Empathy, distress and mindfulness

One of the main thrusts of the paper by Hadjistavropoulos, Craig, Duck, Cano, Goubert, Jackson, et al., is that pain communication can serve several functions – it can be an action where a message is sent or received; it can be an interaction where the message is sent, received and interpreted; or it can be a transaction where the messages are exchanged but something other than the messages exchanged actually occurs such as a verbal exchange that results in a contractual agreement.

Communication as action can be something like when a person groans, rates their pain as “really bad”, or goes to a clinic.  Communication as interaction can be when a person is able to communicate their distress to their partner so the partner can understand how the person is feeling.  And when that person sees a doctor, tells him or her about the pain and the doctor makes a diagnosis and then starts treatment, communication as transaction has occurred.

It’s the communication as interaction that I want to talk about today, and particularly in the case of someone in distress – because that interaction can move from simply an interaction to a transaction depending on how the communication is interpreted.  Let me explain.

A person I’ve been seeing (and don’t forget, details are modified to protect confidentiality) has low back pain.  She has completed her pain management programme but every now and then makes contact.  Yesterday I had a message given to me by our receptionist saying that Andrea had phoned, sounded really upset and could I call back as soon as possible.  This is communication as transaction – the receptionist had made a commitment to do something.

Anyway, I phoned Andrea and she did sound incredibly distressed.  Her voice wobbled and I could hear her breathing in short gasps.

“I’ve hurt my back again”, she said. “I can’t move my neck, my shoulder, and I can’t lie down, I don’t know what to do!  My doctor wants to send me to hospital. I’ve taken all the meds I’m allowed to, and they’re not working. I haven’t slept. What do I do?”

Well, to me she sounded pretty unhappy! My interpretation of her tone of voice, the panting and gasping I could hear and the words she used was that she was scared, she was struggling to maintain control, and she wanted rescuing.  This is communication as interaction.

I had a choice. I could tell her what to do. Take control of the situation and “do something” just as her doctor had.  But what would my doing so communicate to her?  Where was my belief that she had skills, she knew what to do?  And, more importantly, was this what she really wanted from our interaction?

Another option was to try to soothe her, talk her through her distress and ease her fears, to settle her down. What would my doing this communicate to her? Would it teach her that she had every right to feel upset and out of control, to fear this flare-up of pain, to avoid experiencing it?  And would I be doing this out of my concern for her, or to reduce my own distress at the rawness of her emotions?

I learned, way back in my early training, that empathy can be defined as “being able to walk an another person’s moccasins”.  Apparently this was a Native American saying to show that to really know where someone is coming from means to feel the blisters their shoes make on your feet.  Being empathic is an important part of clinical work.  But there are drawbacks – standing with another’s emotions can expose your own vulnerability, and it involves effort. It can be fatiguing.

For many clinicians, I think it’s difficult to allow someone else to feel their own feelings without wanting to “take the pain away”.  I wonder whether this is (a) what the person wants, someone to “fix the problem” and (b) teaching the person that these emotions are bad, wrong or to be feared.  And I wonder whether this response says more about the clinician’s own ability to be present with distress.

Mindfulness is about “making room for” the wide range of human emotion, in a nonjudgemental way.  Mindfulness acknowledges the presence of sadness, fear, anger, joy, desire, and allows it to pass.

My choice with Andrea was to ask her if she was prepared to sit with her feelings with me. I asked her to just breathe, to feel the flow of air in and out of her body, to feel the contact of her body on the chair, the sensation of warmth where her fingers lay on her leg, the rise and fall of her emotions as we made room for them to be present.

I asked her to be present with her pain too, to feel the sensations and to allow them to be experienced as they are instead of what she feared they represented. Because it wasn’t the actual sensations that Andrea was worried about – it was her fears that the pain wouldn’t ever go away, that she’d never be able to sleep properly again, that they’d escalate, that the pain would spread, that all the things she’d learned wouldn’t work, and she was remembering how she’d felt right back before we’d started to work on her pain management.

And together we made it through and Andrea said, with some surprise, that she felt the pain but it wasn’t bothering her as much.

Hadjistavropoulos, T., Craig, K., Duck, S., Cano, A., Goubert, L., Jackson, P., Mogil, J., Rainville, P., Sullivan, M., de C. Williams, A., Vervoort, T., & Fitzgerald, T. (2011). A biopsychosocial formulation of pain communication. Psychological Bulletin DOI: 10.1037/a0023876


  1. A beautiful post. Taking these kinds of distressed phone calls is one of the most challenging parts of what we do. Nicely handled.

  2. I really like the idea on mindfulness…making room for emotion without trying to make judgment about them. Interpretation of pain (distress) signals by observer is really important in the communication. Both underestimation and overestimation of these signals can result in more distress for patients and will interrupt the therapeutic process. Being mindful, will let us to stay safe from biased interpretation of these signals, and will let us to complete the transaction in a productive way….thanks for this nice post

  3. I am working my way backwards on your previous posts.
    As the others, this one really speaks to me. The need for the therapist to be present and witness the patient’s pain without judging, or attempting to invalidate what the patient feels is paramount. I often say when I am teaching: “if you lack the powers of empathy, or sympathy, please give up on massage and look into a career in physical therapy”. Of course this is a joke because some I have taught and worked on have gone on to be exceptional PTs. ” It’s ok! Some of my best friends are physical therapists!” 😉
    Great post, B.T.! Together, the readers of your blog can change modern medicine for the better.

    B.J. Erkan, L.M.P.

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