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Emotional reasoning.

Mr. Smith had been a powerful executive until a sudden neurological disorder rendered him totally dependent. He was paralyzed from the neck down, unable to breathe without a ventilator. He refused to communicate and refused physical therapy, without which he could not recover. His medical team called in Jodi Halpern as a consulting psychiatrist. In training at the time, she recounts that in response to her gentle, sorrowful invitation to talk, Mr. Smith "struggled, trembling and red-faced, to speak a few words through his tracheostomy tube, then asked me to leave him to rest, and his eyes glazed over." She left feeling ashamed and hopeless.

She related her feelings of shame and hopelessness to "having pushed him to make a futile effort" and being too inexperienced to help him. A colleague suggested that she regard these feelings in a different light. Perhaps they had arisen in Mr. Smith's presence through resonance, the nonverbal communication of intense emotion from one person to another. For Halpern, the suggestion awakened curiosity about how Mr. Smith actually felt. "I imagined what it would be like to be a powerful older man, suddenly enfeebled, handled by one young doctor after the next. I found myself moved to feel impatience, then rage at being trapped in a body that no one knew how to help. I felt mounting frustration and something else--a sense of shame."

She returned to address the successful businessman, not the paralyzed body he was trapped in. "What is it about talking with me that you don't like?" This time Mr. Smith declared his fury at the doctors for exposing him to his family in such a helpless state. Halpern could now appreciate his situation as infuriating, in ways specific to his experience of a starkly visible loss of control and power. From here on she and Mr. Smith were able to talk effectively (pp. 86-88).

This case illustrates what Halpern calls emotional reasoning, the core skill of clinical empathy (pp. 39-61; 67-94). Emotional reasoning is reasoning in that it is a mental process meant to correct and make more specific one's understanding of another person's experience. It is emotional in that one's own feelings, as evoked by the other person's situation, are what organize and guide the process. In some cases the starting point may be a "gut feeling" that arises through resonance (pp. 47-49), as in the case of Mr. Smith. But resonance may not always occur and is not necessary. Emotional reasoning can start from curiosity, or from listening to and being moved by someone else's story (pp. 130-32).

It is part of clinical empathy to treat these starting points, and their imaginative associations, not as conclusions but as cues to seek further evidence in dialogue with the patient (pp. 47, 129-36). Discerning what to probe for in dialogue requires a subtle reflective process. The first step is to acknowledge your feelings, as Halpern acknowledged her shame and hopelessness after talking with Mr. Smith. The next step is to recognize that you have an automatic way of reacting to them. In Halpern's illustration, her automatic reaction was to worry about her own inadequacy as a doctor. You then have to resist taking the automatic path, and reconsider your feelings from a standpoint centered in imaginative curiosity about the other person--as Halpern did when she imagined how it would feel to be "a powerful older man, suddenly enfeebled." The point is to mark the distinction between your own emotional experience and the other person's. Ideally, you are then able to bring the other person's experience into sharper focus, seeking correction, confirmation, and further cues through dialogue.

Clinical empathy depends on the ability to reflect with honesty and realism on one's own emotional responses and those of others. Doctors' routine working conditions create treacherous currents to swim against here (pp. 60, 145). The strongest is the constant presence of suffering, loss, dying, and death--to which we respond, naturally, with our most visceral aversions and most elaborate psychological defenses. Yet clinical empathy is most valuable precisely when a patient's situation hardly bears imagining. To empathize is to overcome the compulsion to turn away, and instead to open your imagination to the specific reality of how another person suffers.

This takes training. Halpern draws from Sheldon Margen, Howard Brody, and Rita Charon to suggest that medical students could begin to cultivate empathic curiosity by listening to patients' personal narratives about their illnesses, and writing or repeating them while sticking to the specific words and images patients choose (pp. 130-31). Even these common-sense methods for training doctors in elementary skills are controversial, however. And it takes more extensive training to learn how to avoid harmful errors, such as treating one's own affective experience as conclusive evidence about how a patient feels (p. 132).

Halpern argues that clinical empathy is sometimes necessary to avoid serious errors in diagnosis and treatment, to make therapeutic benefit possible at all, and to secure genuine protection of a patient's autonomy (pp. 1-12; 39-61; 101-125). If she is right, then we should hope that full psychiatric training is not the only route to the emotional sophistication characteristic of excellence in psychiatry. From Detached Concern to Empathy promises to sharpen debate about good practice and effective training for the doctor-patient encounter.

From Detached Concern to Empathy: Humanizing Medical Practice. By Jodi Halpern. Oxford: Oxford University Press, 2001. 165 pp. $29.50, hardback.

Maria Merritt teaches philosophy at the College of William and Mary in Williamsburg, Virginia. She recently completed a postdoctoral fellowship in the Department of Clinical Bioethics at the National Institutes of Health, where her research focused on the ethical obligations of physician-investigators. Her current work deals with the ethics of virtue and character.
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Author:Merritt, Maria
Publication:The Hastings Center Report
Geographic Code:1USA
Date:Sep 1, 2002
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