What exactly is empathy in clinical practice?

  • February 19, 2024

In a recent British Journal of Psychiatry editorial summarising key points from the latest NICE guideline on management of self-harm, the authors led with a section headed “The need for empathy” – a rallying call that seems on the face of it unproblematic. Empathy is however underspecified in their article (as it so often is in psychiatry) both in terms of its defining features and in relation to what exactly should be the interventions to ensure it happens.

Interestingly the word empathy appears for the first time only in the supplement to the OED. It has gained currency since then but with a rather blurry feel-good meaning. The OED defines empathy as: “The power of entering into the experience of…emotions outside ourselves”. An early use referred to the experience of a work of art, the ability to “feel oneself into it”. These definitions too are rather hard to grasp but they suggest a state that it is unrealistic to expect a clinician to achieve – especially in relation to somebody met only briefly and in unusual circumstances, whose emotions and responses to them are likely to arise from experiences well outside the clinician’s own.

Some people claim that they can teach healthcare professionals how to be empathic. What it seems to boil down to is usually something like being attuned to implicit or non-verbal expressions of emotion, acknowledging and responding to them. This of course isn’t empathy but a sort of social practice. For that reason the more sophisticated versions of acknowledging and responding to patients has been likened to method acting.

Instead of continuing with this (frankly rather pretentious) focus on empathy, there are some less nebulous aspects of sensitive and non-aversive care that can be taught.

First is courtesy and professionalism. These, unlike empathy, can be taught and supervised by attention to behaviour – how to introduce yourself, asking how the patient wants to be addressed, paying attention to privacy and confidentiality and so on. And if that fails there is a question about lack of professionalism for which there are other remedies.

Second is being well-informed about causes and consequences. My own experience suggests that many clinicians are not au fait with what is now known about reasons for self-harm – in the sense of what its functions might be. One indication is the frequency with which discussions centre around diagnosis, which is except in a minority of no help in understanding what is going on. Another is the persistence of stereotypes about self-injury. It is difficult to undertake a sensitive and meaningful psychosocial assessment if you don’t know what you’re looking for. I wouldn’t downplay the importance of person-centred care or the value of service user involvement in training, but clinically oriented postgraduate education also needs to develop in this space. This sounds too fact-based to have anything to do with “empathy” but then I have always thought that a better word than empathy is sympathy – the sense of feeling onside with somebody that comes from a shared understanding of the situation. And how to elicit that shared understanding can be taught.

Third is the question of competence in practice and here there is a real challenge. Hardly anybody provides comprehensive psychological or psychosocial treatment services in the post-acute period – not in liaison psychiatry where most acute presentations are seen, nor in clinical psychology, nor in CMHTs. Good management involves, for sure, a professional attitude and behaviour and sound knowledge both about therapies and about the specific problem being tackled – but also the generic (transferable) skills, behavioural and emotional repertoire and expertise that come from experience. How can we enhance care in this area if we don’t provide the services within which all this can be developed?


If we are to improve how we treat people we need to go beyond rather general appeals to good practice. We need to develop self-harm services and to specify the curriculum for education and supervised training that will develop those working in such services to act professionally and sympathetically, as well as with a competence derived from education and from experience in practice.  

Putin’s mental state? It’s time we dropped the childish and uninformative mad man view of history

  • March 4, 2022

Former UK foreign secretary David Owen has recently been reported as saying that Putin’s aggressive behaviour on the international stage may be a consequence of taking steroids. The evidence for this assertion is that Vlad’s got fatter in the face in recent times and is being unreasonably aggressive.

Owen has form in the cod diagnosis of politicians – giving us in 2019 the ridiculous condition of Hubris Syndrome – or hubris as we used to call it. My reading of the formulation there (excuse the technical jargon) is that after a few years in power people tend to get up themselves a bit, arrogant and not keen on being contradicted. However, I may be wrong and there’s more to it: a senior neuropsychologist tells us that Hubris Syndrome affects the frontal lobes drenching them in dopamine, and this could be the cause of Putin’s behaviour.

