empathy healthcare essay

Empathy in Healthcare: Putting Care Back into the System

More compassion, less judgmentalism, will help both doctors and patients..

Posted January 31, 2023 | Reviewed by Hara Estroff Marano

• The Importance of Empathy
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• Listening to patient concerns can create opportunity for open dialogue in the healthcare setting.
• Putting yourself in your patients' shoes can allow for understanding and empathy.
• Being open-minded, patient, and understanding to patients' concerns can build trust over time.
• Compassion is warranted for patients' healthcare concerns, not judgment.

In today's fast-paced world, healthcare providers are often under immense pressure to diagnose and treat patients quickly and efficiently. However, in their quest for efficiency, it is all too easy for them to lose sight of the fact that their patients are human beings with emotions, fears, and concerns. This is where empathy comes in. Empathy is the ability to understand and share the feelings of another person. It is a vital component of patient-centered care and one that is often overlooked in today's healthcare system.

The lack of empathy in healthcare has become a growing issue, particularly in cases where healthcare concerns are ignored or mothers are threatened in medical settings. A recent study, entitled "Giving Voice to Mothers," reviewed the inequities and mistreatment of mothers in medical decision-making . Out of the 2,700 participants surveyed, one in six women reported experiencing one or more forms of mistreatment, including being ignored, refused, shouted at, scolded, or threatened by their healthcare provider. The rates of mistreatment of women of color were consistently higher, at 27.2%, compared to 18.7% of their white counterparts.

Providers may bully patients into compliance by threatening to call child protective services, as seen in cases of mothers who hesitate or disagree with treatment protocols for their children. They may suggest the parents are neglectful without evidence.

Such actions go against the ethical guidelines set by the American College of Obstetrics and Gynecology, which condemns the use of legal threats to coerce patients into treatment. The study highlights the need for increased empathy in healthcare to ensure that mothers receive respectful, informed, and dignified care.

This type of behavior goes against the very principles of patient-centered care. It is important to remember that patients are not just bodies that need to be treated; they are individuals with their own unique experiences and perspectives. By showing empathy, healthcare providers can create a more positive and supportive environment that not only improves patient outcomes but also reduces the risk of burnout among healthcare professionals.

So, how can healthcare providers put care back into the system by incorporating empathy into their practice? Here are some tips:

Listen to patients' concerns and feelings One of the simplest and most effective ways to show empathy is to listen to what patients are saying. Give them your full attention and try to understand their perspective. This can help to build trust and create a more positive relationship between the patient and the healthcare provider.

Put yourself in the patient's shoes. Another way to show empathy is to try and imagine what it would be like to be in the patient's situation. This can help you to understand their feelings and concerns and respond in a way that is more supportive and understanding.

Be patient and nonjudgmental. Patients who are already worried or anxious about their health will likely be even more so in the face of a healthcare provider who seems impatient or judgmental. By being patient and nonjudgmental, healthcare providers can create a more positive and supportive environment for their patients.

Show compassion. Compassion is an important aspect of empathy, and it is often the missing ingredient in many healthcare interactions. Showing compassion can be as simple as smiling, making eye contact, or offering a comforting touch.

Encourage open communication. Open communication is key to building a positive relationship with patients. Encourage patients to ask questions and express their concerns. This not only shows that you are listening but also helps to build trust and improve patient outcomes.

By incorporating empathy into their practice, healthcare providers can put care back into the system and create a more positive and supportive environment for patients. Not only does this help to improve patient outcomes, but it also reduces the risk of burnout among healthcare professionals.

Remember, patients are individuals with their own unique experiences and perspectives, and it is our job as healthcare providers to show them the empathy and compassion that they deserve. By doing so, we can help to build trust and create a more positive and supportive environment for both our patients and ourselves.

DiBlasio, A., & Barazandeh, M. (2010). The importance of empathy in patient-physician relationships. The Journal of Family Practice, 59(2), 84-89.

Epstein, R. M. (1999). Mindful practice in medicine. The Journal of the American Medical Association, 282(9), 833-839.

