Is empathy an innate trait or a learnable skill?
Following my recent post about cognitive and affective empathy, a friend sent me a CBC story about oncologists who participated in a study that tested a computer-based empathy and communication skills training program. The doctors in the study were recorded during interactions with their patients, and received one month of feedback and training on how to recognize and improve their response to patients' distress signals. They were taught how to present information about prognosis empathetically, and how to identify opportunities to allow patients to talk about their feelings. The doctors were subsequently measured on "emotion-handling skills" (i.e., naming, understanding, respecting, supporting, and exploring emotions, rather than changing the topic, joking, denying the emotion, or ending the conversation). Patients' perceptions of their physician were also measured.
Results: At the end of the study, the empathy-trained doctors responded empathetically to their patients twice as often as did a control group of doctors who merely attended a lecture on communication skills. More importantly, patients whose doctors were in the training group reported greater trust in their doctor and greater perceived empathy from their doctor, and were more likely to report that they felt understood as "a whole person."
I thought this was pretty great--what's better than doctors who are willing to improve their bedside manner and patients who benefit? Not everyone agreed. In fact, several commenters on the CBC story seemed quite offended by the idea of empathy as a teachable skill and argued that in-born empathy is a required trait for good doctors.
This seems misguided. Insisting on strong innate empathy as a prerequisite for access to healthcare professions would exclude many intelligent and intuitive people who have excellent diagnostic and technical skills and who want to help others. I'm not suggesting that doctors don't need empathy, but who cares whether or not it's innate? It's hardly uncommon for professionals to take continuing education courses to brush up on skills and to fill gaps in their training.
Another commenter wondered whether the doctors in the study really learned empathy or whether they simply learned empathy behaviour. For the purposes of the doctor-patient relationship, I'm not sure there's a difference. The oncology patients in the study knew that their doctors were participating in a program to improve their empathy skills, but they still reported that they felt better understood and listened to--that is, they felt that their doctors were empathetic. That the doctors learned empathy from a computer didn't bother the patients and didn't limit the positive impact of the program on the doctor-patient relationship.
Any intervention that improves healthcare professionals' clinical skills and makes patients feel better supported should be applauded and pursued. I would love it if my doctor took an empathy course. Likewise, I would love it if I had a therapist who participated in a skills training program to improve her ability to identify and respond appropriately to my distress signals. Wouldn't you?
Showing posts with label In the News. Show all posts
Showing posts with label In the News. Show all posts
November 30, 2011
September 19, 2011
Decision and Will Power Fatigue
Subsequent to my post about will power and rules, my sister sent me an article about decision fatigue and will power fatigue. Apparently, decision-making and self-control take up energy, and if you have to make many decisions or exert continued will power, you end up in a state of ego depletion, a condition of low mental energy that can lead to poor self-control and bad decisions. In ego depletion, your brain is too tired to weigh advantages and disadvantages, and resorts instead to one of two strategies: you become reckless and obey impulses rather than thinking decisions through (e.g., yes, I should buy these shoes, eat this entire pie, take this shortcut through a deserted park at night), or you avoid making decisions by sticking to the status quo (e.g., I'll just get the same bottle of wine I always get; I'll just continue dating this person for now).
Decision fatigue occurs a) when you have to make decision after decision, and b) when your blood sugar is low. One of the studies cited in the article found that Israeli prison parole boards more often granted parole to prisoners whose cases were reviewed first thing in the morning or right after lunch. In contrast, prisoners whose cases were reviewed right before lunch or at the end of the day were less likely to be granted parole; suffering from low blood sugar and decision fatigue, the parole board couldn't undertake the mental work of evaluating cases and therefore opted to stick to the status quo (i.e., prisoners remain in prison).
Decision fatigue can happen in any situation that requires numerous or repeated decisions. Imagine sitting down with a decorator to outfit your new home. At the beginning, you and your partner eagerly contrast and debate the merits of various dimmer switches, cabinet knobs, and shades of hardwood; after a long day during which you choose from thousands of options for lighting, counter-tops, and flooring, when the decorator pulls out paint chips, you're liable to groan and say "Just paint the whole thing cream!" To avoid hasty or bad choices in decision-heavy situations (e.g., wedding planning), your best bet is to make your choices when you are well-fed, and in more than one session.
