Hey friends. Welcome back to the podcast. I'm Amanda. I'm Laura. And I'm Kendra. And today we are continuing our emotional intelligence series. Specifically, this topic is gonna be about empathy, what it is, what it isn't, why some forms of empathy help us become better clinicians and better humans, and why other forms can leave us completely wrung out.
Because I think a lot of us were handed some pretty confused messages about empathy growing up, or from culture or from whatever, and we're here to straighten it out. The message was basically this, if you really care, you should feel. A lot. You should absorb the pain in the room. You should ache with people.
And if you don't, maybe you're detached, maybe you're frigid, maybe you're ice cold. But the worst part about the whole thing is thinking that perhaps you're losing your humanity. And I don't think that that's true. I think empathy is more nuanced than that. I think there's different kinds of empathy. There are
things that affect us differently at work, and I think part of emotional intelligence is learning how to be deeply present with someone else's suffering without getting swallowed by it. So let's talk about that. Okay. When most people say empathy, they're usually lumping several different things together.
One part is affective empathy, and this is the emotional resonance piece. It's when someone else's pain lands in your body, you see a family member crying and your chest tightens. You hear fear in a patient's voice and you feel that little drop in your stomach, you witness grief and something in you reacts before you even have time to think about it.
The other part is cognitive empathy, and that's the understanding piece. This is the ability to step into someone else's perspective and make sense of what they may be feeling, fearing, needing, or trying to communicate. It's less like, I feel your pain in my body and more I understand what this experience may be like for you.
Social neuroscience and clinical empathy research commonly describe empathy as involving affective, cognitive, and regulatory components rather than being one single thing. Clinical empathy in medicine is often framed less as emotional merging and more as understanding another person's experience accurately and responding helpfully.
And that distinction matters because many of us, especially in medicine, caregiving, teaching, parenting, coaching, all of the spaces in which we help for a living, we're quietly taught the more pain we absorb, the more loving we are, but absorbing is not the same as understanding and feeling is not the same as helping.
Flooding is not the same as caring. So for example, Dr. Jane is discussing a new cancer diagnosis with a patient and the patient's husband. The husband is staring at the floor silent and the patient keeps asking the same question over and over. So what happens next? Affective empathy is the part of Dr.
Jane that feels the heaviness in the room. She feels the fear. She feels the grief. She feels how devastating this might be for the patient and her husband. Cognitive empathy is the part that says they are probably overwhelmed and not processing very well. Repetition here is not because they're not listening, it's because their brains are flooded.
The second move is still empathy, and actually in many professional settings, that second move is the one that keeps empathy useful because once you can understand what's happening, you can actually respond better. You can slow down, you can simplify, you can orient, you can be steady, and that steadiness is often more loving than joining them in the panic.
Or how about another case? Let's talk about Dr. Jane discussing a delayed discharge with a family member who is angry and very sharp. He says, no one here knows what they're even doing. If she only reacts from the affective layer, she may instantly feel threatened, irritated, or maybe a little bit of shame, like maybe no one does know what's going on, but if she brings in cognitive empathy, she can think
this anger can come out of fear and it also may be helplessness, but it may be what comes out when someone feels out of control. And clearly this situation is out of the patient and their family member's control. But that doesn't mean she becomes boundaryless. It doesn't mean she lets them mistreat her.
It just means she sees this situation more clearly, and clarity is actually one of the deepest forms of empathy, right? As I reflect on that case, I think how much this skill of empathy has built on the other skills of emotional intelligence that we've talked about. To be able to empathize, we have to be aware of what's happening in ourselves and what's happening in others.
And we have to be able to regulate our own emotions rather than just reacting to whatever is happening. And I've certainly had those where I felt like a patient's family member was kind of coming at me and it is easy to react because it's not right, it's not just, that's the part of me that likes to react.
If there's injustice, stand up and say something. But pulling in our emotional intelligence skills, we can be more aware and decide, hey, is that actually the part of me that I want showing up right now? And there's actually not surprisingly neurobiology to why these different forms of empathy feel so different.
Affective empathy, or felt empathy, is the faster, and I will say for many of us it's a more automatic pathway. There are some of us who are actually kind of limited in this particular form of empathy and find it difficult to feel other people's feelings with them. But some of us grew up in situations where it was very important to know what other people were feeling and
it landed in our bodies very clearly when somebody was dysregulated and maybe we needed to do something to help keep the peace. So this affective empathy is this body-based, something is happening here response, and research has linked that kind of empathic arousal to systems involved in salience, interoception, and emotional pain, especially in the anterior insula, anterior cingulate cortex, and amygdala.
