Below, I have posted an article by Milton Cohen & John Quintner. It is a much shortened version of their 2011 publication [Cohen, M., Quintner, J., Buchanan, D., Nielsen, M. & Guy, L. Stigmatization of patients with chronic pain: the extinction of empathy. Pain Medicine (2011)]. The original article is, I believe, rather better, conveying more of their thinking and logic. Although copyright law prevents us from reprinting that version, you can, if you hurry, download a PDF version of their work by searching for the title in scholar.google.com.
There is much in their article with which I disagree, and I will follow-up with a longer post on some of the issues I see. But for now, read below or, better, get the original article from the web.
Chronic Pain and the Negation of Empathy by Milton Cohen & John Quintner
Health professionals usually regard empathy as a positive attribute to be conveyed by them to their patients.1 Empathy denotes the capacity of the clinician to sense the emotions and feelings of the patient.2
Derived from the Greek empatheia for “in suffering or passion,” empathy implies a shared phenomenology wherein a person is able to both accept and understand the expression of another person’s experience because it reflects the formers own experience.3
Empathy functions as a foundation for other acts (e.g. compassion, prosocial behaviour) that allow one to enter the experience of the “other” in an intuitive manner without the necessity of having to share that same experience, especially at an emotional level, as is the case for sympathy.4 In medical practice, the patient’s lived experience of pain is a common substrate for empathy.
However, empatheia includes the sharing of strong negative emotions, such as those that may accompany a sense of personal danger or hostility or prejudice,5 which could be directed at a clinician, especially when the legitimacy of that patient’s distress is in doubt and their presentation challenges the clinician’s expectation of a linear relationship between the severity of pain and the extent of tissue damage.6 Often there may be no discernible evidence of the latter.
The simulation theory of empathy proposes an analogical mapping process from one person’s situation to another.7 Such mapping occurs automatically at an unconscious level, but it can also depend on rule-based reasoning, making it more deliberate and theoretical.8 It is used both to produce the experience and to decode it when the “other” is experiencing it.
Neuroscientific research supports the existence of this reciprocal process, suggesting that the act of observing others who are experiencing pain triggers activation of neural networks that have been implicated in the direct lived experience of pain.9
Importantly, these networks also include those that have been found to accompany the observation of strong negative emotional expressions such as disgust, fear, anger and sadness.9
Empathy may then mutate into a projection of negative emotion and judgment towards the other person and even a conscious avoidance of compassion.6 When empathy is extinguished, and compassion disappears, we have coined the term “negative-empathy”.
“Negative-empathy” allows community-based stereotypes of chronic pain sufferers to pervade the clinical encounter.10 As stereotypes may contain negative emotional valence (e.g. “putting it on,” “all in the mind”), “negative-empathy” on the part of their health professionals can become a significant component of the complex process of stigmatisation of chronic pain sufferers.
Sociologist Erving Goffman11 defined stigmatisation as a process by which the reactions of a community to specific personal characteristics reduce a person’s identity “from a whole and usual person to a tainted, discounted one”, causing that person to be discredited, devalued, rejected and socially excluded from having a voice.
Because clinical relationships are morally charged, chronic pain sufferers are also at risk of being placed in “moral jeopardy” by their clinicians.12 Should they fail to validate the effectiveness claimed by their health professionals, or should they challenge their clinicians’ power to control the relationship, patients may acquire negative labels denoting that their motives are suspect and the legitimacy or reality of their symptoms doubted.
Moreover, clinicians can themselves encounter the same lack of validation should their choice of treatment happen to conflict with the views of regulatory authorities.13 The prescribing of opioid medications is a case in point.14
Remediation of negative empathy might commence with an examination of binary terminologies that are readily found both in medical teaching and clinical practice: objective/subjective; normal/abnormal; body (nociception)/mind (somatisation). Recognition of how these dualistic frames can work against patients’ best interests would be integral to a program that seeks not to perpetuate them. The stage would then be set for the emergence of pain theories with greater explanatory power.
Such theories would transcend the body/mind dualistic frame attributed to Descartes.15 They would incorporate the findings from neuroscience as they compel clinicians to accept empathy in all its connotations as being of fundamental importance to the understanding and management of patients presenting with complex pain states.
A new model of clinical engagement will emerge, one that is both scientifically and ethically obliged to discard conceptual frames that perpetuate negative stereotypes. There must be no hidden rules of the consultation (such as those governed by power imbalance) that might hinder a rapprochement between clinician and patient.
In proposing what might be termed a social neuroscience paradigm, we invoke the concept of the intersubjective or “third space” 16,17 which allows for many different ways of communication. In this space, the experiences of both patient and clinician are shared and negotiated, neither being an “expert” compared with the other, thereby resisting socially or culturally determined stereotypes.
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15. Descartes R (1649). The Passions of the Soul. Steven Voss (trans.) Indianapolis: Hackett Publishing, 1989.
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17. Husserl E. Cartesian Meditations: an Introduction to Phenomenology, transl. Dorian Cairns. The Hague: Martinus Nijhoff, 1973.