Empirical evidence

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

Empirical research has demonstrated that contingent interpersonal responses are accompanied by contingent neurobiological responses. Depending on the social context, such responses have been variously labeled sociophysiology between therapists and patients,5^,6 and among nonhuman mammals7; interpersonal neurobiology in child development8; affect attunement between caregivers and infants9; and physiological linkage between empathic spouses.10 More recently, neuroscientists have discovered a mirror neuronal system that contributes to this attuned responsiveness, with special relevance to empathy.11–13

 

Starting in the mid-1950s with investigations of the psychiatric interview, researchers described an “interpersonal physiology,” which referred to a correlation of selected physiologic indicators of autonomic activity—heart rate,5 heart lability, skin temperature,14 and muscle tension15—that varied together between psychotherapists and patients. It was speculated that this similarity of patterning was a “physiological identification” between therapist and patient and might turn out to be an objective measurement of rapport.14 These findings were confirmed by other researchers,6 and it was also demonstrated that the physiologic correlation was the result of empathy rather than a common reaction to the same events.16^,17 Aside from studies of the “physiological linkage”18 between empathic spouses, few other clinical explorations of sociophysiology were performed.10

Animal ethologists applied sociophysiologic research strategies to look at how mutually regulatory physiologic feedback loops establish and maintain nonhuman mammalian social organizations.7^,19^,20 This was demonstrated at a number of levels of mammalian social organization: the mother–offspring bond,21 conspecific (peer) relationships,22 the adult pair-bond,23 hierarchical relationships,24^,25 sexual development,26^,27 and sexual reproduction.28^,29

Subsequently, Gardner used the term sociophysiology to refer to the hypothesis that current psychopathology is a consequence of evolutionarily selected characteristics of brain physiology.30 My use of the term preserves its original meaning as an interpersonal physiological engagement, occurring in real time and having continuous here-and-now physiologic consequences. As applied to the patient–physician relationship, sociophysiology encompasses two overlapping processes. First, intrapsychically, anticipated, planned, and remembered social experiences are inseparable from their concomitant physiology. Second, interpersonally, social relationships influence physiology and vice versa. For humans, these two processes may be hardly distinguishable because even when alone, people are usually in the company of imagined others,31 and their physiology will reflect this. So, even between medical encounters, and years later, the biopsychosocial relational process can continue.

The unfolding neural circuitry of the developing brain is configured by social interaction, variously described as interpersonal neurobiology32 and the social construction of the human brain.33 Throughout the lifespan, social interaction continues to modify neural structures34^,35 and maintain the integrated functioning of neural circuits.4 Consistent with complexity theory, reciprocal, modifiable neurobiological, and neuroendocrine patterns of response affect and are affected by social attachment.36–38 The propensity for the kind of self-organizing physiological attunement that regulates the mother–infant relationship may continue into adult interpersonal relationships and may serve a similar physiologic regulatory function.39^,40 The physiologic consequences of bereavement in adults are very similar to those of maternal separation in infants and may be partially accounted for by the loss of an external physiologic regulator.41

 

Studies by infancy researchers have demonstrated the precisely calibrated feedback loop through which caregivers modulate infants’ physiological responses by a nuanced combination of stimulation and soothing.42–46 Stern has labeled this interactive regulatory process “affect attunement.”9 Through this self-organizing developmental process,47 caregiver and infant co-operate the neurobiological responses that establish and maintain their attachment.

This “dance of attunement”48 creates a secure, affectional bond49 that synchronizes the level of autonomic arousal in both infant and caregiver,48 is usually experienced by the caregiver as deeply satisfying, and tends to have a calming effect on the infant. To this end, caregivers report being guided in their attuned responses by an empathic feeling with the infant.50 Because much of this mutual responsiveness occurs too instantaneously to be under conscious control, it had been anticipated that innate imitative neural circuits would be discovered.51 Neuroscience has now provided such a candidate neural mechanism.11,52

Neuroscience research, first in monkeys53,54 and then in humans,55^,56 has discovered a mirror neuronal system that can account for a cognitively unmediated responsive feedback loop underlying interpersonal communication. Mirror neurons discharge when a specific motor action is performed and when an individual observes another individual performing a similar motor action.57^,58 Because the mirror neuronal system in both humans and monkeys59^,60 is connected to parts of the brain that are critical for the recognition of facial expressions and emotional behaviors,12^,59 the observation of emotions can influence the emotional experience of the observer. In this way, the mirror neuronal system may provide a neurobiological grounding for interpersonal empathy.12^,13^,61–63

 

Further support for the view that empathy is a neurobiological response has been provided by the use of positron emission tomography (PET) to demonstrate that accurate empathy of distress is correlated with the activation of specific neural networks.64 Accordingly, empathy can be thought of as the neurobiological experience of what we know and how we know it.17^,61^,65

In a study of empathy in marital couples, those spouses who exhibited the most accurate empathy regarding each other’s negative feelings had the most synchronous patterns of autonomic activation—described as a “physiological linkage.”17 In another study, the degree of physiological synchrony between spouses on four measures (heart rate, pulse transmission time to finger, skin conductance level, and general somatic activity) was shown to correlate with both their emotional synchrony and marital satisfaction.66

Both complexity theory and empirical evidence support the proposition that the empathy in the patient–physician relationship is constituted by the reciprocal, emergent biopsychosocial responses of each party.