Open Access

Peer-reviewed

Research Article

Main Article Content

Lindsay L. Benstercorresponding author
Neal R. Swerdlow

Abstract

Stigmatization contributes to morbidity associated with mental illness, impeding treatment - from recognition and help-seeking, to recovery and resocialization.  In contrast, empathy in mental health clinical practice is associated with less stigmatization and better outcomes. Among providers, empathy may be under-utilized as a positive therapeutic tool, and levels of empathy may be diminished by heavy clinical workloads. Strategies for “teaching empathy” have been proposed, and different forms of empathy training for medical and mental health professionals have been evaluated. This review summarizes the effectiveness of the most studied forms of formal empathy training - communication skills, simulation, audiotape analyses, perspective-taking and mindfulness training - as well as informal empathy training achieved by increased exposure to relevant populations. Effectiveness, assessed by a variety of metrics, was detected for several training approaches, applied to different cohorts of clinical providers and trainees, with effect sizes ranging from smaller to large. Despite the substantial variations in designs and target cohorts, the evidence suggests that empathy can be taught effectively to mental health providers, in a manner that should enhance clinician awareness and utilization of empathy as a tool to reduce stigmatization and improve life quality among patients with mental illness.

Keywords
empathy, training, mental health, mental illness, clinicians

Article Details

How to Cite
Benster, L., & Swerdlow, N. (2020). Pathways to empathy in mental health care providers. Advances in Health and Behavior, 3(1), 125-135. https://doi.org/10.25082/AHB.2020.01.004

