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Humanities: Art, Language, and Spirituality in Health Care Series Editors: Christina M. Puchalski, MD, MS, and Charles G. Sasser, MD Narrative Empathy and How Dealing with Stories Helps: Creating a Space for Empathy in Culturally Diverse Care Settings Rhonda J. Moore, PhD, and James Hallenbeck, MD Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (R.J.M.); and Division of General Internal Medicine (J.H.), Department of Medicine, Stanford School of Medicine, and the VA Palo Alto Health Care System (J.H.), Palo Alto, California, USA .We start our lives as if they were momen- tous stories, with a beginning, a middle and an appropriate end, only to find that they are mostly middles. Anatole Broyard 1 .Everything is possible again .We could retell our stories and make them better, more representative or aspirational. Or we could choose to tell different stories. The world itself has a chance. Jonathan Safran Foer 2 The universe is made of stories, not of atoms. Muriel Rukeyser 3 Empathy is essential to patient-centered care and is a crucial component of effective clinician-patient communication. 4e20 Evi- dence suggests that empathy in medical prac- tice may be on the decline. 21e29 The growing popularity of palliative care can be understood as one response to this problem. In this article, we briefly describe the importance of narrative empathy. We suggest that dealing with stories and becoming aware of the high and low con- texts of communication can aid in the develop- ment of a shared language and culturally tailored experience that can enhance the clinician-patient relationship. Narrative Empathy and Why Stories Matter Empathy has been described as the ability to share, appreciate, and understand the affective, cognitive, existential, and experiential worlds of other people. 6,7,16e18,26,27,29e32 Evolutionary, developmental, sociocultural, and neurobio- logical perspectives highlight the significance of empathy as a survival benefit for our spe- cies. 30e32 There is evidence that somatic senso- rimotor resonance in pain-processing areas between other and the self may trigger em- pathic concern and feelings of sympathy. 18 Pain serves as a warning signal. 33 This signal may constitute a “threat” to the clinician that can lead to “personal distress or even compas- sion fatigue.” 18 If a clinician does not become self-aware (i.e., self-regulation), this distress can be costly, both psycho-physiologically and cognitively, and can eventually conflict with the capacity to be of assistance to others. 18 Yet, other studies note that an active (con- scious) regulation of negative emotion (i.e., decreased empathy) also has adverse physio- logical and sociopsychological costs. 34 Active regulation of negative emotion has been shown to disrupt patterns of communication and other aspects of social exchange, increase blood pressure, and create stress for both the regulator and the interaction partner. 18,34 In the clinical context, empathy also has been Address correspondence to: Rhonda J. Moore, PhD, Division of Cancer Control and Population Sci- ences, National Cancer Institute, 6116 Executive Blvd., Suite 404, Room 4041, Bethesda, MD 20892- 7363, USA. E-mail: [email protected] Accepted for publication: March 24, 2010. Ó 2010 U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved. 0885-3924/$ - see front matter doi:10.1016/j.jpainsymman.2010.03.013 Vol. 40 No. 3 September 2010 Journal of Pain and Symptom Management 471

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Page 1: Narrative Empathy and How Dealing with Stories Helps: Creating a Space for Empathy in Culturally Diverse Care Settings

Vol. 40 No. 3 September 2010 Journal of Pain and Symptom Management 471

Humanities: Art, Language, and Spirituality in Health CareSeries Editors: Christina M. Puchalski, MD, MS, and Charles G. Sasser, MD

Narrative Empathy and How Dealingwith Stories Helps: Creating a Space forEmpathy in Culturally Diverse Care SettingsRhonda J. Moore, PhD, and James Hallenbeck, MDDivision of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland

(R.J.M.); and Division of General Internal Medicine (J.H.), Department of Medicine, Stanford School

of Medicine, and the VA Palo Alto Health Care System (J.H.), Palo Alto, California, USA

.We start our lives as if they were momen-tous stories, with a beginning, a middleand an appropriate end, only to find thatthey are mostly middles.

Anatole Broyard1

.Everything is possible again .We couldretell our stories and make them better,more representative or aspirational. Or wecould choose to tell different stories. Theworld itself has a chance.

Jonathan Safran Foer2

The universe is made of stories, not of atoms.

