rapport with clients, and would also concur that good communication is essential for good clinical practice (Rhoades, 2001). This connection between the client and clinician that facilitates a positive influence in treatment is empathy.
I realized the importance of empathy when I noticed that the connection I made with clients during treatment could enhance their satisfaction. This was clear from positive results on patient satisfaction surveys. Even more interesting was that not all of these clients had even reached their goals in treatment; however, they were still highly satisfied with their overall experience.
What Is Empathy?
Webster's Dictionary defines empathy as "the projection of one's own personality into the personality of another in order to understand the person better; ability to share in another's emotions, thoughts, feelings." Stephanie Preston, a cognitive neuroscientist, proposes a combined empathy theory that divides the concept into two levels (ultimate and proximal). The ultimate empathy is related to mother-infant interaction and responsiveness as well as the "fight or flight" response we need to flee a dangerous situation.
The proximal empathy, and the portion of the theory that we most relate to as clinicians, is linked to one's emotions. The proximal level is derived from a "direct mapping of another's behavioral state onto a subject's behavioral representations" (Preston & deWall, 2000, p. 2). Preston further identifies the disparity in the literature, speculating on whether empathy is cognitively or emotionally based. According to Preston, this is directly related to the clinical situation since the client's emotional state is reflective of the clinician's emotional state. To simplify, if the clinician is in a bad mood, this may put the client in a bad mood as well; essentially, it is like looking into a mirror.
With this description, one could posit that empathy is an emotional state of being that allows each member of a communication dyad to understand how the other is feeling. As communicators, we understand that this emotional reciprocity appears to be present in the communication of most healthy individuals. Is this true also of the client-clinician relationship?
Empathy in the Client-Clinician Relationship
According to a common scenario presented by Rhoades (2001), the average time a physician spent with his patient was 11 minutes. The patient had an opportunity to speak for four minutes and was interrupted at least twice (by a phone call, knocking at the door, or a pager) during a visit. Although this study did not fully describe how the patients felt during these interactions, one can assume that the patient's satisfaction was questionable.
Thankfully, most of us have had better experiences, during which the physician listened and answered questions in an empathic fashion. Imagine how our clients must feel, especially with the additional challenge of a communication disorder, if we are rushed, harried, or curt during our interactions. From my own clinical experience at Southwestern Vermont Medical Center (where QUESTS-Quality, Empathy, Safety, Teamwork, and Stewardship-is part of our value statement), most patients credit their treatment outcome directly to those caregivers who demonstrate a concern for them.
There is a great deal of literature on developing empathy within the physician-client or psychoanalyst-client dyad but little examination of the cultivation of empathy in the audiologist/speech-language pathologist-client dyad. Keisler (1979) and Squire (1990) propose that the cultivation of empathy is salient to establishing rapport in the therapeutic relationship. Keisler underscored the need for more research examining variables such as practitioner differences in the components of empathy and empathic compatibility in clinician-client dyads.
Others (Buie, 1981; Decety, 2002) also have stressed the importance of empathy, but counterintuitively suggest that empathy can interfere with a therapeutic relationship. Edwards (2001) concurs, stating that it is not necessary to cultivate empathy during the physician-patient relationship as this may actually hinder the physician's ability to be unbiased. This is a paradox in the literature that should be examined to procure a more basic understanding of empathy and its importance in the SLP-client relationship.
Researchers on Empathy
The development of an empathic concern remains a topic of debate in neuro-cognitive science. Some scientists think they have discovered the origin. "We're all mind readers," they say (Than, 2001). In 1996, neuroscientists were probing the brain of a macaque monkey when they discovered that a cluster of cells in the pre-motor cortex fired not only when the monkey performed an action but also when the monkey saw the same action performed by someone else. Thus the discovery of "mirror neurons."
Since their discovery, mirror neurons have been implicated in a variety of mental disorders, such as schizophrenia, autism spectrum disorders, Asperger's syndrome, and Lesh-Nyhan syndrome (a failure of self-regulation and self-control that leads to self-injury). Cognitive scientists speculate that persons with these disorders exhibit a lack of understanding and interpretation of social cues that may be a direct manifestation of problems in the mirror neuron system.
Cognitive scientists also have used mirror neurons to help understand Theory of Mind (ToM), an individual's understanding that others have feelings and emotions of their own, or the individual's ability to understand perspective-taking. Empathy is a substrate of ToM, as perspective-taking must be present before a person can demonstrate empathy for others. According to Tiffany Hutchins (2005) in her study focusing on remediation of the core deficits of autism with use of social stories, ToM is clearly lacking in the autism spectrum disorders/Asperger's population.
Even more recently, Wicker's (2001) fMRI (functional magnetic resonance imaging) studies revealed that when a person visualizes another experiencing an emotion, the same area of the brain is activated in both the person experiencing the emotion as well as the observer. Gallese (2005) supports Wicker's (2001) work with mirror neurons by examining the mirror neuron system and its role in interpersonal relations for establishing attunement.
Gallese believes that when we interact with someone we do more than just observe the other person's behavior. He believes we create internal representations of the person's actions, sensations, and emotions within ourselves, as if we were the ones sensing and feeling. During his studies of F5 neurons, Gallese describes how some of these neurons discharge in the monkey when the researcher is using facial expressions that communicate meaning (as cited in Ferrari 2003).