And so for people who are impaired and are unable to access affective empathy, this sometimes occurs in cluster B personalities or in other situations. Certain attachment styles may have more limited affective empathy. And they may have, on scans, decreased activity in the anterior insula.
These systems help us rapidly register distress. You know, the amygdala is part of our threat detection system. And so for those of us who were peacekeepers in our homes, that threat detection helps us tap into that anterior insula, really attune to what other people are feeling. And that's why sometimes you might walk into a room and you can feel the distress before anyone even says a word.
And that goes for at work and at home. Your body can pick up on people's tone, their expressions, tension in the air, the urgency they might feel, grief they're experiencing, frustration, anger, their fear and it's important to note that this is a way that we're wired for human connection. Being able to feel other people's feelings helps other people feel seen and heard, and helps them to feel connected to us.
However, we can become flooded by it. We'll talk about that a little bit later. Cognitive empathy is different and it recruits more of the perspective taking and self-other distinction systems, whereas affective empathy
we might not be able to tell who the bad thing is happening to. With cognitive empathy, we can create a little bit more separation. Those are the areas often associated with mentalizing and top-down processing, such as the medial prefrontal cortex and the temporal parietal junction. That's the part of the brain that helps you say, what is this person likely feeling?
Notice it's a sentence. It's an actual thought rather than an emotion kind of hitting us like a wall. What makes sense here? What is underneath their behavior? So in a way, affective empathy helps you register suffering, which is important, right? It's important for us to be able to register people's suffering so that we don't dismiss them, and cognitive empathy helps us to be able to interpret it.
And here's where this becomes really important at work. If affective empathy is high and regulation is low, empathy can tip into what researchers often call personal distress or empathic distress. And that's when someone else's suffering stops being something you're with and starts becoming something that overwhelms you.
And I think many of us have been there. It's hard to imagine a situation where you're working in medicine and that doesn't sometimes happen because of the sheer volume of suffering we experience. Doctors have a unique job where we interact with people who are suffering all the time, and I'm not sure that our nervous systems were wired for that level of secondary
distress and traumatic experience. Research on empathy and compassion describes intense sharing of another person's suffering as potentially aversive and distinguishes empathic distress from compassion, so we can still be compassionate and not be overwhelmed with empathic distress. And coming from a place of compassion, rather than allowing yourself to go into that empathic distress, is going to keep us in a more steady, stable place and help our nervous systems realize it's not actually happening to us, it's happening to someone else.
And that's a big deal. That's important because I think what many people call empathy fatigue is often this exact pattern. You care, you feel, you resonate. You keep doing that over and over in a high stress environment, and eventually your system starts saying, I cannot keep taking this much in.
And I certainly have been there and still get there sometimes. In healthcare literature, clinicians' repeated exposure to negative emotion and suffering is recognized as a real strain that can contribute to compassion fatigue. Yeah. Like we're like, duh, of course it contributes to emotional exhaustion and sometimes impaired care when the balance between over identification and detachment gets disrupted.
So there's a fine balance that we need to learn how to strike, so we can register people's distress and not allow it to take over. Empathy fatigue is not usually a sign that you're a bad person. I think you know that. We're never gonna say that you're a bad person.
It's just that your nervous system has had too much. And I'm reminded, recently there was a medical student who posted that she was worried that medical school was turning her into a psychopath or a sociopath, I can't remember what she said, because she noticed this loss of empathy that she was experiencing.
So when we're noticing that, that's a time to just get curious about, okay, well, why? Am I really just turning into a psychopath? No, probably not. It's usually a sign that your nervous system has been doing a tremendous amount of emotional labor without enough regulation, recovery, rest, or skillful boundaries, which we've talked a lot about. How doctors
we just were not trained to have boundaries. We're trained to not have boundaries, and so it's no surprise that this happens to us sometimes. So going back to Dr. Jane again here. Dr. Jane is discussing end of life options with the daughter of an elderly patient. The daughter starts crying and says, I don't want her to think I'm giving up on her.
Dr. Jane feels tears behind her own eyes. That's affective empathy. But if Dr. Jane leaves that room carrying the daughter's guilt, replaying it all night and feeling like she has somehow failed if the daughter remains devastated, that can shift into empathic distress.