Muriel Rukeyser3

Empathy is essential to patient-centered careand is a crucial component of effectiveclinician-patient communication.4e20 Evi-dence suggests that empathy in medical prac-tice may be on the decline.21e29 The growingpopularity of palliative care can be understoodas one response to this problem. In this article,we briefly describe the importance of narrativeempathy. We suggest that dealing with storiesand becoming aware of the high and low con-texts of communication can aid in the develop-ment of a shared language and culturally

Address correspondence to: Rhonda J. Moore, PhD,Division of Cancer Control and Population Sci-ences, National Cancer Institute, 6116 ExecutiveBlvd., Suite 404, Room 4041, Bethesda, MD 20892-7363, USA. E-mail: [email protected]

Accepted for publication: March 24, 2010.

� 2010 U.S. Cancer Pain Relief CommitteePublished by Elsevier Inc. All rights reserved.

tailored experience that can enhance theclinician-patient relationship.

Narrative Empathy and Why StoriesMatter

Empathy has been described as the ability toshare, appreciate, and understand the affective,cognitive, existential, and experiential worlds ofother people.6,7,16e18,26,27,29e32 Evolutionary,developmental, sociocultural, and neurobio-logical perspectives highlight the significanceof empathy as a survival benefit for our spe-cies.30e32 There is evidence that somatic senso-rimotor resonance in pain-processing areasbetween other and the self may trigger em-pathic concern and feelings of sympathy.18

Pain serves as a warning signal.33 This signalmay constitute a “threat” to the clinician thatcan lead to “personal distress or even compas-sion fatigue.”18 If a clinician does not becomeself-aware (i.e., self-regulation), this distresscan be costly, both psycho-physiologically andcognitively, and can eventually conflict withthe capacity to be of assistance to others.18

Yet, other studies note that an active (con-scious) regulation of negative emotion (i.e.,decreased empathy) also has adverse physio-logical and sociopsychological costs.34 Activeregulation of negative emotion has beenshown to disrupt patterns of communicationand other aspects of social exchange, increaseblood pressure, and create stress for both theregulator and the interaction partner.18,34 Inthe clinical context, empathy also has been

0885-3924/$ - see front matterdoi:10.1016/j.jpainsymman.2010.03.013

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472 Vol. 40 No. 3 September 2010Moore and Hallenbeck

associated with other positive health benefitsand outcomes, including increased patientsatisfaction, the efficacy patient-centered treat-ment, decreased malpractice lawsuits, betteradherence and compliance to medical treat-ment, quality of care, and decreased clinicianburnout.18,26,27,34 Moreover, by positivelyinvesting in interpersonal relationships, by be-coming aware of our own and others’ emo-tions, desires, intentions, and by sharingexperiences and meaning, mutual empathyand understanding are enhanced.

Narratives are valued across all culturalgroups, as one method of promoting mutualunderstanding. Patients with chronic illnessalso experience the meaning in their livesand themselves as part of a larger life narrative,a story, which may have been disrupted or frag-mented by illness and associated pain and suf-fering.1,5,8,30,35e43 Narrative models the flow oflife, provides a social commentary, and helpsus to understand and share our lives with oth-ers.35e38,44,45 We live, survive, thrive, and die inthe context of a larger life narrative, woventogether by personal stories of caring.5,8,44,45

However, in the context of illness and pain,personal identities and story lines often be-come destabilized and may even break.46,47

Narrative is crucial to the process of recogniz-ing and integrating repressed and alienatedselves that suffer.28e30,38e43,48e55 Narrativealso can become an important tool to probe,resurrect, and forge new identities withinnew story lines, and thereby promote healing.Any new identity requires a “new” understand-ing of self, a self that arises through empathyand union with others.

Charon and others5e9 have argued that,along with scientific expertise, clinicians needto acquire narrative competence or the abilityto listen to the narrative of the patient, respond-ing to these context and culturally specific nar-ratives with empathy. Narrative empathyaddresses culture as the primary frame of refer-ence, and the needs and goals of another per-son can be communicated, ideally allowing theclinician to respond appropriately.6,7,56 In theclinical encounter, narrative empathy can occuras a result of the clinician’s effort and imagina-tive engagement with the patient’s story.1,6e8

Through an awareness of one’s own and theother’s behavior, the clinician and patient alsocan come to recognize and understand each

other’s predicament. Through this insight to-gether, they also may choose to construct newstories of healing.6,10,13,44

