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      The caregiver's dilemma: in search of sustainable medical empathy

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      Lancet (London, England)
      Elsevier Ltd.

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          Abstract

          In 2015, our daughter Alma was delivered by emergency caesarean section at a local children's hospital. I listened for her cries, but she was silent. The medical team, too, was eerily quiet, gripped with concern. Alma struggled to live. We learned later that during her birth she had suffered a stroke. In those first moments as a parent, I realised two things. First, I wanted to protect my daughter more than anything I'd ever wanted. Second, I had already failed. Alma was whisked to the intensive care nursery (ICN), where the staff treated us with heroic kindness. Physicians, social workers, and nurses took time to answer all our questions, welcomed our emotion, and even cried with us. Alma is thriving now, but those first weeks could have been much worse. As a research psychologist and neuroscientist, I have spent my career studying empathy—people's ability to share, understand, and care about each other's emotions. But I have never needed empathy from strangers, or received it from them, the way I did after Alma's birth. In some ways, the ICN staff members were closer to us than anyone else during our hardest moments. Their compassion helped us get through an agonising time. Our family is not alone. Once viewed as a fuzzy soft skill, empathy is now regarded as a key element in effective medical treatment. Patients of empathic, versus less empathic, physicians are generally more satisfied with their care and more likely to heed medical recommendations. Receiving empathic care also seems to improve some patients' outcomes. This does not mean empathy is easy, especially for clinicians. As my family's haze of worry cleared in Alma's early days, I began to wonder about the people caring for her. A few feet to her right and her left were other struggling babies; hovering over their incubators, other anguished families. The ICN specialises in treating very premature babies, many of whom die. If suffering were light, the ICN would be visible from space. How could these nurses and doctors witness so much pain, go home to their families, and then return the next day to do it again? For how long? And at what cost? © 2020 Rubberball/Getty Images 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. Many months after Alma's birth, these questions remained with me. I had begun work on a book, The War for Kindness, which focuses on how individuals can learn to empathise more effectively. As background research, I shadowed people in the “trenches” of empathy, including teachers, actors, police trainers, and the ICN staff. My return to the ICN was eerie. The intense emotions I had felt as a parent were gone, but many other things were familiar. The pastel-coloured flower murals and uncomfortable vinyl chairs rang bells. I recognised some staff members, but only vaguely, like they were characters from a dream. My phone remembered the unit's Wi-Fi. Just like before, the ICN nurses' and physicians' compassion shone through in all their interactions with patients and families. But this time I also realised how deeply many of them struggled. In interviews, one nurse remembered a patient she had worried about constantly, even outside of work. A physician recounted a time he had avoided delivering bad news clearly, for fear of causing further pain. Other staff members reported symptoms of anxiety and depression related to difficult cases and patient deaths. I asked one staff member how he dealt with the emotion of his job, and he responded, “I just push it down until it becomes a health problem.” These are examples of caregivers' psychological struggles, which include secondary trauma—PTSD-like symptoms associated with witnessing others' suffering—compassion fatigue—emotional numbing in the face of that suffering—and burnout—general exhaustion and loss of meaning. Research has shown that burnout, the most studied of these phenomena, is more prevalent among physicians in the USA than in the general working population. It's tempting to view trauma, fatigue, and burnout as empathy's repetitive strain injuries. In my conversations at the ICN and beyond, health-care professionals voiced this concern so often I have come to think of it as the caregiver's dilemma—the notion that chronic, full contact caring can contribute to burnout in health-care workers. Medical professionals who believe in the caregiver's dilemma might see themselves as trapped by a double bind. Do they keep connecting with their patients but wear down in the process, or preserve themselves by turning their empathy off? Whether they know it or not, some clinicians seem to make the second choice. Medical students' empathy declines sharply in their third year of training, just when they begin regular patient contact. Physicians may exhibit blunted physiological empathy, and both nurses and physicians can underestimate patients' pain and suffering. Some caregivers engage in defensive dehumanisation, whereby they reduce their distress by ignoring or denying patients' emotions. Others might derogate patients or blame them for their suffering. These strategies