Okay? So we can see the difference. We can have that affective empathic experience in the moment, and we have to be able to let it pass through us. So a more sustainable internal response might be, this is heartbreaking. This daughter really loves her mother, and my job is to bring steadiness,
clarity, and compassion here. I do not have to take her guilt home with me in order to care well. That shift really matters, and I am gonna just put a little side note in here. I work in a pediatric emergency department. It is particularly challenging for me when working with kids to set that down.
Let go of what's not in my control. I can do the very best with what's in my control and then if I were to go home and ruminate on the bad things I've seen done to kids, which I still do some, but if I were to allow that to take over my time at home, I would lose my mind. Compassion sounds like I care,
I want to help, I can stay. Empathic distress sounds like this is too much, I'm overwhelmed, and I need to shut down. And what we tell our clients all the time is if we get to that point, we are no good to our patients if we can't go to work and help them. So it is worth preserving our nervous system's bandwidth
by learning how to separate out, allow ourselves to have enough affective empathy to allow it to register. And certainly with your family members at home, that's where you really wanna have affective empathy with your spouse, with your kids, you really want to deeply understand their feelings, but when you're seeing dozens and dozens of patients every day, that's where it becomes too much.
Interestingly, compassion training research suggests that compassion is not just a softer word for empathy. It may actually involve a different emotional and neural pattern, which is more associated with warmth, approach, resilience, and pro-social motivation. So it's not that we're just
experiencing their feelings or thinking about their feelings, we're moved to do something to help, and it's more associated with those pro-social behaviors than with aversive distress. So we can see how compassion would be a more helpful place to be than empathic distress. Studies comparing empathy focused and compassion focused training found that compassion training was associated with neural activity in reward and affiliation related regions.
So my guess is there was some dopamine involved there, such as the ventral striatum, pregenual anterior cingulate, and medial orbital frontal cortex, and was proposed as a way to overcome empathic distress and strengthen resilience. We all know doctors are very resilient, and if you're having empathic distress, focusing on developing compassion rather than just deepening that affective empathy might be helpful.
So the goal at work is not to become colder, that's not what we're saying. It's not to become so defended that nothing touches you. That is not what we're saying. The goal is to move from distress resonance to steady compassion. I see you're suffering and I'm moved to help you. And there are practical ways to do that.
One is to remind yourself my job is to understand and respond, not to absorb and carry. Another is to strengthen self-other distinction, this is theirs. I am with them. I'm not merged with them. That's going back to especially those of us who grew up in family systems where other people's emotions felt dangerous and we tried to manage them.
That was emotional fusion, and so it is our work now as adults to see where we're emotionally fused. A lot of us get emotionally fused with our children and we don't feel okay unless they're okay. If they're in distress, we can't get ourselves out of distress, and that is actually not healthy.
It's shocking, I know. It is more healthy for us to be in a place where I can witness this without becoming it. Another way is to use your body intentionally. Notice where you're feeling the things in your body. Drop your shoulders. Feel your feet. Unclench your jaw. Take a slower exhale before you go in the next room.
Sometimes washing your hands and really being mindful about the feeling of the soap and the cold water. Even just feeling the handle of the door under your hand. Those little things, they may seem small. They really can help our nervous system stay present and not go under. I like that because that's where empathy ties so beautifully into emotional intelligence, because emotional intelligence is not just being nice or being emotional, it's the ability to recognize what's happening in you,
to understand what may be happening in someone else, and then regulate yourself well enough to respond effectively. It's a tool, it's a skill, and that means empathy sits right in the middle of emotional intelligence, but it doesn't work well without the other parts. So you need self-awareness to notice what's happening in you.
You then need to be able to self-regulate so that you don't become reactive, flooded, shut down, or defensive. You need other awareness, or awareness of others, so that you can accurately read what may be happening in the other person. And then you need that relational skill so your response is what's appropriate.
It's what actually helps. Research on empathy and burnout suggests this matters in a very practical way. Cognitive empathy appears to have a particularly protective relationship with burnout outcomes including lower depersonalization and stronger personal accomplishment,
while affective empathy by itself does not show the same protective pattern. You can get swept away in all of it and lose yourself or have to mount a defense against it. So I love that because it means the answer is not to feel more intensely. We've probably all been there, maybe too much. The answer is to develop more skill, and that's something that we're particularly good at.