Firth-Cozens, J. (1997). Empathy in general practice consultations: A research review. British Journal of General Practice, 47(420), 723-727.

Hojat, M., & Gonnella, J. S. (2015). The impact of empathy in medical care: A systematic review. PloS one, 10(3), e0122171.

Richardson, A. (2018, November 20). The use of Child Protective Services and court orders to enforce medical compliance in the labor and Delivery Room: How Threats of Legal Action Limit Reproductive Choice . Harvard Journal of Law & Gender. Retrieved January 30, 2023, from https://harvardjlg.com/2018/11/the-use-of-child-protective-services-and…

Vedam, S., Stoll, K., Taiwo, T. K., Rubashkin, N., Cheyney, M., Strauss, N., McLemore, M., Cadena, M., Nethery, E., Rushton, E., Schummers, L., & Declercq, E. (2019, June 11). The giving voice to mothers study: Inequity and mistreatment during pregnancy and childbirth in the United States - Reproductive Health . BioMed Central. Retrieved January 30, 2023, from https://reproductive-health-journal.biomedcentral.com/articles/10.1186/…

Erica Steele, DNM, ND, a naturopathic doctor in family practice, is trained in holistic medicine, functional medicine, integrative medicine, and homeopathy, and helps people heal all over the world.

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Teaching Empathy in Healthcare

Building a New Core Competency

• © 2019
• Adriana E. Foster 0 ,
• Zimri S. Yaseen 1

Department of Psychiatry and Behavioral Health, Herbert Wertheim College of Medicine, Florida International University, Miami, USA

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Department of Psychiatry and Behavioral Health, Icahn School of Medicine, Mount Sinai Beth Israel, New York, USA

• Draws on a wide range of contributors across many disciplines
• Appeals to a broad readership of clinicians, educators, and researchers in clinical medicine, neuroscience, behavioral health, and the social sciences
• Takes an evidence-based, longitudinal approach to clinical empathy
• Explores empathy in the clinical context from three perspectives: understanding what empathy is (and how it can be measured), approaches to empathy education, and the systemic perspective, focusing on issues such as equity, stigma, and law.

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About this book

Perspectives among the interdisciplinary chapters include:

• Neurobiology of empathy   
• Measuring empathy in healthcare   
• Teaching clinicians about affect   
• Teaching cultural humility: Understanding the core of others by reflecting on ours   
• Empathy and implicit bias: Can empathy training improve equity?   

Teaching Empathy in Healthcare: Building a New Core Competency  takes an innovative and comprehensive approach towards a developed understanding of empathy in the clinical context. This evidence-based book is set to become a classic text on the topic ofempathy in healthcare settings, and will appeal to a broad readership of clinicians, educators, and researchers in clinical medicine, neuroscience, behavioral health, and the social sciences, leaders in educational and professional organizations, and anyone interested in the healthcare services they utilize.

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• cultural humanity
• dehumanization
• facial affective behavior
• mirror neurons
• non-verbal behavior
• patient-clinician communication
• self-awareness
• virtual humans
• medical education
• therapeutic alliance
• working alliance

Table of contents (18 chapters)

Front matter, what is empathy and how can it be evaluated, what is empathy.

• Zimri S. Yaseen, Adriana E. Foster

Neurobiology of Empathy

• Michelle Trieu, Adriana E. Foster, Zimri S. Yaseen, Courtnie Beaubian, Raffaella Calati

The Physiological Nature of Caring: Understanding Nonverbal Behavior

• Anjelica J. Halim, Adriana E. Foster, Laura Ayala, Erica D. Musser

Measuring Empathy in Health Care

• Gabriel Sanchez, Melissa Ward Peterson, Erica D. Musser, Igor Galynker, Simran Sandhu, Adriana E. Foster

Approaches to Empathy Education

Teaching clinicians about affect.