Will power fatigue occurs when you have to exert repeated or prolonged self-control. Will power fatigue explains why, when you're trying to cut back on drinking, you're able to turn down champagne at a wedding the first few times it's offered, but by midnight, you're so depleted from saying no that you grab and chug three glasses. Will power fatigue also explains why, after months of resisting your gorgeous, flirtatious, available co-worker, one night you give in and cheat on your partner. To avoid will power fatigue, your best bet is to get out of the situation that requires continued will power (e.g., tell the waiters at the wedding that you don't drink, so they won't keep offering to fill your glass; don't go to post-work cocktail hour when your co-worker is there).
Are some people more prone than others to ego depletion from will power or decision fatigue? According to one of the researchers interviewed for the article, self-control and good decision-making aren't personality traits; rather, the people with these skills are the ones who organize their lives to conserve will power and avoid decision fatigue. They don't go to all-you-can-eat buffets, browse online for items they can't afford, or schedule important meetings late in the afternoon. Further, they establish routines or habits that prevent them from having to make decisions or exercise will power.
Here's where my post about rules fits in. If you have a strict routine of going to the gym after work Monday through Thursday, or a rule that you never watch TV on weekends, you don't have to use will power or make decisions; it goes without saying that you're going to work out four times per week and you aren't going to stream the latest episode of House until Monday. If your firm rule is that you only eat dessert on special occasions, you don't have to decide and redecide every time you walk by the plate of cookies some demon left in the lunchroom at work.
In this way, rules, routines, and smart planning allow you to conserve will power and save your decision-making energy for important decisions or unexpected situations.
Decision fatigue occurs a) when you have to make decision after decision, and b) when your blood sugar is low. One of the studies cited in the article found that Israeli prison parole boards more often granted parole to prisoners whose cases were reviewed first thing in the morning or right after lunch. In contrast, prisoners whose cases were reviewed right before lunch or at the end of the day were less likely to be granted parole; suffering from low blood sugar and decision fatigue, the parole board couldn't undertake the mental work of evaluating cases and therefore opted to stick to the status quo (i.e., prisoners remain in prison).
Decision fatigue can happen in any situation that requires numerous or repeated decisions. Imagine sitting down with a decorator to outfit your new home. At the beginning, you and your partner eagerly contrast and debate the merits of various dimmer switches, cabinet knobs, and shades of hardwood; after a long day during which you choose from thousands of options for lighting, counter-tops, and flooring, when the decorator pulls out paint chips, you're liable to groan and say "Just paint the whole thing cream!" To avoid hasty or bad choices in decision-heavy situations (e.g., wedding planning), your best bet is to make your choices when you are well-fed, and in more than one session.
Will power fatigue occurs when you have to exert repeated or prolonged self-control. Will power fatigue explains why, when you're trying to cut back on drinking, you're able to turn down champagne at a wedding the first few times it's offered, but by midnight, you're so depleted from saying no that you grab and chug three glasses. Will power fatigue also explains why, after months of resisting your gorgeous, flirtatious, available co-worker, one night you give in and cheat on your partner. To avoid will power fatigue, your best bet is to get out of the situation that requires continued will power (e.g., tell the waiters at the wedding that you don't drink, so they won't keep offering to fill your glass; don't go to post-work cocktail hour when your co-worker is there).
Are some people more prone than others to ego depletion from will power or decision fatigue? According to one of the researchers interviewed for the article, self-control and good decision-making aren't personality traits; rather, the people with these skills are the ones who organize their lives to conserve will power and avoid decision fatigue. They don't go to all-you-can-eat buffets, browse online for items they can't afford, or schedule important meetings late in the afternoon. Further, they establish routines or habits that prevent them from having to make decisions or exercise will power.
Here's where my post about rules fits in. If you have a strict routine of going to the gym after work Monday through Thursday, or a rule that you never watch TV on weekends, you don't have to use will power or make decisions; it goes without saying that you're going to work out four times per week and you aren't going to stream the latest episode of House until Monday. If your firm rule is that you only eat dessert on special occasions, you don't have to decide and redecide every time you walk by the plate of cookies some demon left in the lunchroom at work.
In this way, rules, routines, and smart planning allow you to conserve will power and save your decision-making energy for important decisions or unexpected situations.
July 14, 2011
Criteria Controversy
How do you know if a given behaviour or group of symptoms constitutes a psychiatric or psychological disorder? This is an important question, and particularly relevant right now as psychiatrists work on the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), to be published in 2013.
