"Beyond transference, empathy and patient centred medicine - towards compassion, self compassion and a collaborative model of care. "
Conclusions from a GP VTS (General Practice Vocational Training Scheme) seminar, 26th October 2017 - Dr P J McNally.
Is Empathy hopelessly patient centred, and (almost) as bad?
Is Compassion a way forward, and better suited to 21st Century medicine?
What follows is a write-up of a GPVTS teaching session I delivered, aiming to promote thought and understanding in this fascinating area.
Dear all GPSTs,
Thank you for joining together to consider this subject.
I had several requests afterwards for the videos and source material.
We started by defining transference, and rapidly came to some everyday working GPs' descriptions:
"If I start feeling XYZ, it may be that my patient is feeling XYZ too"
"when my patient is sad, I start to feel sad too"
"be aware that the feelings you're feeling, may not be your own"
We shared experiences of this in our own working lives.
We then noted that Sigmund Freud's concept of transference was something quite different:
"Transference is a phenomenon characterized by unconscious redirection of feelings from one person to another. One definition of transference is "the inappropriate repetition in the present of a relationship that was important in a person's childhood". Another definition is "the redirection of feelings and desires and especially of those unconsciously retained from childhood toward a new object."
"Countertransference" is defined as "redirection of a therapist's feelings toward a patient, or more generally, as a therapist's emotional entanglement with a patient".
We noted that our everyday GP definition is actually more like "Emotional resonance" (also known as "emotional contagion").
For the social context we then watched the beginning (00:00 to 10:22) of:
Adam Curtis' "The Century of the Self" - Part 1: "Happiness Machines"
This illustrated the psychoanalytic insight, that much of human behaviour is decided by feelings, not thinking.
We then broke into small groups, to define:
- sympathy
- empathy
- compassion
At this point we again shared examples from our own working lives.
There was a brief, interesting digression into consulting patients with personality disorders. We noted that our usual "Comm Skills" often don't work, and that these patients can invoke strong "somatic countertransference" or "Body-centred countertransference".
We noted how exhausting Empathy could be, for the doctor.
The Compassion group suggested that compassion might be more holistic; "I see you hurting", "caring concern", "I want to help". Altruism or kindness was mentioned.
We then watched 00:00 to 06:47 of:
The Trap Part 1 "F**k You Buddy"
This included the economist Friedrich von Hayek, asserting there is no role for altruism in his social theory. It gave useful context about the society in which we're practising.
Next, our small groups considered 3 problems:
Group 1:
What are the effects of empathy within the consultation, ouside and beyond the consultation?
Is there a role for staff to staff empathy?
What about patient to staff empathy?
And how can we promote this?
Group 2:
Context - how does this influence empathy - eg: our human world (you may wish to consider society, economy, family, community, culture, setting)
Group 3:
Do you need to feel (in the consultation / in work)?
Or is it enough, to try and understand?
How can we promote / improve this?
What actions, behaviours etc can demonstrate that empathy is being expressed?
We rejoined the main group and shared the conclusions.
We noted the need for time, resources etc, but also clear boundaries, and mutual respect, between doctors and patients.
A colleague shared a story about a time on the ward when she had to speak to relatives of a patient. She recalled one relative asking "Doctor, are you sure you're ok? Would you like a glass of water?" She remembered this feeling strange, and rare. She described realizing, "I'm allowed", and this being surprising.
We noted that compassion begins at home: with self compassion, for the doctor. We noted Carl Jung's description of "the wounded healer".
By now we had identified 3 steps of compassion; recognizing suffering, sitting with it (acceptance), and a commitment to doing something about it.
We then watched:
Kristin Neff: The Three Components of Self-Compassion
This reinforced that we may try to jump straight from "there is a problem" to "I need to fix it", without taking the time to accept and acknowledge the suffering. She described self-compassion as "self-kindness, common humanity, and mindfulness".
We concluded, noting that transference is a doctor-centric concept, while empathy is a key component of patient centred care.
In the current environment, we may therefore find it more sustainable to move towards a more collaborative model, neither patient nor doctor centred. Key elements of this include clear boundaries, mutual respect between doctors and patients, and compassion (to include self-compassion).
We then learnt a brief mindfulness / self-soothing intervention we could try during our consultations, involving awareness of our pulse or bodily warmth. This resembled "giving ourselves a hug". Finally, we turned this outwards, and gave a hug to our neighbours!
I hope this was useful.
For more on the subject:
Aronson, October 14th, 21st and 28th 2016:
Dr Kristin Neff, self-compassion.org
ACT, acceptance and commitment therapy
"Against Empathy: The Case for Rational Compassion" -
Paul Bloom, Penguin Random House, 2016. http://amzn.eu/hKK6mYU
Oxford Empathy Programme