In the same article that reported the Hubris Syndrome idea, a different expert suggests that it’s something to do with the cognitive effects Long Covid. No less absurd as a hypothesis but I suppose it has the advantage of being bang up to date.

If any of this sounds familiar that’s because it is. Not that long ago experts were telling us that President Trump wasn’t just horrible but mentally disordered – most infamously in the multi-contributor volume The Dangerous Case of Donald Trump. And of course the most famous mad man of recent history is Hitler – name-checked 59 times in the Trump book in case we didn’t spot the provenance of the line of thinking. I could keep going but the trail is long – back to Suetonius at least (I’d have to stop there, my ancient history’s a bit thin).

It’s tempting to dismiss all this as ridiculous, which of course it is. It’s raised a momentary laugh when I’ve chatted about it with friends and that’s about what it’s worth. But there are reasons to think we could do with less of it, for the effect it has on the quality of public discourse.

First, pathologizing of political motives as symptoms of mental disorder is really just a variant of psychiatric name-calling, which is a form of insult we could do without. And it infantilizes public discussion about serious matters. Do we really think that the Ukraine invasion is the result of an aggressive impulse by somebody who has temporarily taken leave of his senses? Or that one man can run not just a complex military adventure but a whole country – without the collusion of others in it for the power, money, sex or whatever it is that motivates them?

Malignant despots have something in common, I think, with buffoon politicians like our own prime minister. They are symptoms of the system that allows them to stay where they are, their endurance reflecting not just something about their callous self-interest but also the values of those on whose collusive support they depend.  All of which is kept out of the spotlight by daft pseudo-diagnostic medicalisation, a sort of dark-side version of the Great Man of History story which downplays the systemic and societal and privileges the role of the individual actor.

Personality disorder as a diagnosis: stereotyping and discrimination aren’t avoidable complications, they are inherent to the diagnostic process.

  • February 14, 2022

In clinical practice, a full diagnosis typically consists in the description of a particular presentation coupled with an account of the associated (causal) pathology that explains the presentation.  Thus: you are breathless and I can’t hear breath sounds on the right side when I listen with my stethoscope (the presentation) because you have fluid surrounding your lung due to tuberculosis (the explanatory pathology). Diagnosis in psychiatry is rarely full in this way, typically consisting only of a description of the presentation.

If we consider the diagnosis of personality disorder in this light, does it make sense? The diagnostic statement is that the person is the presentation, and although there is assumed to be some sort of underlying deficit in psychological function that constitutes the associated (causal) pathology, it has to be said that after 100 years of inquiry what it is remains to be revealed. We are left with the diagnostic statement – your emotions, actions, thoughts aren’t symptoms of some condition you have; they are simply the expression (presentation) of your personality and therefore who you are is a mental disorder.

If that’s right, can debate about the status of the diagnosis be bracketed with debates about the clinical or social status of autism or physical disability? That is, the diagnosis can be criticised for pathologizing diversity or for essentialising the individual who becomes the problems they present?  I don’t think this quite works as an analogy. For example, there is no ineluctable presentation in personality disorder which is why categorising sub-types has proved such a failure. Autism is autism is autism, while psychopathy can look like any number of things.

Apart from the mutability difference, there is something different from the neuro-diversity analogy in the way the “disorder” of personality disorder is defined – not just in social or interpersonal terms but in judgemental terms. The judgements are, at root, about acceptability of behaviour, emotional expression and so on.

So, making a diagnosis of personality disorder isn’t stereotyping or stigmatising as an unfortunate side-effect of the way some ill-informed people choose to treat those so diagnosed, it is inherent to the diagnostic process. If we say that who somebody is constitutes a mental disorder the features of which are socially and personally undesirable, and this “who somebody is” fits them in a category of similar people with the same mental disorder, then how could it be other than stereotyping and stigmatising, with the resulting responses being those we might expect towards anybody who is by definition undesirable?