Proposed additions to the DSM like Internet Addiction and Premenstrual Dysphoric Disorder (PMDD) are raising the ire of DSM critics who argue that the manual medicalizes and pathologizes normal behaviour. While this criticism is valid and worthy of discussion, people making this argument have the frustrating habit of selecting one symptom from the list of DSM criteria for a given disorder and using it to claim that the criteria describe normal behaviour. The most recent person to do so is Ian Brown of the Globe & Mail. In his article, Brown gives the example of one criterion for the proposed DSM-V diagnosis of compulsive hoarding: "Persistent difficult discarding or parting with possessions, regardless of the value others may attribute to those possessions."
According to Brown, this symptom describes "anyone with a basement." Such is the problem of selecting and criticizing a diagnostic criterion in isolation. Anyone wishing to make a similarly unsophisticated argument could choose "Eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances" from the proposed criteria for binge eating disorder (BED) or "Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful or increased sensitivity to rejection) prior to most menstrual cycles" from the proposed criteria for PMDD. They could argue that they often overeat at dinner parties and experience mood swings before they menstruate and that the inclusion of BED and PMDD in DSM-V would unfairly pathologize their behaviour.
This argument fails to acknowledge a) the other diagnostic criteria for the respective disorders and, importantly, b) the additional criterion of significant distress. The diagnostic criteria for most of the DSM disorders include "Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning." This is a key criterion: If you have a basement full of junk, but it's not bothering you or anyone else (and not causing a health or safety risk), no one is going to accuse you of being a compulsive hoarder. If you overeat at dinner parties and binge on chips during the Superbowl, but it doesn't cause you lasting distress (or health problems), no one is going to label you with binge eating disorder. Writers like Brown are advised to keep the distress criterion in mind--as well as the entirety of the criteria for a given disorder--when they're fretting about the pathologizing of normal behaviour.
NB: My endorsement of the significant distress criterion is not a defense of the singular use of the DSM to decide what is and isn't a clinical problem. If your symptoms or behaviour don't cause you distress or impairment, you probably don't have a clinical problem. But: if you experience significant distress or impairment despite having only minor symptoms, it's still a problem. That is, if you binge eat only four times per year at holidays or only experience mood swings every third time you menstruate--but it causes you significant distress or impairment--ignore the doctor telling you your symptoms are subclinical according to the DSM, and seek help elsewhere. Distress is distress.
Proposed additions to the DSM like Internet Addiction and Premenstrual Dysphoric Disorder (PMDD) are raising the ire of DSM critics who argue that the manual medicalizes and pathologizes normal behaviour. While this criticism is valid and worthy of discussion, people making this argument have the frustrating habit of selecting one symptom from the list of DSM criteria for a given disorder and using it to claim that the criteria describe normal behaviour. The most recent person to do so is Ian Brown of the Globe & Mail. In his article, Brown gives the example of one criterion for the proposed DSM-V diagnosis of compulsive hoarding: "Persistent difficult discarding or parting with possessions, regardless of the value others may attribute to those possessions."
According to Brown, this symptom describes "anyone with a basement." Such is the problem of selecting and criticizing a diagnostic criterion in isolation. Anyone wishing to make a similarly unsophisticated argument could choose "Eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances" from the proposed criteria for binge eating disorder (BED) or "Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful or increased sensitivity to rejection) prior to most menstrual cycles" from the proposed criteria for PMDD. They could argue that they often overeat at dinner parties and experience mood swings before they menstruate and that the inclusion of BED and PMDD in DSM-V would unfairly pathologize their behaviour.
This argument fails to acknowledge a) the other diagnostic criteria for the respective disorders and, importantly, b) the additional criterion of significant distress. The diagnostic criteria for most of the DSM disorders include "Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning." This is a key criterion: If you have a basement full of junk, but it's not bothering you or anyone else (and not causing a health or safety risk), no one is going to accuse you of being a compulsive hoarder. If you overeat at dinner parties and binge on chips during the Superbowl, but it doesn't cause you lasting distress (or health problems), no one is going to label you with binge eating disorder. Writers like Brown are advised to keep the distress criterion in mind--as well as the entirety of the criteria for a given disorder--when they're fretting about the pathologizing of normal behaviour.
NB: My endorsement of the significant distress criterion is not a defense of the singular use of the DSM to decide what is and isn't a clinical problem. If your symptoms or behaviour don't cause you distress or impairment, you probably don't have a clinical problem. But: if you experience significant distress or impairment despite having only minor symptoms, it's still a problem. That is, if you binge eat only four times per year at holidays or only experience mood swings every third time you menstruate--but it causes you significant distress or impairment--ignore the doctor telling you your symptoms are subclinical according to the DSM, and seek help elsewhere. Distress is distress.