This gives some interesting insight into the understanding of empathy and its communication within a dyad. Gallese's view is in agreement with Preston's and notes that if the clinician's manner is anxious or unpleasant, the client is sensitive to this. Furthermore, if the client has a communication disorder, this ability to perceive and understand facial expressions and other non-verbal language cues may actually impede the true understanding of the clinician's intentions. Some clients may not be able to distinguish between a clinician's personal issues (i.e., being tired or busy) and may misinterpret the clinician's mood as a lack of concern. This is likely to inhibit the facilitation of rapport, in addition to hindering the progress of therapeutic intervention.
Non-Verbal Language and Empathy
How is empathy communicated within the dyad? Is it verbalized? Does one partner actually say, "I'm feeling empathic toward you at this moment"? Most would agree that this is not the case. Rather, it seems to be more communicated via the non-linguistic channel. Marc Pell, at the Symposium on Understanding Emotions: Insights Emotion, Communication and The Brain, explains this with his research on emotional prosody. His research indicates that a speaker's emotional state can be expressed without the use of words and be understood just by listening to the speaker's voice. A good example of this is how a speaker's voice during a telephone conversation can reveal his or her illness or emotional upset without the speaker indicating such.
The literature (e.g., Ekman, 1993; Johnson, 1994; Mehrabian, 1972) reveals inconsistent evidence on the role of non-verbal language in emotions such as empathy, anger, and fear. Ekman provides an excellent explanation for how non-verbal language cues (body posture and facial expressions) convey more meaning than their verbal counterpart. Mehrabian's ratio explains how the areas of communication are divided for the interpretation of a message: 93% by non-verbal language-55% facial expressions, posture, and gesture, and 38% tone of voice-and only 7% words. Although Johnson disagrees with both Ekman and Mehrabian stating that non-verbal language really isn't important in understanding a message, Mehrabian's ratio does support that non-linguistic language cues are the salient features in revealing emotions such as anger, fear, sadness, and disgust.
Within the clinical arena, my student clinicians have expressed that it is important to establish a consistent means of communicating an empathic concern to patients. Students further explain that empathy is most easily expressed to clients through an increase of eye contact, forward body posture, use of a soft tone of voice, nodding more frequently, and listening without interruption in a non-judgmental manner.
Why Is It Important to Understand Empathy?
Understanding the origins of empathy is important not only in theory, but also on a practical level. Recently, there is a strong focus on evidence-based practice (EPB) in the discipline. One example has been Linda Shuster's article in The ASHA Leader (March 1, 2005) which states "it is not enough to base a treatment on theory, because not all theories are equal." Shuster describes the early use of insulin coma therapy that was practiced on patients with schizophrenia. This is a quite radical example used to prove the point that evidence is required for best practice.
I agree that to measure efficacy and to base treatment on sound techniques should always be a priority, but what are the other variables that influence a patient's outcome? Are we seeing "the tree and not the forest"? There must be more than just evidence-based clinical treatments that influence a patient's outcome (Clark, 2005).
I encourage clinicians to consider empathy as an influence on outcome in the treatment session. Physicians are beginning to make this connection and courses on enhancing communication and empathy are becoming more prevalent. One such course is offered at Southwestern Vermont Medical Center by David Clarke, from Bayer Institute for Health Care Communication. Clark presents a program for health care workers to engage, empathize, educate, and enlist patients in their own care. This improves patients' feelings of satisfaction with care, improves pain management, and allows them to feel more "in control" of their own treatment. Furthermore, an interesting relationship that has developed from improving empathy is the reduction of medical errors (such as coding errors, and mistakes in medication administration).
Within our own profession, SLPs Karen Perry and Nina Simmons-Mackie from Southeastern Louisiana University further explored empathy. They developed a protocol that involves classroom experiences such as role-play of an assigned neurological disorder and various other hands-on empathy experiences to build awareness (ASHA Convention, 2004). From the qualitative data collected they report benefits to the class such as increased knowledge of disorders, associated disabilities, and insight into living with a disorder, as well as increased confidence levels for interactions with clients.
Understanding empathy could facilitate the rapport building stage in initiating the therapeutic process, maximizing personal interactions with others, and facilitating the development of diagnostic and treatment materials. More research on empathy could better help to identify and possibly quantify verbal and non-verbal language and facilitate the development of better assessment tools (such as Bryant's Empathy Scale used by psychologists).
Moreover, since empathy is lacking in populations with affective disorders, the study of empathy could have great benefit in assisting us to understand people with autism spectrum disorders and psychopathology. A better understanding of ToM could enhance social language skills and assist with clients' ability to engage in appropriate peer interactions. For example, Marco Iacoboni (2005) from UCLA, suggests that the building blocks of social behavior help people with autism better understand intentions and empathize with feelings. Hopefully, researchers will further explore this area so that all clinicians can learn to incorporate a healthy empathic concern into their treatment.
Many thanks to Tiffany Hutchins, who edited portions of this article, and whose avid desire for research is an inspiration to all who know her.
Quotes in the article are taken from The Zen of Listening, by Rebecca Shafir.