• Tamara Zec, David Forrest

Teaching Emotional Self-Awareness and What to Do with It in Patient Encounters

• Zimri S. Yaseen, Sarah Bloch-Elkouby, Shira Barzilay

Getting on the Same Page: Introducing Alliance Rupture as a Path to Mutual Empathy and Change in Psychotherapy

• Lauren M. Lipner, Di Liu, J. Christopher Muran

The Empathy Seminar: Building a Strong Foundation for Caregiving Competency

• James W. Lomax, Adriana E. Foster

Can Virtual Humans Teach Empathy?

• Benjamin Lok, Adriana E. Foster

Developing Empathy Through Narrative Medicine

• Gregory Schneider, Marin Gillis, Heidi von Harscher

Teaching Cultural Humility: Understanding Others by Reflecting on Ourselves

• Carissa Cabán-Alemán, Jordanne King, Auralyd Padilla, Jeanie Tse

Coaching Nurses to Care: Empathetic Communication in Challenging Situations

• Jean Hannan, Mark Fonseca, Edgar Garcia Lara, Mercedes Braithwaite, Faith Irving, Elizabeth Azutillo

Teaching Advanced Communication Skills to Trainees Caring for the Critically Injured

• Sangeeta Lamba, Anastasia Kunac, Anne Mosenthal

Empathy: A Systemic Perspective

Empathy and implicit bias: can empathy training improve equity.

• Javeed Sukhera

Empathy, Burnout, and the Hidden Curriculum in Medical Training

• Rabia Khan, Maria Athina (Tina) Martimianakis

Thwarting Stigma and Dehumanization Through Empathy

• Aniuska M. Luna, Emily Jurich, Francisco Quintana

Editors and Affiliations

Adriana E. Foster

Zimri S. Yaseen

About the editors

Adriana Foster, MD is a practicing psychiatrist, educator and researcher. Foster’s clinical experience includes inpatient, outpatient and emergency psychiatry settings. Foster has been actively teaching clinical medicine and psychiatric curriculum for the past 17 years. Foster led a Veterans Affairs clinical program and was a psychiatry clerkship director for a large medical school. Currently, Dr Foster is the Vice-Chair for Clinical and Research programs in the Department of Psychiatry and Behavioral Health at Herbert Wertheim College of Medicine, Florida International University, in Miami, Florida. Foster’s educational research focuses on simulation in medical education and exploring the utility of virtual patients in teaching empathy in medical interview. Foster co-led a group of educators at the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) who created a free online collection of peer-reviewed mental health educational tools. Foster has longcollaborated with Virtual Experiences Research Group at University of Florida’s Computer Information Science and Engineering. Foster published numerous peer-reviewed papers and educational tools, which are available for widespread use on platforms like ADMSEP’s website and AAMC’s MedEdPORTAL.

Zimri Yaseen, MD is a practicing psychiatrist, educator and researcher. His clinical experience includes inpatient, emergency, and outpatient psychiatry. He has been actively teaching clinical psychiatry, psychotherapy, and the integration of psychodynamic approaches with psychopharmacology for the past 6 years. He is assistant director at the Family Center for Bipolar Disorder, and an active collaborator and psychotherapy supervisor with the Brief Relational Therapy research project at Mount Sinai Beth Israel. Dr. Yaseen’s clinical research experience includes that of co-investigator on foundation-sponsored studies on suicide and adult attachment. Dr. Yaseen has publishednumerous peer-reviewed papers on these topics.

Bibliographic Information

Book Title : Teaching Empathy in Healthcare

Book Subtitle : Building a New Core Competency

Editors : Adriana E. Foster, Zimri S. Yaseen

DOI : https://doi.org/10.1007/978-3-030-29876-0

Publisher : Springer Cham

eBook Packages : Behavioral Science and Psychology , Behavioral Science and Psychology (R0)

Copyright Information : Springer Nature Switzerland AG 2019

Hardcover ISBN : 978-3-030-29875-3 Published: 28 November 2019

Softcover ISBN : 978-3-030-29878-4 Published: 28 November 2020

eBook ISBN : 978-3-030-29876-0 Published: 18 November 2019

Edition Number : 1

Number of Pages : XV, 307

Number of Illustrations : 4 b/w illustrations, 13 illustrations in colour

Topics : Health Psychology , Counselling and Interpersonal Skills

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How to Overcome Barriers to Empathy in Health Care

The field of medicine is facing a dilemma when it comes to empathy. On one hand, research has found that receiving empathy from caregivers—feeling understood and accepted—is critical for patient satisfaction , a key aspect of hospital reimbursement . On the other hand, over 60 percent of health care providers are experiencing burnout across professions, making now a harder time than ever to prioritize additional training.