High and Low Context in the Culture ofBiomedicineCultural groups vary in the types of stories

they most value, and in some cases privilegeto listen to or hear when communicating.Cross-cultural misunderstandings and miscom-munication occur when people from differentgroups talk “past” each other by using very dif-ferent narrative styles, which can lead to mis-understandings and misperceptions aboutwhether empathy exists in encounters. Emerg-ing from primarily Northern European roots,biomedicine is a culture unto itself. In thecase of chronic illness, modern biomedicinehas historically tended to focus on clinical dis-tance and detached concern amidst measuredhope as an appropriate response to humansuffering.8e10,39,41,42

Detachment is Janus faced, in that it isdeemed to work by protecting the physicianfrombeing overwhelmedby the pain and suffer-ing of the patient and also by protecting the pa-tient from any potential bias that mightcontaminate otherwise objective medical deci-sions.8e10,18,39e42 Thus, in the world of biomed-icine, good decision making and quality carehas focused on objective reality and the use ofrelated technology and eschews subjective as-pects of reality and human relations.8e10

In the language of the anthropologic fieldintercultural communication, this is a low-context approach to healing.46,47,49e57 Low-context communication emphasizes just suchobjective aspects of reality and tends to be taskoriented. In contrast, high-context communica-tion focuses more on the context within whichpeople are communicating and specifically onthe relationships among and between people.So what does such a low-context approach to

medicine have to do with storytelling? In bio-medicine, stories are still told and heard bypeople who often care deeply about outcomes.However, the stories themselves lack people.There are no heroes, villains, or other actorsin this human drama. Biomedical stories em-phasize mechanistic causality. Stories of illnessare told in terms of disease processes arising

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from particular interactions of disordered phys-iologieswithin brokenbodies.49,51 Thepredom-inantmessage or “moral” of such stories is that ifwe understand where physiologic chains havebecome broken, we can fix them and rebuildthe body from the ground up. Thus, biomedicalstories fit well into the paradigm of low-contextcommunication, as first proposed by Hall.52,53

Yet, even where the biomedical framing of dis-ease is cognitively accepted, illness itself is expe-rienced as a drama, rich in symbols, feelings,and meanings, involving many characters andplot twists. As such, illnesses, especially ad-vanced or terminal illness, are inherently high-context events.40,54

Both high- and low-context approaches tounderstanding and sharing the experience ofillness are important and necessary. Problemsarise when people attempt to use these verydifferent styles as they communicate with oneanother. Paraphrasing George Bernard Shaw,too often there is only an illusion of communi-cation. By way of example, a clinician may talkwith a patient about a new illness and proposea particular treatment. The clinician may un-derstand and tell his or her story by way ofa tale of deranged physiology, and how tomake it right by the proposed treatment.Such would be a rational low-context ap-proach. The patient may hear this story andreinterpret it in terms of a more personalhigh-context communicative framing.

What are the implications of this illness onthat person’s life narrative and the interwovennarratives of loved ones? While the clinicianmay speak of causalities and probabilities, thepatient may listen and understand in termsof personal story line themes. As an example,one study of hormone replacement therapyfound that many women paid little attentionto probabilities of benefits or burdens of possi-ble therapy. Instead, what they decided to dowas based on how someone they knew haddone on the therapy. Thus, the functioningstory line for a particular patient might be,“My aunt did well (or poorly) on the drug, soI will (won’t) take the medicine.”48,54

We suggest that such problems of communi-cation are very common when clinicians en-counter patients and families in the midst ofserious illness. When communication breaksdown, often involved parties complain thatthe other side just did not “get it.” Clinicians,

especially in end-of-life situations, may com-plain that patients or families are “in denial,”although we suspect true denial is rarely a ma-jor factor. Patients and families may complainthat clinicians do not listen to them. We sus-pect that most clinicians do listen, but thatthey are often working along such differentstory lines that what is heard is poorly under-stood or deemed irrelevant. In cases of ad-vanced illness, palliative care consultants maybe brought in. Much of the good work thatconsultants do probably arises from acting ascultural and narrative brokers among protago-nists working along alien high- and low-contextstory lines.

What then of narrative empathy, in terms ofthis framing of high- and low-context commu-nication? One way to understand narrativeempathy is in terms of resonance. By way ofmetaphor, a high C note on a piano when hitwill cause other C notes to vibrate slightly be-cause of resonance. Perhaps the human equiv-alent of this is compassion. Compassion meansto suffer with and as such represents a type ofresonance. Like resonance, compassion ariseswithout will. Yet, proper tuning is required tomaximize its potential, which we may call nar-rative empathy. This process of tuning or align-ment in clinical practice can be considereda medical virtue. A good doctor or other clini-cian tunes and retunes his or her instrumentseeking alignment with the patient. It is clearthat clinician and patient may not be on thesame note. However, they need to mutuallyrecognize enough commonality of being andstory lines that empathetic resonance becomespossible.

