Richard A. Friedman
“Can I ask you a question?” the young woman ventured. “Have you ever been depressed? Do you have any idea how bad it feels?”
The patient, a married woman in her late 20s, had been tearfully describing her symptoms of depression during a consultation when she suddenly popped this question.
How could I possibly understand or help her, she seemed to be asking, if I had not personally experienced her pain?
Her question caught me by surprise and made me pause. O.K., I’ll admit it. I’m a cheerful guy who’s never really tasted clinical depression. But along the way I think I’ve successfully treated many severely depressed patients.
Is shared experience really necessary for a physician to understand or treat a patient? I wonder. After all, who would argue that a cardiologist would be more competent if he had had his own heart attack, or an oncologist more effective if he had had a brush with cancer?
Of course, a patient might feel more comfortable with a physician who has had personal experience with his medical illness, but that alone wouldn’t guarantee understanding, much less good treatment.
Still, many patients want their doctor to be someone with whom they can identify, not just a technically competent professional who can alleviate their pain.
As a psychiatrist, I’ve met many patients who have made requests for a specific type of therapist: African-Americans who want a black psychiatrist, Orthodox Jews who insist on a Jewish psychotherapist, women who ask for a feminist therapist and so on.
Not long ago, a gay man in his 30s called me to ask for a referral to a gay therapist. He was adamant about seeing only a gay clinician. “I can’t take the chance of getting a homophobic shrink,” he said.
His assumption was that if a therapist shared his sexual orientation or ethnic group, there would be a kind of guaranteed basis for understanding or acceptance.
I did, in fact, refer him to an excellent colleague who happens to be gay, but the brief conversation left me troubled. All these patients who were searching for understanding had a misconception, I think, of what empathy is all about.
What is critical to understanding someone is not necessarily having had his or her experience; it is being able to imagine what it would be like to have it. Thus, I do not have to be black to empathize with the toxic effects of racial prejudice, or be a woman to know how I would feel about being denied promotion on the basis of sex.
Contrary to what many people believe, being empathic is not the same thing as being nice. In fact, empathy can sometimes be put to a very dark purpose.
When the Nazis were bombing Rotterdam in World War II, for example, they put sirens on the Stuka dive-bombers knowing full well that the sound would terrify and disorganize the Dutch. The Nazis imagined perfectly how the Dutch would feel and react. Fiendish, but the very essence of empathy.
In the right hands, empathy has tremendous positive therapeutic force and can narrow what looks like an unbridgeable gap between patients and therapists.
A few years back, I saw an elderly woman who had just lost her husband to cancer. “Oh, I hadn’t realized you were so young!” she exclaimed. “No offense, but maybe I need to see someone who’s a bit older.”
I asked her, “Are you worried that I can’t know what it feels like to lose someone you love and face life without him?”
True, I had never lost a partner, but it wasn’t hard to imagine her grief and anxiety about her future. That must have done the trick, because she stayed in treatment and never again mentioned my age.
Sometimes, though, patients should get exactly what they ask for in a therapist. One of my residents once saw a young woman from Africa who had survived hideous torture and rape and said that she didn’t think she could see a male therapist.
That struck me as entirely appropriate. Given her trauma, she simply could not have put her trust in a male therapist, no matter how empathic he might actually be.
What about patients whose demand for a particular therapist springs from nothing more than everyday prejudice? I remember a patient who once stormed into my office and demanded a white therapist to replace his therapist, who was black.
That’s a request I turned down, even knowing that this patient’s biased beliefs were an appropriate target for treatment. To do otherwise would have vindicated his prejudice and fundamentally compromised the therapy from the start.
In the end, empathy is what makes it possible for us to read each other. And it is the reason your doctor can understand your problem without actually having to live it.
Richard A. Friedman is director of the psychopharmacology clinic at the Weill Medical College of Cornell University.
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