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Will our health care system be able to embrace empathy as a core value going forward?

I recently spent an evening in front of a live audience in conversation with author, doctor, and empathy researcher Helen Riess to discuss her new book, The Empathy Effect . Riess—who has been a mentor and friend to me over several years—is an assistant professor of medicine and the director of the Empathy and Relational Science Program at Harvard Medical School and founder and chief scientific officer at Empathetics, which offers empathy training across industries. Her research suggests that empathy is a skill that can be taught—not something we just have or we don’t—and further research has found that empathic doctors have patients with greater adherence to medications, improved trust (fewer malpractice suits), and even reduced symptoms.

How can health care providers learn skills to help others with an open heart when they already feel overworked, emotionally depleted, and cynical? In our conversation below, Riess and I address this difficult question, as well as other barriers to empathy, and explore how empathy can promote more meaningful work and greater compassion.

Eve Ekman: I want to start with a simple question: Why did you write this book and why now?

Helen Riess: This topic has been very near and dear to me throughout my psychiatry training, and then it has become more and more critical as I’ve worked in the health care world, where I have seen a dramatic drop in empathy. Through my own clinical practice, I have heard many patients complain bitterly about a lack of empathy. They describe how little contact they actually have with their caregivers and how they’re treated like a number. Medical care has become so focused on getting people in and out of doctor’s offices that they are missing out on the true healing in a relationship that is so vital.

I started this book for the medical profession, but in my empathy training work, I get calls from every industry—from the law, to parenting, to business, and leadership. I’m confident that if everybody were given a choice, they would prefer a more empathic interaction than a less empathic interaction, and yet it’s still such an obstacle. We need training.

EE: I often hear people concerned that if they increase their empathy, they will be overwhelmed: “The world is so painful and stressful; how am I going to manage all of that?” What are your thoughts on the relationship between burnout and empathy?

HR: As you said, some people think that if they open their hearts to too many more people, they’re just going to be flooded with everyone’s burdens, and they’re going to be crushed by the needs and the emotional weight of connecting. Actually, I think that’s absolutely a risk, but I also think that the secret is learning self-regulation skills, such as meditating, learning how to name and identify emotions, how to manage them, and self-care.

Self-care practices are needed to simply “fill the tank.” I think what contributes to burnout is when the tank is empty and we don’t take time to fill it with what truly nourishes and soothes us. We keep trying to be a certain way (like compassionate) when we haven’t filled ourselves up adequately for the task. So I think empathy and self-care are really intricately interdependent.

Empathy can make us burn out if we don’t tend to ourselves, but empathy can also actually enliven and invigorate us. One author in the Journal of the American Medical Association , Michael Kearney, wrote about the concept of “exquisite empathy.” He used that phrase to refer to that magical moment when a person feels thoroughly cared about; it enlivens and quickens the relationship not just for the patient but also for the caregiver.

EE: There is a provocative viral video making the rounds among health care professionals suggesting that burnout is the wrong term and we should call it moral injury—the result of being asked to work in an environment that is toxic and untenable. Beyond not filling our own tanks, are there more systemic causes of burnout, whether it’s in a hospital or a company?

HR: Burnout is an interesting word, because I think it implies to the burned-out person that it’s their fault—that they’re not resilient, not tough, or that they’re weak. Statistics in the last ten years show that up to 60 percent of physicians are showing symptoms of burnout, with equal numbers of nurses. It can’t be that all of a sudden 60 percent of the workforce is unable to cope. Something’s happening within the whole system of health care. The disconnection in these systems is that the people making decisions about how medicine is practiced are not the ones in the frontlines.