References

  1. Whiteford HA, Degenhardt L, Rehm J, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. The Lancet, 2013, 382: 9-15. https://doi.org/10.1016/S0140-6736(13)61611-6
  2. Any Mental Illness (AMI) Among Adults. http://www.nimh.nih.gov/health/statistics/premental-illness-ami-among-adults.shtml
  3. Mental Health America (MHA). The State of Mental Health in America 201. http://www.mentalhealthamerica.net/issues/state-mental-health-america
  4. Angermeyer MC and Matschinger H. The stigma of mental illness: Effects of labelling on public attitudes towards people with mental disorder. Acta Psychiatr Scand, 2003, 108: 304-309. https://doi.org/10.1034/j.1600-0447.2003.00150.x
  5. Bordieri JE and Drehmer DE. Hiring decisions for disabled workers: looking at the cause. Journal of Applied Social Psychology, 2006, 16: 197-208. https://doi.org/10.1111/j.1559-1816.1986.tb01135.x
  6. Corrigan PW. Mental health stigma as social attribution: implications for research methods and attitude change. Clinical Psychology: Science and Practice, 2006, 7: 48-67. https://doi.org/10.1093/clipsy.7.1.48
  7. Farina A, Thaw J, Lovern JD, et al. People’s reactions to a former mental patient moving to their neighborhood. American Journal of Community Psychology, 2006, 2: 108-112. https://doi.org/10.1002/1520-6629(197404)2:2h108::AID-JCOP2290020204i3.0.CO;2-6
  8. Sosowsky L. Explaining the increased arrest rate among mental patients: a cautionary note. American Journal of Psychiatry, 2006, 137: 1602-1605. https://doi.org/10.1176/ajp.137.12.1602
  9. Teplin LA. Criminalizing mental disorder: The comparative arrest rate of the mentally ill. American Psychologist, 1984, 39: 794-803. https://doi.org/10.1037/0003-066X.39.7.794
  10. Steadman HJ, McCarty DW and Morrissey JP. The mentally ill in jail: Planning for essential services. New York: Guilford, 1989.
  11. Deegan PE. Spirit breaking: when the helping professions hurt. Journal of Humanistic Psychology, 1980, 18: 301-313. https://doi.org/10.1080/08873267.1990.9976897
  12. Lawrence D and Kisely S. Review: Inequalities in healthcare provision for people with severe mental illness. Journal of Clinical Psychopharmacology, 2010, 24: 61-68. https://doi.org/10.1177/1359786810382058
  13. Correll CU, Detraux J, Lepeleire JD, et al. Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder. World Psychiatry, 2015, 14: 119-136. https://doi.org/10.1002/wps.20204
  14. Overton SL and Medina SL. The stigma of mental illness. Journal of Counseling & Development, 2008, 86: 143-151. https://doi.org/10.1002/j.1556-6678.2008.tb00491.x
  15. Doyle C, Lennox L and Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open, 2013, 3: 1-18. https://doi.org/10.1136/bmjopen-2012-001570
  16. Drwecki BB, Moore CF, Ward SE, et al. Reducing racial disparities in pain treatment: The role of empathy and perspective-taking. Pain, 2011, 152: 1001-1006. https://doi.org/10.1016/j.pain.2010.12.005
  17. O’Connor K, King R, Malone KM, et al. Clinical examiners, simulated patients, and student self-assessed empathy in medical students during a psychiatry objective structured clinical examination. Academic Psychiatry, 2014, 38: 451- 457. https://doi.org/10.1007/s40596-014-0133-8
  18. Neumann M, Edelhuser F, Tauschel D, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Academic Medicine, 2011, 86: 996- 1009. https://doi.org/10.1097/ACM.0b013e318221e615
  19. Gleichgerrcht E and Decety J. The relationship between different facets of empathy, pain perception and compassion fatigue among physicians. Frontiers in Behavioral Neuroscience, 2014, 8: 243. https://doi.org/10.3389/fnbeh.2014.00243
  20. Hojat M. The Jefferson Scale of Physician Empathy. Empathy in Patient Care, 2007, 87-115. https://doi.org/10.1007/0-387-33608-7_7
  21. Davis MH. Interpersonal Reactivity Index. PsycTESTS Dataset 1980. https://doi.org/10.1037/t01093-000
  22. Truax CB. A scale for the measurement of accurate empathy. Psychiatric Institute Bulletin. Wisconsin: Wisconsin Psychiatric Institute, 1961.
