Two illustrative clinical examples

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

Matthews and colleagues have described the feelings attendant to “connexional moments” in the medical encounter as “the culmination of effective empathy.”85 In essence, they argue that effective empathy is the subjective experience of a salutary attunement in a biopsychosocial relational process.

One of the authors (Suchman),85 describes a patient under his care, an often-hospitalized asthmatic woman with a “borderline personality,” who was, once again, admitted for extreme dyspnea. Her respiratory distress could not be accounted for by her physical findings. Suchman encouraged the patient to talk about what she was experiencing during her latest episode. As he listened earnestly to her story, he found himself palpably experiencing the void she must have been experiencing. He conveyed this by saying, “I’m beginning to understand how hard it is to be you.” Then, he recounted, “Her eyes welled up, and she nodded slowly. Seeing how much it meant to her to have someone grasp even momentarily the private hell she had to endure, I found my eyes welling up, too, and I felt a chill in my neck and spine. For a moment, it felt like we were joined, both parts of some larger whole; it was very peaceful and reassuring, even loving. A feeling of calm and joy was with me for the rest of the day. R seemed peaceful, too. She went home the next day, and although she is certainly not ‘cured’ of her personality disorder, she has not been admitted again in the 5 years since.”85

This vignette illustrates how clinical empathy was used as a clinical procedure.

The clinical indication was a problem with R’s psychobiology that had not responded very well to her previous medical care. The clinical procedure began with Suchman’s recognition that his dysphoric feelings about R were empathic indicators of what she was probably feeling. His statement, “I’m beginning to understand how hard it is to be you,” could only have been convincing because it was accompanied by emotional expressions that R perceived as authentic and attuned to her predicament.71 This attuned empathic communication joined Suchman and R as co-participants in an emergent interpersonal neurobiology. Their co-participation was evidenced by the responsive welling up of R’s eyes leading to a reciprocal autonomic response in Suchman. Their emergent relationship was evidenced by their apparently shared feelings of joy and calmness.

The clinical outcome of this encounter may be gauged by the ensuing feelings of mutual satisfaction, understood as subjective indicators of at least two overlapping psychobiological effects. The experience of a secure attachment has a nonspecific stress-buffering effect.86 In addition, this clinical procedure may have had a transformative effect that changed how R and Suchman felt about themselves and how they felt about each other. Other clinical outcomes were a decrease in hospital admissions for R and a decrease in the risk of burnout87,88 for Suchman.

The mutually salutary effects in the case of Suchman and R apparently continued long after the medical encounter. The effectiveness of that clinical procedure is very likely renewed at relevant moments by the recollections each party has given to the other.

Clinicians may employ their affect attunement to improve patients’ attitudes toward their personhood, now threatened by a medical problem. The successful conveyance of a salutary attitude can change the meaning of the experience along with its psychobiologic consequences.

One of my patients reported the lifelong consequences of a change in attitude that occurred during a medical encounter. She will always remember an off-hand response that rescued her from self-defeating despair. When she was 20 and single, her gynecologist diagnosed genital herpes during a pelvic examination. The patient felt like a pariah. “No one will ever want me,” she remembers sobbing. “Can I ever have an honest sex life?” The gynecologist matter-of-factly replied, “I don’t know why not.” He then followed up with information about herpes, recommended a helpful book, and informed her of an internet dating service for people with herpes. He also pointed out that now she had another good reason to establish trusting relationships before sexual relations. In the telling of this story, now 10 years later, the patient triumphantly reenacted the casual hand gesture, shrug, and bemused expression that accompanied the physician’s words. That attitude with its concomitant psychobiology was no longer just his; it had become hers. The patient recalled that she had immediately felt herself transformed from a disdained miscreant to a person with a manageable problem. She also recalled that what mainly repaired her self-image was seeing herself reflected by her physician’s expression. This deftly performed interpersonal clinical procedure, which entailed one phrase, a few expressive gestures, and medical information, revitalized her psychobiology—then and now. While I do not know this physician, the biopsychosocial relational process suggests that his psychobiology likewise benefited from this attuned self-organizing process because the feedback loop was now infused with the patient’s appreciation.89