Since empathy involves sharing another person’s emotions and thoughts, shouldn’t having had experiences similar to the other person’s make it easier to empathize? Most people, including doctors and psychotherapists, struggle at least occasionally with urges to overindulge—in food, sex, spending, gaming, alcohol, tobacco, or other substances. This inclination to lose control and devote too much time, resources, and mental energy to such activities is the core of addiction. All substances of abuse, as well as gambling, have been shown to produce pleasurable feelings by activating the brain’s reward circuits—this is the source of craving. The evidence is less clear for other so-called “behavioral addictions,” but clinical experience has convinced me that for some people, craving and loss of control of eating, gaming, or sex are very much like what happens in the recognized addictions. If clinicians share with their patients the human tendency toward addiction, why do so many have trouble empathizing?
It turns out that having personal experience with a patient’s problems doesn’t necessarily promote empathy. It may help, but it can also get in the way of relating to what the patient is going through. Here I’ll explore how a clinician’s personal addictive tendencies can promote or impede empathy with addiction and in the process shed some light on the nature of empathy itself.
Neurobiological research has identified four major components of empathy. Emotional empathy is the automatic visceral response we feel in the presence of another person expressing emotion. The same sensorimotor, limbic, and paralimbic areas are activated in the observer’s brain as in the brain of the person experiencing the distress—as if we were experiencing the distress ourselves. The cognitive element of empathy, which is how we comprehend what the other person is thinking, involves different brain areas—the temporal lobe and prefrontal cortex. A third component—emotional regulation—serves to prevent over-identification with a patient in distress. It depends on executive functions in the orbitofrontal cortex, medial prefrontal cortex, dorsolateral prefrontal cortex, and limbic structures. Finally, clinical empathy includes motivation to help someone in distress, which involves mammalian circuits in the brain stem, midbrain and hypothalamus, as well as the ventral tegmental area’s dopamine reward system (which is also involved in addiction.) While the interactions among these complex systems are only beginning to be understood, it is useful to consider how each of them contributes to empathy with patients.
What happens when a clinician—let’s call him Dr. F.—who struggles with urges to binge on ice cream after work, sits down with his last patient of the day, who is a woman in the throes of an alcoholic relapse? She went out after work to celebrate a friend’s engagement and after “too many margaritas to count” walked home, where her husband accused her of “feeling so good you couldn’t remember to pick up your own children.” Her words, and especially her facial expression, tone of voice, posture, and gestures, resonate with Dr. F’s addictive tendency and evoke his ever-present desire to pick up a quart of ice cream on the way home. On some, possibly unconscious, level, he says to himself, “Hey, I know that feeling.” He hears the patient struggle, “This is not me—I don’t ever want to put my family through that again,” and “I just have to try harder.” He is worried—will she be able to get back on track?—and skeptical—she’s re-sensitized her brain to alcohol. He believes she’ll need more help to get her addiction back under control. This is a helpful, empathic response so far.
But as the patient goes on to describe how much she enjoyed being with her drinking friends again and how she’s sure she’ll be okay back at the bar if she just orders Pepsi, other feelings and thoughts are triggered: self-pity for having to delay enjoying his ice cream, guilt for endangering his health by gaining weight, and shame that he can’t control his own cravings. Paradoxically, these dysphoric feelings don’t produce determination to skip ice cream and go to the gym instead. To relieve his dysphoria, he craves the ice cream even more. He abruptly ends the interview by telling the patient that if she returns to the bar she’ll get drunk again and insisting she stop all drinking immediately and go back to Alcoholics Anonymous (A.A.) As an afterthought, he advises her to increase the dose of her antidepressant.
Why did this highly trained physician, whose own addictive tendency is quite mild, have so much trouble empathizing that he dismissed his patient with a boilerplate set of recommendations? Dr. F. understood on an emotional level what his patient was experiencing as she relapsed, and he had no trouble with the cognitive aspect of empathy—he recognized that she was minimizing her addiction and its dangerous implications. But as she proceeded to deny the risks of her behavior, her underlying urge to continue drinking resonated with his own craving for ice cream. This brought out shame and guilt about his addictive behavior, which overwhelmed his compassion.
Consider another possibility: the same patient sits down with Mr. C., a counselor who is himself in recovery from cocaine addiction. When he hears of his patient’s craving, loss of control, neglect of her children, and risk to herself from walking home alone, he experiences emotions connected with his own addictive experience: fear, longing for help, and gratitude that he is now in recovery. In contrast to Dr. F., he feels little shame and guilt, for he has learned to accept his addiction and atoned when possible for the harm he did. He is also much more practiced than Dr. F. in coping with situations, including interviews with relapsing patients, which might trigger his own addiction.
Mr. C. understands his patient’s attraction to the bar’s warm comfort and has no illusions that she will be able to limit herself to Pepsi—he has felt even stronger urges himself. But importantly, unlike Dr. F., he no longer has to disavow his addictive struggle because of shame and guilt. He can help the patient look at the dangers of her relapse without eliciting defensiveness and challenge her rationalizations from the point of view of one who has been there. From this position of empathy, he is able to guide the patient to make her own decision to call her A.A. sponsor, tell her husband she has to go to a meeting that night, and see him again the next week.
In neurobiological terms, both Dr. F. and Mr. C. experienced emotional empathy, but Dr. F.’s feelings were weighted toward shame and guilt, which interfered with his clinical compassion. Both understood the patient’s desire to resume socializing with friends and her rationalization that she could handle it. But the emotional regulation aspect of Dr. F.’s response was to distance himself with un-empathic judgment about the risks she was taking. In contrast, Mr. C. was able to relate to the patient’s own fear and concern about her relapse, help her think through its meaning, and take responsibility for her own plan. Mr. C. could use his emotional response to identify with the patient in a clinically helpful way. Dr. F., who had not accepted his own mild addiction, was sidetracked by shame and guilt.
Does this mean that only clinicians who have overcome their own addictive tendencies are in a position to treat patients with addictions? Or in a more general sense, does clinical empathy require that a clinician not only experience problems similar to a patient’s—addiction, depression, anxiety, psychological trauma, relationship problems—but also overcome them? Not at all. I am arguing that empathy with a patient’s problems requires a sense of comfort and safety discussing such issues, and that a clinician who has addictive or other personal problems he is does not feel secure about may distance himself from patients’ problems in a way that interferes with useful empathy.
Further reading: Ezequiel Gleichgerrcht and Jean Decety, The Costs of Empathy Among Health Professionals, in Empathy: From Bench to Bedside, edited by Jean Decety, MIT Press, 2012. Pages 245-261.