The clinical application of empathy in the patient-physician relationship

- Toward a Biopsychosocial Understanding of the Patient–Physician Relationship: An Emerging Dialogue

Empathy includes both the subjective perception of attuned interpersonal neurobiology and the moment-to-moment process of this attunement—the more accurate the reciprocal responses, the more synchronous the attunement. Importantly, even small changes introduced by either patient or physician can cascade into large neurobiological changes. Herein lies the therapeutic potential of clinical empathy, defined as the physician’s use of the empathic process to directly affect the patient’s psychobiology. Whether clinical empathy is conceptualized as a primarily cognitive process67 that makes patients feel understood or as a primarily affective process68 that makes them “feel felt,”32 it is an emergent neurobiological process.

While biopsychosocial responsiveness between patients and physicians is reciprocal and mutual, it is not symmetrical because patients and society grant clinicians the responsibility to focus attention and treat biological and psychological aspects of a patient’s disease. Treatment includes: prescribing medication, providing information, and performing clinical procedures. The physician’s use of empathy, warrants consideration as a clinical procedure because it uses “emotional resonance”69 to achieve skilled “communicative attunement”70 that produces a neurobiological intervention.

Three additional features of clinical empathy support its consideration as a clinical procedure: (1) it has a medical indication; (2) it is a skilled, interpersonal performance requiring “emotional labor”;71 and (3) it attempts to achieve a specific outcome—an improvement in the patient’s psychobiology.

Beginning with the indication, the distress of sickness can result in both an activation of the hypothalamic–pituitary–adrenal axis and an ensuing need to seek psychobiological relief through the formation of a secure attachment bond with a caregiver.72 At this vulnerable point in the patient’s life, the effect of clinical empathy on the patient’s psychobiology is likely to be enhanced.73^,74 With regard to performance, clinical empathy is a skilled interpersonal intervention that uses an asymmetrical affect attunement to modify the patient’s psychobiology. This attunement may be facilitated71 by inserting a collaborative comment or question at the right moment during the history—“Let me see if I have this right”75—or by making a permissive request at the seeming conclusion—“Was there anything else?”—that can bridge the synapses between and within patients and physicians. With regard to outcome, the process of self-organizing attunement is also its product.76 Clinicians’ active co-participation in their patients’ state of autonomic arousal may shift it toward homeostasis77^,78 and decrease their allostatic load—the physiologic burden of adjusting to stressors.79 Such an interactive physiologic regulation may even reestablish the patient’s positive psychobiological state.80

Clinicians can learn much about the process and therapeutic potential of interpersonal neurobiology from studies of caregiver–infant interaction. Almost immediately postpartum, both caregiver and infant engage in a feedback loop of contingent, responsive, matching behaviors, primarily those conveying emotions.51,81 Through such communications, caregiver and infant mutually regulate each other’s psychobiology, but not to an equal degree, because the caregiver’s self-regulatory capacity acts as an external organizer of the infant’s biobehavior.82,83 When successful, they self-organize a unique relationship80 that is both their process of attunement and its product—a more stable infant neurobiology on its way to resilience and self-regulation.84

I am proposing that the empathic clinician may similarly use the relational process to effect a direct biological treatment. This clinical procedure is guided by the subjective experience of empathy and is operationalized by saying the right words in the right way at the right time. The intended clinical outcome is an improvement in the patient’s psychobiology, perhaps just for the duration of the medical encounter, perhaps for much longer.