might protect caregivers in the short term, but can damage the therapeutic alliance, undermine clinicians' ability to treat the whole person, and leave patients feeling alienated. Yet the caregiver's dilemma is a false choice. Systemic changes, such as reducing administrative burden, efforts to foster positive learning environments, and creation of strong peer support networks, can help. So can individual-level practices such as mindfulness, counselling, and self-care. And crucially, research from psychology and neuroscience offers strategies for sustainable empathy, through which clinicians can emotionally connect with their patients without sacrificing themselves. Two insights are especially worth considering. First, empathy is more than one thing. Psychologists largely agree it is best considered an umbrella term that describes related but distinct ways people respond to others' emotions. These include emotional empathy—vicariously sharing others' feelings—cognitive empathy—inferring what others feel and why—and empathic concern, also referred to as compassion—a desire for someone else's wellbeing to improve. Although these elements of empathy are related, they can also split apart. For instance, emotional and cognitive empathy develop at different ages, are affected by different psychiatric conditions, and are supported by different systems in the brain. One distinction could be useful for medical practice. Emotional empathy—especially taking on others' distress—is a risk factor for burnout and fatigue among physicians, but empathic concern may help reduce the risk of those same negative outcomes. In other words, caregivers need not choose between their own wellbeing and empathy for their patients. If they can feel for patients and families without feeling as they do, empathy can be both connective and sustainable. This is especially useful given a second insight: empathy is a skill. People often assume that empathy is a fixed trait, baked into our genes and hard-wired into our brains. In fact, it is more like a skill. Empathic ability is partly genetic, but our experiences also shape how we empathise. Crucially, this means that through the choices we make and habits we adopt, people can purposefully grow, broaden, and fine-tune their capacity for care. Medical schools have increasingly leveraged this insight. Whereas “bedside manner” was once viewed as a quality professionals simply had or lacked, various training programmes now teach empathy in patient care. These include role playing in which trainees practise delivering bad news, perspective taking exercises through which they simulate patients' experiences, and education around the power of empathy to improve clinical outcomes. Nursing and medical students could also benefit from an additional strategy: learning to tune their empathy away from sharing others' distress and towards empathic concern. Research suggests that such tuning is possible. Some studies have examined the effects of short-term contemplative practices, such as compassion meditation, aimed at strengthening empathic concern. These practices may increase individuals' generosity and their ability to decipher what others are feeling. They may also reduce personal distress in the face of others' suffering, suggesting that they could be useful in solving the caregiver's dilemma. Compassion training classes may also help caregivers to develop greater connection with patients. A tenet of compassion training holds that rather than trying to escape suffering, we can recognise that it knits us together through shared struggle. The ICN staff saw my family's suffering; it was an honour for me to witness theirs as well, and to realise that in caring for people like us, they felt emotions not so different from our own. Medical professionals often try to withdraw their emotions from interactions with patients, so as to maintain professional distance. But we patients and family members always see someone on the other side of those conversations. If that person appears unfeeling, we imagine they do not care. They recede behind a white coat and a degree, and seem fundamentally unlike us. By sharing some of their feelings, and their concern for our feelings, caregivers can cross that divide, reach out, and turn painful moments into opportunities for fellowship, meaning, and healing together. This is all the more important now, as the COVID-19 pandemic has multiplied these painful moments. In countless tragic cases, physicians and nurses have been the only company for patients with COVID-19 as they take their final breaths. The pandemic has adversely affected mental health of some citizens and also front-line health professionals. Addressing these difficulties will require comprehensive efforts, including broadening access to psychological services and formalising social support networks within health-care settings. I also believe that efforts based on developing sustainable empathy and human connection may be another way to help if we hope to manage the pandemic's long-term psychological impact. I will forever remember the warmth with which the ICN staff treated my family in our darkest hours. My hope is that my own and others' research on empathy can reciprocate in some small way—by helping medical professionals continue to connect with patients while also maintaining their own wellbeing.

