Empathy in case-taking

stethoscopeThis article was prompted by a discussion with a colleague regarding an old post of mine, entitled “What We Know and What We don’t Know”. Our discussion took us into the subject covered by Dr. Gary Weaver’s original post, on “The Realities of Practice”. In his article, amongst other things Gary set out a prescribing process for a busy clinic where 40-100 patients may be seen a day by splitting up case-taking between one prescriber and two or three nurses or advanced students.  The main symptoms of the case are elicited by the prescriber’s assistants.   The patient is then brought to the prescriber for further questioning, analysis and prescription. This kind of clinic is more common in India, and much less common elsewhere. Many, if not most of us work privately with patients, and I don’t know if any such volume clinics exist in the West.

The point, however, is that clear symptoms may be taken by the assistants within 20 minutes, and that deeper investigation and analysis should not take the prescriber longer than a further half an hour, often much less.

My colleague expressed the view that the method Gary describes for case-taking – which is based on the method Hahnemann describes in the Organon – does not provide a sufficiently “safe” case-taking process where the patient will feel comfortable disclosing symptoms or etiologies which may be embarrassing or too humiliating to narrate under such circumstances. He suggested that for the patient to feel “safe” within the therapeutic session, time and empathy on the part of the homoeopath is required – a suggestion which is completely valid if the objective of the session is to get the patient to open up on the deepest level possible.

The comment raised several questions for me. What makes the therapeutic session with the prescriber feel “safe”? What is the importance of “empathy” in homoeopathic prescribing? And what exactly is the objective of the therapeutic session?

To begin – as is my wont – with the last question: what is the objective of a case-taking session?

Let’s start with why the patient comes to us. He or she comes to us with a problem which is to be cured with a homoeopathic prescription. Therefore, the objective of a case-taking session is to prescribe – or to determine that the case cannot be helped with a homoeopathic prescription and a different therapeutic may be required (physical manipulation, lancing a boil etc.).

In order to prescribe, we require symptoms which we can use for prescription. So to enhance our definition of the objective of case-taking – it is to elicit prescribing signs and symptoms from the patient, whether directly from the patient, through signs exhibited by the patient and observed by the homoeopath, and through reports of those close to the patient. In fact, the whole process of case-taking may be summed up as the search for prescribing symptoms – the search for the remedy based on those symptoms comes later. During our case-taking we have to be on constant look-out for what individualizes the malady to our patient, what makes it worse, what makes it better, is it periodical, is it at a particular time of day, after a meal, before a meal, and so much more. See the Organon aphorisms 88 and 89 for Hahnemann’s examples of this process. And the element that hones and focuses case-taking? Aphorism 6 – take note of “nothing…except the changes in the health of the body and of the mind”

In view of this, the importance of etiology must be examined. Although it is important to know causation, what is even more important is to know the patient’s response to that causation, especially where something deep changed in the patient’s nature and physiology. I feel all too often that causations such as abuse – emotional, physical, sexual – have become “named diseases” in modern homoeopathic prescribing. Once a causation such as sexual abuse is known – a whole group of remedies come into play and the response of such prescribers is more “disease” oriented, and less individualized.

The same is true regarding mental symptoms such as dreams. Some prescribers will have the patients report their dreams in agonizing detail, and then proceed to an analysis of the patient and the dream which has nothing to do with prescribing symptoms. More relevant is how the patient responded to the dream, whether physically through thrashing about in bed, crying or talking in sleep, waking well or miserably, than whether the dream was about rabbits, crocodiles, or extraterrestrials. Dreams can be anxious, argumentative, about people who have died, and patients can report this quickly without obscuring the view of these and other prescribing symptoms with a full account of slain ninja turtles, bank robberies and trips to outer space.

I know that my discussion of this subject raises even more questions, and it is intended to do so. We as homoeopaths need to be very careful not to cross the line, beyond which we are no longer homoeopaths, rather psychotherapists, confessors, confidantes and other roles which will not help us find prescribing symptoms.

This brings me to the question – what is the importance of empathy in treatment?

The words “empathy” and “sympathy” are frequently bandied around without clear indication as to their meaning.  While I’m on the subject, I’d like to clarify the difference between the two, summed up very nicely in dictionary.com (bold is mine):

“What is the difference between empathy and sympathy?

Both empathy and sympathy are feelings concerning other people. Sympathy is literally ‘feeling with‘ – compassion for or commiseration with another person.

Empathy, by contrast, is literally ‘feeling into’ – the ability to project one’s personality into another person and more fully understand that person.

Sympathy derives from Latin and Greek words meaning ‘having a fellow feeling’.

The term empathy originated in psychology (translation of a German term, c. 1903) and has now come to mean the ability to imagine or project oneself into another person’s position and experience all the sensations involved in that position.

You feel empathy when you’ve “been there”, and sympathy when you haven’t. Examples: We felt sympathy for the team members who tried hard but were not appreciated. / We felt empathy for children with asthma because their parents won’t remove pets from the household.”

At the beginning of my path in this field, I almost had my ears boxed when I mentioned the importance of “empathy” to a more experienced practitioner. “With empathy, your patient is in a pit, and you say I’ll join you down there… and then who’s going to get you both out? Empathy has no place in treatment!” he yelled, and his words have resonance for me till today.

I did a search for “sympathy” in the Organon. The only form of the word that appears is where the organism acts in sympathy to an external injury (Aphorism 186), or the context of a “powerful sympathetic will” within the context of mesmerism (Aphorism 228). Searches for synonyms brought up nothing further. We can see qualities required in the homoeopath most clearly from Hahnemann’s disgust with many allopaths: The homoeopath must not be pompous, must speak in language that can be clearly understood, must listen to the patient fully, must not assume anything about the patient based on a theory…but no mention of sympathy. Definitely too long to go into here, but you get the idea.

The concept of a “safe place”, feeling “safe”, is crucial when working with people. However, the definition of that “safety” will change from role to role, and will depend greatly on whether we are offering homoeopathic treatment or psychological counseling. So where does the concept of “safety” come into homoeopathic case-taking?

The concert-goer feels “safe” as he sits down to listen to an acclaimed pianist, relaxing in the knowledge that he won’t be traumatised by cacophony and mistakes.

The “foodie” feels “safe” sitting down to a meal in his favourite restaurant, knowing that all will be prepared and served the way it should be, and that the food won’t land in his lap, or give him food poisoning.

The patient feels “safe” with a doctor when it is clear that the doctor is well trained and competent, and that the nature of her office, her questions, her responses, offer evidence of her professionalism. The patient feels he is in “safe” hands and that he can talk of his disease freely.

Ultimately, we feel safe with any kind of practitioner where they are fully professional. Merriam Webster has a definition which I like for “professional”:

(1) :  characterized by or conforming to the technical or ethical standards of a profession (2) :  exhibiting a courteous, conscientious, and generally businesslike manner in the workplace

As homoeopaths, we are practicing a medical therapeutic, and therefore – easier, perhaps for those who are MDs – professionalism means the behaviour and environment we would expect from any physician. This usually covers a degree of sympathy and courteousness, but does not as a rule extend to empathy or lengthy time slots.

If we see ourselves more as therapists and counselors, our perception of “safety” may well bring us more to issues of empathy and time, blur the lines and behaviours required during the treatment, and lead us away from the main objective of case-taking – to determine prescribing symptoms which will lead us to the best remedy for curing the patient.

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