  23. Mehrabian A and Epstein N. A measure of emotional empathy. Journal of Personalized Medicine, 1972, 40: 52-543. https://doi.org/10.1111/j.1467-6494.1972.tb00078.x
  24. Rees C, Sheard C and Davies S. Communication Skills Attitude Scale. Medical Education, 2002, 36: 141-147. https://doi.org/10.1046/j.1365-2923.2002.01072.x
  25. Engram BE and Vandergoot D. Correlation between the Truax and Carkhuff scales for measurement of empathy. Journal of Counseling Psychology, 1978, 25: 349-351. https://doi.org/10.1037/0022-0167.25.4.349
  26. La Monica EL. Construct validity of an empathy instrument. Research in Nursing & Health, 1981, 4: 389-400. https://doi.org/10.1002/nur.4770040406
  27. Bonvicini KA, Perlin MJ, Bylund, CL, et al. Impact of communication training on physician expression of empathy in patient encounters. Patient Education and Counseling, 2009, 75: 3-10. https://doi.org/10.1016/j.pec.2008.09.007
  28. Hogan R. Development of an empathy scale. Journal of Consulting and Clinical Psychology, 1969, 33: 307-316. https://doi.org/10.1037/h0027580
  29. Gantt S, Billingsley D and Giordano JA. Paraprofessional skill: maintenance of empathic sensitivity after training. Journal of Counseling Psychology, 1980, 27: 374-379. https://doi.org/10.1037/0022-0167.27.4.374
  30. Baron-Cohen S and Wheelwright S. The empathy quotient: an investigation of adults with Asperger syndrome or high functioning autism, and normal sex differences. Journal of Autism and Developmental Disorders, 2004, 34: 163-175. https://doi.org/10.1023/B:JADD.0000022607.19833.00
  31. Bylund CL and Makoul G. Examining empathy in medical encounters: an observational study using the empathic communication coding system. Health Communication, 2005, 18: 123-140. https://doi.org/10.1207/s15327027hc1802_2
  32. Dkmen, . Measuring empathy based on a model and improving it by psychodrama. Journal of Educational Sciences, 1988, 6: 155-190.
  33. Waal FB. Putting the altruism back into altruism: the evolution of empathy. Annual Review of Psychology, 2008, 59: 279-300. https://doi.org/10.1146/annurev.psych.59.103006.093625
  34. Coplan, A.Will the real empathy please stand up? A case for a narrow conceptualization. Southern Journal of Philosophy, 2011, 49: 40-65. https://doi.org/10.1111/j.2041-6962.2011.00056.x
  35. Benbassat J and Baumal R. What is empathy, and how can it be promoted during clinical clerkships? Academic Medicine, 2004, 79: 832-839. https://doi.org/10.1097/00001888-200409000-00004
  36. Darwin C. The descent of man, and selection in relation to sex. London: J. Murray, 1871. https://doi.org/10.5962/bhl.title.2092
  37. Davis, MH. Empathy: A Social Psychological Approach. Colorado: Westview Press, 1994.
  38. Batson CD. Empathy and altruism. In: The Oxford Handbook of Hypo-egoic Phenomena. Oxford: Oxford University Press, 2017. https://doi.org/10.1093/oxfordhb/9780199328079.013.11
  39. Smith A. Cognitive empathy and emotional empathy in human behavior and evolution. The Psychological Record, 2006, 56: 3-21. https://doi.org/10.1007/BF03395534
  40. Bylund CL and Makoul G. Empathic communication and gender in the physician-patient encounter. Patient Education and Counseling, 2002, 48: 207-216. https://doi.org/10.1016/S0738-3991(02)00173-8
  41. Marci CD, Ham J, Moran E, et al. Physiologic correlates of perceived therapist empathy and social-emotional process during psychotherapy. The Journal of Nervous and Mental Disease, 2007, 195: 103-111. https://doi.org/10.1097/01.nmd.0000253731.71025.fc
  42. Messina I, Palmieri A, Sambin M, et al. Somatic underpinnings of perceived empathy: the importance of psychotherapy training. Psychotherapy Research, 2013, 23: 169-177. https://doi.org/10.1080/10503307.2012.748940/
  43. Winefield HR and Chur-Hansen A. Evaluating the outcome of communication skill teaching for entry-level medical students: does knowledge of empathy increase? Medical Education, 2000, 34: 90-94. https://doi.org/10.1046/j.1365-2923.2000.00463.x