Culture wars, economic hardship and disdain for mental illness and learning disability – a dangerous mix.

  • January 17, 2022

Germany’s asylums between the world wars housed a mixed population – mainly of people with a learning disability or a severe and persistent mental illness. These people became the focus of Nazi interest for two reasons.

First – and this isn’t as widely known as it should be – residents of the asylums were the first large scale victims of the Nazi’s mass murder programmes. The technologies used later, on Jews, Roma, homosexuals, communists and others, were first developed in what is usually known as Aktion T4 (named prosaically enough for the original HQ address Tiergarten 4). That is, T4 developed gas chambers as an efficient method of killing, purpose-built crematoria for disposal of the bodies, and an associated propaganda programme that is hard not to see as enabling a sort of collusion with the general public. An estimated 200,000 people from the asylums were eventually killed in T4 and its sequelae. This history is covered in some detail in Michael Burleigh’s extraordinary 1994 book Death and Deliverance: “euthanasia” in Germany 1900-1945 (Cambridge UP, listed unbelievably as out of print now).

An apparently separate campaign waged by the Nazis took the form of what we would now call culture wars, with modern art as a particular target. The infamous Entartete Kunst (Degenerate Art) exhibitions curated by party members and promoted by Goebbels are well known, but less so is the link to asylum art. A number of key modernists had been intrigued and influenced by the work of apparently mad people – so-called art brut – a significant collection of which had been accrued by Hans Prinzhorn at Heidelberg and valued as being artistically important in its own right, not simply as a window into the mind of the insane.

The Nazis exploited this association in carefully managed presentations associated with the message – look how modern art is no different to the art of lunatics and imbeciles and yet you are duped into paying huge sums for the public galleries to own it.  With the related message of course – it’s all part of a (Jew-orchestrated) conspiracy to undermine true Germanic society through undermining its culture.

The two stories inevitably intersect, with many (amazingly not all) of the asylum art works destroyed and the artists who made them perishing in the mass euthanasia programmes. This story is well told in a new book The Gallery of Miracles and Madness by Charlie English – unlike Burleigh a journalist rather than historian, with a predictably different but nonetheless well researched and engaging style.

The asylum artists who died in the T4 programme were caught in a perfect storm – of culture wars used by an authoritarian government to garner support for their wider political project; the motivating force of economic hardship coupled with the idea that alien enemies are to blame; the promotion of “euthanasia” as a solution to the societal problem of burdensome lives. Sound familiar?

Picturing Long COVID – time to drop a subtly undermining visual rhetoric.

  • October 13, 2021

Usually I ignore the accompanying pictures when I am reading a newspaper article about health. Just recently however, I have noticed something about the pictures that accompany articles about Long COVID.

Here’s a typical example – a picture of somebody, and it’s nearly always a young woman, reclining on a sofa looking exhausted. Of course we don’t need a photo to help us understand the idea of being exhausted, in the way that we might want an illustration for an article about recent floods or trouble at a street demonstration. So I took to wondering what was going on.

The use of such pictures may represent no more than a desire to break up blocks of text.  But there are a couple of features that drew me to thinking of how similar images have been used to convey something about other conditions.

First, here’s a rather typical image from an article about the 19th Century malady neurasthenia: a woman reclines and does not look, if truth be told, especially discomforted by her experience.

From a different era and with another typical feature (hand on forehead) I didn’t have to look far to find this illustration (left) from an article about premenstrual syndrome.  

And just to counter the idea that these things are entirely gendered here’s a picture (below) with another typical feature – it’s the back of the hand on the forehead – from an article about man flu’.

Perhaps what I’m seeing is no more than a lazy use of stock images but regardless of motive it occurs to me that there’s more to be said. The visual rhetoric hints at connections that the written text may not – between Long COVID and a group of conditions that have over the years shared some degree of being dismissed, of dubious provenance and melodramatic in presentation. And by implication, faintly ridiculous.