Leaders who have never been doctors or nurses view health care as a business. In the last few decades, there’s been this “lean six sigma” approach to health care that has nearly dropped the humanity out of it and brought in the spirit of a Toyota factory, where you try to make the parts as cheaply as possible and get the workers to work as quickly as possible. We have kind of lost the magic of what a health care profession can offer. It really is the system that’s burning people out; it’s not that people have become somehow weak.

I think it’s a real challenge to figure out how health care workers can approach their leadership teams and help them to recognize that the organizations they lead are not going to get the outcomes that they want—which are happy, satisfied, and well-cared-for patients—if the providers working with them are emotionally and physically exhausted and deriving very little pleasure from their work. 
 EE: What other challenges do health care providers face when trying to be empathic?

HR: I developed some training around how we maintain empathy even in the most challenging situations. It’s very easy to have empathy if a patient is nice and grateful. However, one example of a challenge is if patients are not so happy with whatever you prescribe—maybe it’s not working and they’re still having symptoms, and they’re calling you frequently because nothing is quite satisfying—that can become challenging merely because it can make physicians and caregivers feel helpless. And when they feel helpless, they don’t like that feeling. They may decide they don’t really like the patient that much and empathy is challenged.

What we were trying to do is help health caregivers see the vulnerability that the patient is feeling, and not dismiss them because they’re having an emotion, but actually figure out what’s going on so we help them with their specific needs. These skills also help with parenting and other important relationships. I wish I had known some of these empathy skills when I was raising my children. I’ve learned a lot along the way.

EE: One of the emotions that gets in the way of these beautiful reflections is a feeling of fear, like when we want to give money or a meal to a person living on the street who’s clearly in need, but feel fearful to engage because they appear mentally ill. How can we work with fear, when we feel threatened personally but actually want empathy to arise?

HR: Empathy is the antidote to fear. When we live in a state of fear, we close off our heart defensively, whereas empathy opens our hearts. As a society, we are living in a state of massive fear exaggeration right now, and it is really closing a lot of hearts and minds. We are all wired to recognize threats, and we recognize threats much more quickly than we recognize gratitude and opportunity. A large percentage of what we perceive as threatening we’re actually projecting out onto others.

So much of the tone that’s been set in medicine has been about rushing into getting the most out of everybody and acting as if there is such a scarcity in everything, which is a kind of fear. I think one of the biggest myths is to have everyone feel as if there’s just “not enough.” If we just flipped that around and said, “There’s enough for everyone,” I think we could ease up on everything. That abundance has to come from our leaders, but also from within.

I would love to see everyone in a leadership position learn about the value of valuing the people who work with you. To recognize that the more you invest in the people, the more you’re going to get out of your bottom line—and the more you use people and treat them like objects and want them to be a cog in the wheel, the more impoverished your organization is going to be. This applies to health care leaders, business leaders, and deans and presidents of all kinds of institutions of education.

EE: How do we train empathy in a way that leads to showing compassion and actually taking action to relieve suffering?

HR: Opening our perceptions of what’s going on in other people typically leads to empathic concern, but the concern doesn’t always lead to action. That transition to compassion has to come from a more reflective life, where you don’t just pass by a homeless person and think, “Oh, I should help,” but never do. We can reflect on the abundance we live with, about humanity as a brotherhood, and the possibility of joining with other people in the journey to have a more compassionate society. The fact that things aren’t this way can embolden us to do more.

EE: In your book, I was really struck by your sharing of your painful personal experiences and how that made you more open to empathy. If people got in touch with their own struggles, would this help them be more present, open, and caring to others?

HR: We know that when people have struggled, they’re much more able to relate to people who have similar struggles. Let’s work toward the end of our conversation with a quote by Carl Jung, who said that “the sole purpose of life is to kindle the light in the darkness of mere being.” And when you think about empathy, I think of it as a light that we’re able to put forth into the world. That just puts a little light into someone’s experience. It doesn’t have to be a heavy lift; it could be a kind word or a knowing look or a nice smile at somebody. But if we think that the sole purpose of life is to kindle the light in the darkness of mere being, there is a lot of darkness in life. We all can make the life of others lighter.