So we can develop more discernment, more regulation, more clarity and more ability to stay grounded while remaining connected. So we're gonna do another case scenario. So this one's Dr. Jeff. He's discussing a medication change with a patient who suddenly says, you doctors never listen. You just do whatever you want.
If Dr. Jeff has low self-awareness, he may go straight into defensiveness. If he has affective empathy without regulation, he may feel ashamed or angry or lose his footing. But if he steps back and uses emotional intelligence and his cognitive empathy, there's a different sequence. First, whoa, I can feel myself —
this body awareness — I can feel myself getting defensive. Second, I wonder what's going on. This patient may be feeling powerless or scared. Why is he saying this? Third, what I can control is how I respond. I can respond to the feeling underneath this accusation without agreeing with the accusation.
So then when he's done this, he might be able to show up and say something like, it sounds like you felt dismissed before. Tell me more. I want to slow down and make sure you understand why I'm recommending this. See how he stepped alongside instead of in confrontation with, that's empathy in action.
It's a skill. It's useful. It's not because he got engulfed. On the contrary, he stayed regulated enough to understand and respond appropriately. So here's another case scenario. Dr. Jeff is discussing a poor prognosis with a family member who keeps interrupting and asking whether another specialist can be called. A dysregulated response
might sound like, I've already explained this. A more emotionally intelligent, empathic response might sound like, hey, I can see how hard this is landing. I think you're trying to make sure nothing is being missed. Can you tell me more? That kind of response does something powerful. It helps the other person feel seen, and then it often deescalates the room without having to emotionally collapse to make that happen, or something that we see all the time, over-apologizing
for things you have nothing to do with. I'm really trying to work on that too. You might have been trained to do it by your hospital. I mean, possibly, yes, for sure, but just notice how many times you're apologizing for something that really isn't, like, an apology's not appropriate.
So this is where empathy fatigue can start to become a useful signal, because when you notice yourself feeling numb, cynical, flat, or unusually irritated by ordinary distress, it may not mean that you've stopped caring. On the contrary, it may mean that your empathic system is overloaded, and so that means you might need recovery.
You probably need some sleep or a debrief. You may need to name what is sad and unfair. It's not the same thing as swallowing it. You may need more self-compassion. I mean, so far in our coaching, I would say like there is an overwhelming amount of us that like cannot identify at all with self-compassion, but then when we do start recognizing the utility of it, it's really awkward.
We're like little baby fawns trying to be compassionate with ourselves. It's just not taught. We aren't as skilled at it as the inner critic is. So you may need better boundaries about what is yours to carry and what is not. There is a thought error, or a very common cognitive distortion, yes, of control fallacies, where there's something called internal control fallacy, meaning you feel responsible for everything. And we see this over and over in medicine where somebody's outcome
is my responsibility. The waiting room's not cleared out, that's my responsibility. There are so many things that are so outside of your control, and yet you carry it as if it's your burden. And that matters because self-compassion and compassion based approaches are increasingly discussed as ways to support helping professionals under strain, rather than having to ask them to simply keep exposing themselves to suffering with no change in stance or skill.
Like, well just keep doing what you're doing and get better while you're at it. Like this is actually a skill that we can build. How though? Well, we get more accurate about our own emotions. That's that emotional granularity which we've talked about in some previous podcasts. What does dread feel like?
What does self-compassion feel like? What is jealousy? What is that trying to tell us? Because it can be useful if you can name what it is and understand what it's trying to tell you. We start to practice perspective taking without mind reading. That's another very common thought error where we just assume we know what the other person's thinking.
How could you possibly know? You're just making it up. You are making it up based on an imaginary version of them that you think is happening. It's so crazy. You would have to ask them what they're feeling. We learned that empathy is not agreement. Acceptance is not the same thing as just signing off like it's all okay.
We build tolerance for emotion without becoming engulfed by it, and we start to ask better questions, not how do I feel this even more, but what's happening here? What might this person need? How do I stay open and steady at the same time? That is empathy in service of emotional intelligence, and honestly, that's what makes empathy sustainable.
Yeah, so maybe that's the big takeaway. Empathy is not the same as drowning. You can feel deeply, understand clearly, stay grounded, and care well, and that may be one of the most emotionally intelligent things we ever learn to do.
That's it for today's episode. Friends, if you found this conversation helpful, the best way to support us is to subscribe. So click that button now and leave us a rating and a review because it helps other physicians find the podcast and moves us up on the list, and we'd love to hear from you.
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