I don’t think this representation of illness does any favours to the discussion about the nature of Long COVID – not just to the question of possible underlying pathophysiology but also to the question of whether some cases are psychosomatic (functional) in part or whole.

My solution would be twofold: time to drop the use of the term Long COVID for the trouble it causes by bundling together so many disparate conditions. And when writing about the sequelae of COVID infection it’s time to drop the use of pictures of tired people resting, hand-on-forehead, on the sofa.

NICE’s ME/CFS 2021 guideline: a much-needed pause for reflection

  • September 9, 2021

There’s more to the debate than disagreement about research findings: prejudice against psychological diagnoses and treatments is also a factor

NICE’s decision to defer publication of its guidance on ME/CFS is welcome, allowing as it does time for reflection about what is going wrong that prevents consensus on the management of this group of conditions.

Actually, just a read through the draft (consultation) guidance provides some clues. It reads less like a dispassionate review of the evidence and more like a one-sided position statement from the ME Association. There is talk about listening to and believing patients, about energy envelopes, and criticism of trials that use “subjective” outcome measures – like self-reported fatigue and quality of life. What exactly these ideas mean isn’t always made clear. Disbelief isn’t likely to be about somebody being ill (symptomatic with functional impairment) but more about that illness being caused by a yet-to-be-identified physical pathophysiology. The energy envelope is an interesting term that I have not come across in this context (as opposed to engineering or acoustics)  except when used by people who dislike the idea of activity pacing, but its physiological (“objective”) basis is as far as I know undefined. Treatments that “only” change symptoms are described as non-curative but then so are stroke rehabilitation, paracetamol and hip replacement.

What is being played out in these guidelines is a long-standing opposition to (sometimes expressed as hostility, anger or aggression) treatments such as CBT and GET. What is that opposition about? The debate is sometimes framed as being about the status of trials’ evidence but I don’t think that explains the emotional tone. I detect in the background a drive to reject these therapies because they suggest there is a large psychological or motivational element to the illness.

We live in a society in which the idea is not widely accepted that physical illness can have predominantly psychological causes or treatments, and of course the personal experience of physical symptoms is so pressing that psychological ideas can just not seem to work as explanations. Beyond that starting point there is something more going on and I think it is an active prejudice against the idea of psychological (and specifically psychosomatic) diagnosis. There are several reasons for such an aversion. The diagnosis may be misunderstood as meaning that an illness is imagined or even deliberately feigned. No doubt this is also part of the “not believed” complaint. On the other hand it is assumed that if the diagnosis is accurate, the person so diagnosed must be really odd. This idea has its roots, I think, in the history of hysteria and its conflation of the hysterical illness with the hysterical personality. And of course there is a threat inherent in the idea that somebody can be so lacking self-awareness that their body generates an illness in a mysterious way that is outside their control.

Is prejudice too strong a word? I don’t think so: it explains the animus in the reaction to psychological research and practice in the field, which clearly reflects more than disagreement about the interpretation of trial results. And it surfaces even in some of the milder critical responses to NICE’s decision, such as use of the word “relegated” to describe people offered psychological diagnosis or input, with its implications of inferiority and failure.

How can professionals with an interest respond? Of course there is a continuing need to engage with constructive critical appraisal of the research literature, including discussion of the use of so-called PROMs (patient-reported outcome measures) in applied health research. In addition there is a need to explore new ways to discuss attitudes to psychological causes and treatment for functional or psychosomatic illnesses, tackling the idea that these are somehow disreputable or demeaning approaches.

This last question is sensitive because of the anger and resistance it can provoke in some quarters. My own sense is that the result of this sensitivity is some professional foot-shuffling. Too much is made of findings that many functional states are not preceded by severely threatening or traumatic life experiences; psychotherapy is discussed at times as if it is synonymous with CBT which in this context functions largely as an adjunct to rehabilitation rather than as a way of exploring more widely into the psychosocial context of illness development and maintenance; a welcome interest in the physiological mediators of symptom production is unnecessarily and incorrectly accompanied by claims that such research heralds the end of dualism (implication, using a psychological vocabulary is so passé…).