  44. Briggs GW and Replogle WH. Effect of communication skills training on residents attitudes toward their patients. Academic Medicine, 1991, 66: 243. https://doi.org/10.1097/00001888-199104000-00020
  45. Erera P. Empathy training for helping professionals. Journal of Social Work Education, 1997, 33: 245-260. https://doi.org/10.1080/10437797.1997.10778868
  46. Fernndez-Olano C, Montoya-Fernndez J and Salinas-Snchez AS. Impact of clinical interview training on the empathy level of medical students and medical residents. Medical Teacher, 2008, 30: 322-324. https://doi.org/10.1080/01421590701802299
  47. Fine VK and Therrien ME. Empathy in the doctor-patient relationship. Academic Medicine, 1977, 52: 752-757. https://doi.org/10.1097/00001888-197709000-00005
  48. Harlak H, Gemalmaz A, Gurel F, et al. Communication skills training: effects on attitudes toward communication skills and empathic tendency. Education for Health, 2008, 21: 62.
  49. Kramer D, Ber R and Moore M. Increasing empathy among medical students. Medical Education, 1989, 23: 168-73. https://doi.org/10.1111/j.1365-2923.1989.tb00881.x
  50. Nerdrum P and Rnnestad MH. The trainees’ perspective: a qualitative study of learning empathic communication in Norwary. Journal of Counseling Psychology, 2002, 30: 609- 629. https://doi.org/10.1177/00100002030004007
  51. Nerdrum P. Maintenance of the effect of training in communication skills: a controlled follow-up study of level of communicated empathy. The British Journal of Social Work, 1997, 27: 705-722. https://doi.org/10.1093/oxfordjournals.bjsw.a011261
  52. Seto A, Young S, Becker KW, et al. Developing multicultural competencies with the triad training model. Hidden Messages in Culture-Centered Counseling: A Triad Training Model, 2011, 101-114.
  53. Bodner E, Cohen-Fridel S, Mashiah M, et al. The attitudes of psychiatric hospital staff toward hospitalization and treatment of patients with borderline personality disorder. BMC Psychiatry 2015, 15: 2. https://doi.org/10.1186/s12888-014-0380-y
  54. Brown NW and Hunter A. Empathy scores of nurses, psychiatrists and hospital administrators on the California Psychological inventory. Psychological Reports, 1987, 60: 295-300. https://doi.org/10.2466/pr0.1987.60.1.295
  55. DiLalla LF, Hull SK and Dorsey JK. Effect of gender, age, and relevant course work on attitudes toward empathy, patient spirituality, and physician wellness. Teaching and Learning in Medicine, 2004, 16: 165-170. https://doi.org/10.1207/s15328015tlm1602_8
  56. Gleichgerrcht E and Decety J. Empathy in clinical practice: how individual dispositions, gender, and experience moderate empathic concern, burnout, and emotional distress in physicians. PLoS One, 2013, 8: e61526. https://doi.org/10.1371/journal.pone.0061526
  57. Handford C, Lemon J, Grimm MC, et al. Empathy as a function of clinical exposure–reading emotion in the eyes. PLoS One, 2013, 8: e65159. https://doi.org/10.1371/journal.pone.0065159
  58. Hojat M, Gonnella J, Nasca T, et al. Physician empathy: definition, components, measurement, and relationship to gender and specialty. American Journal of Psychiatry, 2002, 159: 1563-1569. https://doi.org/10.1176/appi.ajp.159.9.1563
  59. Mousa M. Empathy toward patients with mental illness among baccalaureate nursing students: impact of a psychiatric nursing and mental health educational experience. Journal of Education and Practice, 2015, 6: 98-107.
  60. Santamara-Garca H, Baez S, Garca AM, et al. Empathy for others’ suffering and its mediators in mental health professionals. Scientific Reports, 2017, 7. https://doi.org/10.1038/s41598-017-06775-y
  61. Vaghee S, Lotfabadi MK, AS, NV, et al. Comparing the effects of contact-based education and acceptance and commitment-based training on empathy toward mental illnesses among nursing students. Iranian Journal of Psychiatry, 2018, 13: 119-127.