Some may argue as to whether narrativeempathy exists as an inherent aspect of selfor whether it must be cultivated. This strikesus as a specious low-context approach. Narra-tive empathy is not a discrete measurablething. This is like asking whether a silent pi-ano resonates or not. From a high-contextperspective, narrative empathy is situatedwithin a particular cultural context, and itcannot be understood outside of relation-ships. Although we can accept that peoplevary in their individual empathetic potential,the greater issue is how to maximize reso-nance and compassion among people andhow to enhance narrative empathy, whateverpeople’s innate capabilities.

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Narrative Empathy in the High andLow Context: So Where Do We GoFrom Here?

This is where a discussion of high- and low-context communication may be of use for un-derstanding narrative empathy and whystories matter. The clinician understandingand communicating along a low-context storyline may care very deeply about the patient.This caring may arise from a real appreciationfor the negative consequences of a particularillness and the measured hope that the clini-cian’s technical skills can make things better.The patient or family member in turn maybe so preoccupied with the impact of the ill-ness on their personal story lines that theycannot appreciate what the clinician is tryingto say or the caring motivation that is drivingthe communication. The sad result may bemiscommunication, poor decision making,mutual frustration, and a failed empatheticconnection.

Narrative empathy is not just something“nice” or some laudable aspect of humangoodness. The resonance of empathy is ener-gizing and pushes participants beyond moreisolated perspectives into story lines that aremutually constructed and mutually benefi-cial.58 Narrative empathy is that mutual under-standing in the clinical context of how storiedlives overlap, experiences are shared, and life’sevents and struggles, including pain, suffering,loss, and illness, “fit” into a larger life narrative.We see this when clinicians, patients, and fam-ilies meld together common stories of caring.When done well, we recognize that there isno inherent incompatibility between low-context medical science and high-contexthuman caring. Proper use of medical scienceis just one way to contribute to the greaterhuman drama. Conversely, a lack of empathycannot be viewed simply as an issue of an indi-vidual character flaw. Lack of empathy in rela-tionships is de-energizing and alienating. Justas empathy begets empathy in an iterativefashion, so lack of empathy tends to spiralinto mistrust, anger, and hatred, further dis-tancing people from one another at a timewhen they need each other most.

So the question then becomes, “What can bedone about all this?” The above discussion sug-gests that it is nothing as simple as “making”

people more empathetic. The metaphor ofpiano resonance suggests a general approach.In tuning a piano, one must listen to one’sown instrument, relative to the reference tone.Thus, a first suggested step is cultivating self-awareness in difficult encounters that problemsmay result less because of fundamentally differ-ent beliefs or psychological barriers like denialand more from people being “out of tune,”working along very different story lines.55 Thesestory lines tend to buffer individuals and muteresonance and compassionate interactions.Having recognized this, the next two criticalsteps are self-reflection and deeper listening tothe other. Self-reflection may help the individ-ual rephrase or repackage one’s message ina manner that the other person may better un-derstand. Self-reflection and awareness alsomay allow one to engage story lines within one-self more in sync with another and bring thesetobear in the conversation. For example, if a dis-cussion about medical aspects of a disease doesnot seem to be “working,” one might switch toamore “relational” approach, workingmore ex-plicitly to build trust and respect, before comingto some decision. Consideration of the anotherperson’s story requires suspensionof purposedtrying to get one’s way in the conversationdandrequires an honest search for the “sense” withinthe other’s narrative, even if on the surface it ap-pears to be nonsense. One does not have toagree with this “sense,” but far too often, wecut ourselves off fromeven trying to understandthat there is an internal logic to others withwhom we disagree.We believe that such an approach can foster

narrative empathy, which may in turn enableparticipants to move toward better and mutu-ally constructed stories, which in turn will re-sult in better decision making and improvedhealth care outcomes.

AcknowledgmentsThe views expressed in this article do not

represent the views of or endorsement by theUnited States Government, The US Depart-ment of Health and Human Services, theNational Institutes of Health, or the VA PaloAlto Health Care System. Dr. Hallenbeck’swork is supported by the VA Palo Alto HealthCare System.

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