June 08, 2011
Few Good Men
The New York Times recently published an article about the pervasive lack of male psychologists and psychotherapists. It's unequivocally true that clinical psychology has become a female profession: about 95% of the students in my PhD program are women, and the majority of the psychologists at the research centre where I work are female. This gender disparity is new: at least half of my professors and supervisors are male and most of my female professors and supervisors are relatively young, indicating that a shift occurred in the last generation.
Following the NYT article, a Psychology Today blogger wrote that the evacuation of men from psychologist and psychotherapist positions corresponds to the increased difficulty of earning a good living in these professions. Men seem to be less willing or less able to afford to work in low paying jobs. Moreover, the decreased proportion of men in psychology corresponds to a decrease in the field's status and prestige. The same blogger wrote that, rather than being seen as respected and qualified health care experts, clinical psychologists are viewed as part of a generic mass of mental health workers, indistinguishable from counselors, social workers, and other professionals who do not enjoy the power of psychiatrists to prescribe medication. (NB: psychiatry has not witnessed a gender shift to the same extent.)
Does it matter if your psychologist is male or female? Is one gender better suited than the other to deal with certain issues? Another Psych Today blogger argues that the overrepresentation of women in the field is problematic because it decreases the appeal of psychotherapy to men. Men are already traditionally reluctant to seek therapy, and the inability to find a male therapist may discourage them from getting the help they need. This is a plausible argument: male would-be clients might feel more comfortable speaking with a male therapist about sexual dysfunction, anger or dominance issues, or the pressures of fatherhood,. That said, men may feel more comfortable opening up to a female therapist about less "manly" problems like sadness, fear, and anxiety. Similarly, female clients may feel less confident in a male therapist's capacity to understand body image issues or motherhood or fertility issues, but more comfortable disclosing to a male therapist about traditionally unfeminine issues like aggression or partner abuse.
But if men need male therapists and women need female therapists to properly understand their experience, do disabled people need disabled therapists, visible minorities need visible minority therapists, and elderly people need elderly therapists? As someone who is pro-therapy, to some degree I believe that anything that encourages someone who needs help to get help is good. That is, if the prospect of having a therapist who looks like you or is of your gender will encourage you to seek therapy, that's positive. However, this type of client-therapist matching introduces the risk of a client (or therapist) assuming that her South Asian therapist (or client) has had the same South Asian experience as her, or that his blind therapist has had the same blind experience as him, creating a significant risk of stereotyping, misunderstanding, and disappointment.
Our training as psychologists is supposed to be broad enough to allow us to be empathetic and helpful to clients of both genders and of a wide variety of experiences and walks of life. I have never had a male psychotherapist: I've had a few good and a few bad female therapists, but I can't say that any of them seemed particularly suited or particularly poor at helping me address my problems because of their gender.
Would you prefer a therapist of your own gender? How come?
Following the NYT article, a Psychology Today blogger wrote that the evacuation of men from psychologist and psychotherapist positions corresponds to the increased difficulty of earning a good living in these professions. Men seem to be less willing or less able to afford to work in low paying jobs. Moreover, the decreased proportion of men in psychology corresponds to a decrease in the field's status and prestige. The same blogger wrote that, rather than being seen as respected and qualified health care experts, clinical psychologists are viewed as part of a generic mass of mental health workers, indistinguishable from counselors, social workers, and other professionals who do not enjoy the power of psychiatrists to prescribe medication. (NB: psychiatry has not witnessed a gender shift to the same extent.)
Does it matter if your psychologist is male or female? Is one gender better suited than the other to deal with certain issues? Another Psych Today blogger argues that the overrepresentation of women in the field is problematic because it decreases the appeal of psychotherapy to men. Men are already traditionally reluctant to seek therapy, and the inability to find a male therapist may discourage them from getting the help they need. This is a plausible argument: male would-be clients might feel more comfortable speaking with a male therapist about sexual dysfunction, anger or dominance issues, or the pressures of fatherhood,. That said, men may feel more comfortable opening up to a female therapist about less "manly" problems like sadness, fear, and anxiety. Similarly, female clients may feel less confident in a male therapist's capacity to understand body image issues or motherhood or fertility issues, but more comfortable disclosing to a male therapist about traditionally unfeminine issues like aggression or partner abuse.