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          Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019

          Key Points Question What factors are associated with mental health outcomes among health care workers in China who are treating patients with coronavirus disease 2019 (COVID-19)? Findings In this cross-sectional study of 1257 health care workers in 34 hospitals equipped with fever clinics or wards for patients with COVID-19 in multiple regions of China, a considerable proportion of health care workers reported experiencing symptoms of depression, anxiety, insomnia, and distress, especially women, nurses, those in Wuhan, and front-line health care workers directly engaged in diagnosing, treating, or providing nursing care to patients with suspected or confirmed COVID-19. Meaning These findings suggest that, among Chinese health care workers exposed to COVID-19, women, nurses, those in Wuhan, and front-line health care workers have a high risk of developing unfavorable mental health outcomes and may need psychological support or interventions.
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            Empathy in Clinical Practice: How Individual Dispositions, Gender, and Experience Moderate Empathic Concern, Burnout, and Emotional Distress in Physicians

            To better understand clinical empathy and what factors can undermine its experience and outcome in care-giving settings, a large-scale study was conducted with 7,584 board certified practicing physicians. Online validated instruments assessing different aspects of empathy, distress, burnout, altruistic behavior, emotional awareness, and well-being were used. Compassion satisfaction was strongly associated with empathic concern, perspective taking and altruism, while compassion fatigue (burnout and secondary traumatic stress) was more closely related to personal distress and alexithymia. Gender had a highly selective effect on empathic concern, with women displaying higher values, which led to a wide array of negative and devalued feelings. Years of experience did not influence dispositional measures per se after controlling for the effect of age and gender. Participants who experienced compassion fatigue with little to no compassion satisfaction showed the highest scores on personal distress and alexithymia as well as the strongest indicators of compassion fatigue. Physicians who have difficulty regulating their negative arousal and describing and identifying emotions seem to be more prone to emotional exhaustion, detachment, and a low sense of accomplishment. On the contrary, the ability to engage in self-other awareness and regulate one’s emotions and the tendency to help others, seem to contribute to the sense of compassion that comes from assisting patients in clinical practice.
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              Addressing the public mental health challenge of COVID-19