  62. Muehlehnkamp J, Claes L, Quigley K, et al. Association of Training on Attitudes To-wards Self-Injuring Clients across Health Professionals. Archives of Suicide Research, 2013, 17: 462-468. https://doi.org/10.1080/13811118.2013.801815
  63. BunnWand Terpstra J. Cultivating empathy for the mentally ill using simulated auditory hallucinations. Academic Psychiatry, 2009, 33: 457-460. https://doi.org/10.1176/appi.ap.33.6.457
  64. Chaffin AJ and Adams C. Creating empathy through use of a hearing voices simulation. Clinical Simulation In Nursing, 2013, 9: 293-304. https://doi.org/10.1016/j.ecns.2012.04.004
  65. Dearing KS and Steadman S. Challenging stereotyping and bias: a voice simulation study. Journal of Nursing Education, 2008, 47: 59-65. https://doi.org/10.3928/01484834-20080201-07
  66. Kalyanaraman SS, Penn DL, Ivory JD, et al. The virtual doppelganger: effects of a virtual reality simulator on perceptions of schizophrenia. The Journal of Nervous and Mental Disease, 2010, 198: 437-443. https://doi.org/10.1097/NMD.0b013e3181e07d66
  67. Sanson-Fisher RWand Poole AD. Simulated patients and the assessment of medical students interpersonal skills. Medical Education, 1980, 14: 249-253. https://doi.org/10.1111/j.1365-2923.1980.tb02269.x
  68. Schweller M, Costa FO, Antnio M, et al. The impact of simulated medical consultations on the empathy levels of students at one medical school. Academic Medicine, 2014, 89: 632-637. https://doi.org/10.1097/ACM.0000000000000175
  69. Wndrich M, Schwartz C, Feige B, et al. Empathy training in medical students - a randomized controlled trial. Medical Teacher, 2017, 39: 1096-1098. https://doi.org/10.1080/0142159X.2017.1355451
  70. Formosa NJ, Morrison BW, Hill G, et al. Testing the efficacy of a virtual reality-based simulation in enhancing users’ knowledge, attitudes, and empathy relating to psychosis. Australian Journal of Psychology, 2018, 70: 57-68. https://doi.org/10.1111/ajpy.12167
  71. Riches S, Khan F, Kwieder S, et al. Impact of an auditory hallucinations simulation on trainee and newly qualified clinical psychologists: A mixed-methods cross-sectional study. Clinical Psychology and Psychotherapy, 2019, 26: 277-290. https://doi.org/10.1002/cpp.2349
  72. Barbosa P, Raymond G, Zlotnick, C, et al. Mindfulnessbased stress reduction training is associated with greater empathy and reduced anxiety for graduate healthcare students. Education for Health, 2013, 26: 9-14. https://doi.org/10.4103/1357-6283.112794
  73. Beddoe AE, Murphy SO. Does mindfulness decrease stress and foster empathy among nursing students? Journal of Nursing Education and Practice, 2004, 43: 305-312. https://doi.org/10.3928/01484834-20040701-07
  74. Greason PB, Cashwell CS. Mindfulness and counseling selfefficacy: the mediating role of attention and empathy. Counselor Education and Supervision, 2009, 49: 2-19. https://doi.org/10.1002/j.1556-6978.2009.tb00083.x
  75. Schure MB, Christopher J and Christopher S. Mind-body medicine and the art of self-care: teaching mindfulness to counseling students through yoga, meditation, and Qigong. Journal of Counseling & Development, 2008, 86: 47-56. https://doi.org/10.1002/j.1556-6678.2008.tb00625.x
  76. Bentley PG, Kaplan SG and Mokonogho J. Relational mindfulness for psychiatry residents: a pilot course in empathy development and burnout prevention. Academic Psychiatry, 2018, 42: 668-73. https://doi.org/10.1007/s40596-018-0914-6
  77. Lamothe M, Mcduff P, Pastore YD, et al. Developing professional caregivers’ empathy and emotional competencies through mindfulness-based stress reduction (MBSR): results of two proof-of-concept studies. BMJ Open, 2018, 8: e018421. https://doi.org/10.1136/bmjopen-2017-018421
  78. Shapiro SL, Schwartz GE and Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. Journal of Behavioral Medicine, 1998, 21: 581- 599. https://doi.org/10.1023/A:1018700829825
  79. Easter D and Beach W. Competent patient care is dependent upon attending to empathic opportunities presented during interview sessions. Journal of Current Surgery, 2004, 61: 313-318. https://doi.org/10.1016/j.cursur.2003.12.006