But if men need male therapists and women need female therapists to properly understand their experience, do disabled people need disabled therapists, visible minorities need visible minority therapists, and elderly people need elderly therapists? As someone who is pro-therapy, to some degree I believe that anything that encourages someone who needs help to get help is good. That is, if the prospect of having a therapist who looks like you or is of your gender will encourage you to seek therapy, that's positive. However, this type of client-therapist matching introduces the risk of a client (or therapist) assuming that her South Asian therapist (or client) has had the same South Asian experience as her, or that his blind therapist has had the same blind experience as him, creating a significant risk of stereotyping, misunderstanding, and disappointment.
Our training as psychologists is supposed to be broad enough to allow us to be empathetic and helpful to clients of both genders and of a wide variety of experiences and walks of life. I have never had a male psychotherapist: I've had a few good and a few bad female therapists, but I can't say that any of them seemed particularly suited or particularly poor at helping me address my problems because of their gender.
Would you prefer a therapist of your own gender? How come?
January 23, 2011
Update
To date, no meetings have taken place between representatives of Quebec psychologists and representatives of the provincial Ministry of Health and Social Services.
Other things are happening, though.
1) Even if the Ministry isn’t paying attention, the press is. In the past two weeks, articles about the issue have appeared in the Montreal Gazette and in La Presse. Rose-Marie Charest, president of the Ordre des Psychologues du Québec, and Marcel Courtemanche, president of the comité des chefs de service en psychologie en milieu hospitalier du Québec, were interviewed on Radio-Canada; both commented on the impact of the shortage of public sector psychologists on public accessibility to services, and on the roles of poor working conditions and of the disparity between educational requirements and compensation in perpetuating the shortage.
2) Students waiting for news about internships for next year were advised to expect letters from the sites we applied to, confirming receipt of our applications and advising us that they are keeping our unopened applications on file and will let us know when things change. Here’s the rub, though: not all internship sites are participating in the pressure tactic; even within hospitals that have announced their solidarity with the tactic, some clinics are offering applicants interviews as usual. This means that students who have applied to participating and non-participating sites may be in the awkward position of having to accept or reject an offer from one site before sites in which they are equally interested even review their application. To say nothing of the potential awkwardness of starting an internship as scheduled in September while your fellow students are forced to make other plans.
What to do? Although students are not obliged to support the Quebec psychologists’ position, those who plan to work in Quebec after graduation certainly have an interest in improved salary and working conditions.
Professional respect and decent pay are important. Supporting your future colleagues is important. But so is continuing your training and finishing your degree in a timely fashion.
I’ll keep you posted.
January 12, 2011
Winter of Discontent
In a pressure tactic designed to get the attention of the provincial Ministry of Health and Social Services, Quebec public sector psychologists announced in December 2010 that they are refusing to accept psychology interns for the 2011/2012 school year. Their problem: poor working conditions and lack of respect for their work, as demonstrated by remuneration not commensurate with the demands and the training requirements of the profession.
Yearly salary for a full-time psychologist in the public sector in Quebec is between $37,219 and $70,759 and comparisons with the salaries of psychologists in the rest of Canada ($57,000 to $130,000) and with other health care professionals in Quebec reveal significant discrepancies. For example, although Quebec social workers, nurses, and physiotherapists are eligible to practice as professionals after completing their undergraduate training and psychologists have to complete a PhD (i.e., a minimum of five more years of school, creating a corresponding five more years worth of student loans, and a five-year delay before starting to earn), the former professionals earn salaries that are equal to or higher than that of Quebec psychologists.
In response to the lack of respect and recognition, Quebec psychologists are leaving the public system en masse to work in private practice, where they can earn between $85 and $150 per one-hour session. The holes in the mental health care system mean that full-time psychologists are stretched extremely thin between clinical work (e.g., evaluation, psychometric testing, treatment, crisis management, consultation with other professionals), research, administrative tasks, and teaching and supervision, and that Quebeckers who can’t afford private services face long waiting lists for mental health care.
Refusing to train interns effectively stalls the education of new psychologists in the province, threatening to even further increase the number of vacant psychologist positions in the public system. For Quebec citizens, it means even less accessibility to services. For me, it means that my internship applications for next fall, mailed before Christmas, are being received but not opened, and that my degree—already long—risks being delayed by one year.
However, in the past few days, the Ministry acknowledged the pressure tactic, and a preliminary meeting between Ministry representatives and representatives of Quebec psychologists is in the works. Stay tuned.
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