              The rapid global spread of COVID-19 is having wide-ranging effects on population mental health, which are even greater for particular groups of individuals, including those with pre-existing mental disorder.1, 2 Furthermore, increased COVID-19 infection and mortality would be predicted in individuals with a mental disorder, 1 given that their life expectancy is reduced by 7–25 years, mainly because of higher prevalence of physical ill health when compared with those who do not have a mental disorder. 3 The COVID-19 pandemic presents a triple global public mental health challenge: (1) to prevent an associated increase in mental disorders and a reduction in mental wellbeing across populations; (2) to protect people with a mental disorder from COVID-19, and the associated consequences, given their increased vulnerability; and (3) to provide appropriate public mental health interventions to health professionals and carers. This challenge is compounded by the inadequate population coverage of evidence-based public mental health interventions before COVID-19, even in high-income countries.3, 4 Since the start of the COVID-19 pandemic, the provision of some of these mental health interventions has become more limited by quarantine and lockdown measures. Interventions to prevent, treat, and mitigate the effects of COVID-19 are likely to adversely affect mental health, 5 particularly in those with or at a higher risk of mental disorder.1, 3 However, a key opportunity exists to mitigate this challenge through early action to increase coverage of public mental health interventions. Before COVID-19, 20% of the global disease burden was attributable to mental disorder. 6 Factors contributing to the size of this burden include the high prevalence of mental disorders, most lifetime mental disorders arising before adulthood, and their broad effects on health, education, employment, social interaction, violence, and crime. 3 Evidence suggests that pandemics, including COVID-19, are associated with an increased risk of developing mental disorder and poor mental wellbeing.1, 2 This increase in risk is likely to be mediated by the effects of the pandemic on risk factors, including socioeconomic inequalities, poverty, debt, unemployment,1, 2, 7 food insecurity, social factors, 2 quarantine, 5 physical distancing, and physical inactivity, all of which would also be expected to increase the risk of relapse in individuals with a mental disorder.1, 2, 8 Groups that are likely to experience disproportionate mental health effects from COVID-19 include those with a mental disorder, health professionals and carers, offenders, refugees, and older people, including those in care homes. 8 Public mental health interventions (panel ) are therefore even more important during pandemics to prevent the anticipated higher prevalence of mental disorders, the associated consequences, and poor mental wellbeing.1, 3 Delivery of public mental health interventions occurs at individual, community, and national levels, with groups at a higher risk than the general population requiring more targeted approaches to prevent widening of inequalities. Panel Public mental health interventions3 Public mental health interventions can be divided into mental disorder prevention and mental wellbeing promotion. Such interventions need to be proportionately targeted to groups at a higher risk of mental disorder and poor mental wellbeing than the general population. Mental disorder prevention Mental disorder prevention can occur at primary, secondary, or tertiary levels. Primary prevention Addresses risk factors exacerbated by COVID-19, including socioeconomic inequalities, poverty, debt, unemployment,2, 7 food insecurity, parental mental disorder, child adversity, stress at work (including in health professionals), physical ill health, physical inactivity, and social isolation (including from quarantine 5 ). Secondary prevention Early intervention for mental disorders and their associated effects, including those related to COVID-19. Tertiary prevention Intervention for individuals with an established mental disorder to prevent the associated consequences and disability through treatment, patient education, and addressing health-risk behaviour, physical illness (including from COVID-19), socioeconomic issues, social isolation, stigma, and discrimination. Mental wellbeing promotion Promotion involves first increasing the value that individuals and societies give to mental health and wellbeing, and then implementing interventions to enhance mental wellbeing in different situations. Interventions to enhance mental wellbeing can occur across the life course. Starting well Promotion of parental physical and mental health, infant attachment, and parenting programmes (including digital programmes). Developing well Preschool-based and school-based programmes to promote mental wellbeing, development, and physical health (including through digital programmes). Living well Promotion of social interaction, physical activity, care for physical health, access to green space, arts, culture, creativity, and mindfulness. Working well Promotion of healthy working conditions including through flexible working, training, and online psychological approaches. Ageing well Living well interventions (above), psychosocial interventions, and addressing sensory deficits, such as poor hearing or eyesight. Despite the existence of effective public mental health interventions, implementation is poor.3, 4 Globally, only a minority of individuals with a mental disorder receive any treatment, and coverage of interventions that prevent the associated effects is even poorer, while coverage of interventions to prevent mental disorder or promote mental wellbeing is negligible. This implementation failure contravenes the right to health and leads to preventable suffering at a population level, with the associated effects and economic costs amplified during crises, such as COVID-19. Public mental health practice, including during COVID-19, is a key mechanism to reduce the implementation gap and address this challenge in both the short term and longer term.1, 3 The first step involves assessing the size, impact, and cost of current and anticipated unmet need for public mental health interventions, taking into account the effects of COVID-19. This approach includes identifying appropriate public mental health interventions, and is supported by estimating the impact and associated economic benefits from improved coverage of these interventions. 9 These steps are first required at a national level to inform both policy and transparent decisions about acceptable coverage of different interventions. This process in turn informs the extent of coverage, required resource, commissioning, and coordination between providers of different interventions. Subsequent steps involve appropriate operationalisation to support implementation of the agreed public mental health interventions, followed by evaluation of coverage and outcomes, including for high-risk groups. Appropriate communication to the general population, and health and allied professionals supports the implementation of these interventions, improves awareness and understanding, and reduces distress associated with uncertainty. Population access to public mental health interventions, including during pandemics, can be improved in several ways.1, 3 Training of health and allied professionals improves knowledge about public mental health and COVID-19, while improving population knowledge about mental health, in general and in relation to COVID-19, is important. Digital technology can deliver public mental health interventions, 3 support the mental health of carers and health professionals, reduce social isolation, deliver public mental health training, 10 and facilitate contact tracing. However, risks of excessive screen time need to be mitigated, 3 while also considering the needs of those without such technology. Setting and group approaches enable public mental health interventions to be implemented in large sections of a population, such as schools and workplaces, including through digital means during lockdown or quarantine. Existing resources can be maximised through self-help and the shifting of tasks (eg, treatment) to less trained individuals. The application of relevant legislation can be a major support to the implementation of public mental health measures. In order to prevent the anticipated effects of COVID 19 on population mental health, there is an urgent need for population-scale implementation of effective public mental health interventions, supported by public mental health practice and innovation. Implementing these interventions will mitigate the impact of the pandemic on mental health, improve population wellbeing, prevent mental disorders from arising, and reduce relapse of mental disorders, with associated economic returns, even in the short term. Public mental health practice should be an integral part of the response to COVID-19, and will have immediate positive effects and a legacy likely to long outlast the pandemic.
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                Author and article information

                Contributors
                Journal
                Lancet
                Lancet
                Lancet (London, England)
                Elsevier Ltd.
                0140-6736
                1474-547X
                13 August 2020
                15-21 August 2020
                13 August 2020
                : 396
                : 10249
                : 458-459
                Affiliations
                [a ]Department of Psychology, Stanford University, Stanford, CA 94305, USA
                Article
                S0140-6736(20)31685-8
                10.1016/S0140-6736(20)31685-8
                7426106
                32798479
                52d4cc57-244d-44aa-a86b-5b881c31d423
                © 2020 Elsevier Ltd. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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