  80. Poole AD and Sanson-Fisher RW. Long-term effects of empathy training on the interview skills of medical students. Patient Education and Counseling, 1980, 2: 125-127. https://doi.org/10.1016/S0738-3991(80)80053-X
  81. Sanson-Fisher RW and Poole AD. Training medical students to empathize: an experimental study. The Medical Journal of Australia, 1978, 1: 473-476. https://doi.org/10.5694/j.1326-5377.1978.tb112562.x
  82. Blatt B, Lelacheur SF, Galinsky AD, et al. Does perspectivetaking increase patient satisfaction in medical encounters? Academic Medicin, 2010, 85: 1445-1452. https://doi.org/10.1097/ACM.0b013e3181eae5ec
  83. Feighny KM, Monaco M and Arnold L. Empathy training to improve physician-patient communication skills. Academic Medicine, 1995, 70: 435-436. https://doi.org/10.1097/00001888-199505000-00031
  84. Shapiro J, Rucker L, Boker J, et al. Point-of-view writing: a method for increasing medical students empathy, identification and expression of emotion, and insight. Education for Health: Change in Learning & Practice, 2006, 19: 96-105. https://doi.org/10.1080/13576280500534776
  85. Couture SM and Penn DL. Interpersonal contact and stigma of mental illness: A review of the literature. Journal of Mental Health, 2003, 12: 291-305. https://doi.org/10.1080/09638231000118276
  86. Angermeyer MC and Matschinger H. The effect of personal experience with mental illness on the attitude towards individuals suffering from mental disorders. Social Psychiatry and Psychiatric Epidemiology, 1996, 31: 321-326. https://doi.org/10.1007/BF00783420
  87. Peris TS, Teachman BA and Nosek BA. Implicit and explicit stigma of mental illness. The Journal of Nervous and Mental Disease, 2008, 196: 752-760. https://doi.org/10.1097/NMD.0b013e3181879dfd
  88. Jelencic M. The relationship between attitudes towards people with mental illness, empathy and belief in a just world. Diploma Thesis. Filozofski fakultet u Zagrebu: Department of Psychology, 2013.
  89. Batson D, Chang J, Orr R, et al. Empathy, attitudes and action: can feeling for a member of a stigmatized group motivate one to help the group? Personality and Social Psychology Bulletin, 2002, 28: 1656-1656. https://doi.org/10.1177/014616702237647
  90. Sandhu HS, Arora A, Brasch J, et al. Mental health stigma: explicit and implicit attitudes of Canadian undergraduate students, medical school students, and psychiatrists. The Canadian Journal of Psychiatry, 2018, 64: 209-217. https://doi.org/10.1177/0706743718792193
  91. Hamdan-Mansour A and Wardam L. Attitudes of Jordanian mental health nurses toward mental illness and patients with mental illness. Issues in Ment Health Nurs, 2009, 30: 705- 711. https://doi.org/10.1080/01612840903131792
  92. Ono S, Hanya M, Tanaka H, et al. Changes in Attitudes of Japanese Pharmacy Students towards Mental Illness during the didactic portion of the Curriculum. Pharmacy Education, 2013, 13: 145-150.
  93. Kameg K, Mitchell AM, Clochesy J, et al. Communication and human patient simulation in psychiatric nursing. Issues Ment Health Nurs, 2009, 30: 503-508. https://doi.org/10.1080/01612840802601366
  94. Brown KW and Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 2003, 84: 822-848. https://doi.org/10.1037/0022-3514.84.4.822
  95. Germer CK and Neff KD. Self-compassion in clinical practice. Journal of Clinical Psychology, 2013, 69: 856-867. https://doi.org/10.1002/jclp.22021
  96. Beitel M, Ferrer E and Cecero JJ. Psychological mindedness and awareness of self and others. Journal of Clinical Psychology, 2004, 61: 739-750. https://doi.org/10.1002/jclp.20095
  97. Shanafelt TD. Enhancing meaning in work. JAMA 2009, 302: 1338. https://doi.org/10.1001/jama.2009.1385
  98. Klimecki OM, Leiberg S, Ricard M, et al. Differential pattern of functional brain plasticity after compassion and empathy training. Social Cognitive and Affective Neuroscience, 2013, 9: 873-879. https://doi.org/10.1093/scan/nst060