Time will tell, but my own prediction is that for these reasons the impasse will not be resolved merely by a renewed critical appraisal of the literature. Maybe a “form of words” will be found, but a more useful conclusion would be an acceptance that psychological treatments are important because psychological disorders are important – real, potentially serious, treatable and not inferior to physical diseases.

Searching for meaning in a book “about” mental illness.

  • June 27, 2021

I detect a drift into the mainstream of the idea of personality disorder, and in an attempt to understand why I have been reading some pop books – perhaps the best known being Ronson’s The Psychopath Test.

The book is subtitled “A journey through the madness industry”: it’s never clear what Ronson means by the madness industry but it’s true that the main structuring device is a journey, although it’s from one person to another rather than (unfortunately) from one idea to another.

We start with Ronson meeting a neurologist in a café in London, and an anecdote about an anonymous incoherent book she has received. There are warning signs here about this careless superficial book – the person he’s meeting isn’t a neurologist and even a casual conversation with a few mental health clinicians would have marked his card about how common it is, if you work in that world, to receive unsolicited books and articles from people hoping to interest you in their idiosyncratic view of how things work, and how little such gifts really tell you about either mental illness or mental health services.

It’s difficult to identify a theme in what follows. To start with it seems to be an exploration of psychopathy, which Ronson has been persuaded is routinely diagnosed in clinical and forensic practice on the basis of Hare’s Psychopathy Checklist and as an explanation for which he mentions repeatedly a half-baked idea about amygdala function. So we get a visit to a special hospital, a skimmed review of some aspects of the Oak Ridge scandal, and an interview with a ruthless businessman, but half way through he seems to lose interest in that line of thinking and we get an account of David Shayler’s mental illness, an interview with a guest-booker for (among others) the Jeremy Kyle show, and a drift off into stuff about DSM and the overdiagnosis of bipolar disorder in children in the USA.

All this is sketchily researched. The piece about the Oak Ridge scandal doesn’t mention the Class Action lawsuit started in 2001 against The Ontario Government and Drs. Elliott Barker and Gary Maier for breaching the basic human and civil rights of participants. The account of Shayler’s mental illness has no obvious point in relation to understanding ideas about psychopathy and the egregious picture of Shaler dressed as a woman suggests the main aim is to invite sniggering. In his report of an interview with Hare himself, there’s a recycled anecdote that comes from the introduction to Hare’s 1993 book about psychopathy. The interview with Charlotte Scott (the Jeremy Kyle producer) is mainly a rewarmed version of her earlier mea culpa published in the Guardian.

The people Ronson interviews have a habit of speaking in odd tabloid journalese, issuing stupid one-liners like if you’re worried about being a psychopath then you’re not one. Adam Curtis asks him – what does all this say about our sanity? – one example of recurrent cod philosophy about the difference between sanity and insanity that reminded me of nothing more than Rosenhan’s fraudulent paper On Being Sane in Insane Places.

Reviewers, at least those quoted in the book, apparently find it all hilarious. Will Self says he found himself “laughing like the proverbial loon” for page after page. And this coupled with a comparison one of them makes between Ronson and Louis Theroux provides a clue about what is going on. Ronson tries disarming mentions of his own tendency to anxiety and of the intrusive and disabling nature of mental illness, but in truth this is Barnum and Bailey psychiatry, a parade of grotesques (people and ideas) at which we might laugh or shudder depending upon our disposition. Its appeal is to Hollywood stereotypes – Gordon Gekko meets Michael Corleone – and doesn’t offer anything interesting about the contentious diagnosis of personality disorder (antisocial or otherwise) or sympathetic to the popular understanding of mental illness or the people who try to treat it.

I guess it’s that appeal to the familiar that accounts for the popularity of this grim book – the offer of a reassuring romp through a landscape populated by really odd people who aren’t like us. I didn’t find it remotely funny, just rather unpleasant.

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