About the Author

Eve Ekman, Ph.D., MSW , is a GGSC Senior Fellow. An experienced speaker, researcher, and group facilitator, she brings a unique background ideally suited to training individuals and organizations in the science of happiness, resilience, compassion, mindfulness, and emotional awareness.

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Knowledge at Wharton Podcast

Why empathy in health care matters, may 23, 2023 •.

A new study co-authored by Wharton’s Ingrid Nembhard finds that patients who are treated with empathy have better health outcomes. She explains why empathy in health care delivery should become standard.

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Patients who are treated with empathy by their doctors and other clinicians have better health care outcomes, according to a new study from Wharton health care management professors Ingrid Nembhard and Guy David . The paper is titled “A Systematic Review of Empathy in Health Care,” and it appears in the journal Health Services Research . The co-authors are Wharton undergraduate student Iman Ezzeddine, and David Betts and Jennifer Radin, both of Deloitte Consulting.

Nembhard spoke to Knowledge at Wharton about the study, which concludes with a call for more organizational-level interventions to ensure empathy for all patients, systematically.

How Do We Define Empathy in Health Care?

Angie Basiouny: Why is empathy in health care important? If my doctor is board certified and graduated at the top of her class, I know I’m going to get good care. What difference does it make if she doesn’t make me feel warm and fuzzy?

Ingrid Nembhard: You may get great clinical care, but that’s different from empathy. We assume that everyone is clear on what empathy is and what its role is in health care. Broadly speaking, empathy refers to understanding another person’s feelings and their thoughts, and feeling those congruent thoughts and states. In health care, empathy is defined as “understanding and feeling a patient’s emotions and perspective.” It’s also offering a response — for example, how you communicate with that patient — that reflects understanding and that actually aims to help them.

Why does empathy matter in health care? Well, when there’s insufficient empathy, there’s diminished understanding of the patient’s perspective. On the other hand, when there is higher empathy, there is understanding. In principle, that understanding matters because it cultivates efforts to better meet patient needs through both interpersonal choices, such as speaking with care, and operational choices, such as connecting patients with resources, whether they need mental health providers or transportation — things that can facilitate their care experience and their actual care and health.

We know now from looking at the research, and even if you thought about this theoretically, that the more that understanding is present, the more patient-centered care plans are likely to be made, the better the patient care experience will be, and the greater patient adherence to their plans will be. That all means that we can expect better patient, worker, and organizational outcomes, whether you think about clinical outcomes, or you think about worker job satisfaction, because they’re getting the information they need to be able to treat patients the way they should. And they’re getting better patient experience ratings.

So, why it matters is that it’s the beginning of a positive cascade, I think, for patients and health care, and even for workers.

Taking Stock of Empathy in Health Care

Basiouny: In the paper, you mention that there’s a great deal of disjointed information about empathy in health care, but that it’s emerging as its own research field. What were you and your co-authors hoping to contribute to the literature?

Nembhard: I do a lot of research on patient care experience in addition to understanding the organizational side of care. The data at this point is pretty robust that a lot of patients are having poor patient care experiences, and there has been this growing attention now to the relational side of health care. That has really led to a lot of investigation about what facilitates and what hinders empathy. What outcomes come from empathy? How best can we measure empathy? Who is likely to give you empathy, and who is unlikely to give empathy? Who is likely to get empathy? Who is unlikely to get empathy? And then how do you go about increasing it?

These kinds of investigations have been occurring for the last 50 years. We see that largely they’ve been occurring by individual researchers in independent investigations that have been published in a wide variety of journals. That means that we can now say that there is an actual research field of empathy, because there has been a lot of attention in this field, but it’s all disparate. You haven’t had yet the research that integrates all of that knowledge.

My colleagues and I thought we’ve reached a time now where we need to pause and take stock of the field. We need to see what lessons can be extracted from the 50 years of research, and we need to see if we can create clarity about the way empathy is operating in our health care system.

We can then start to identify where we need to do more research and where practice needs to change in order to achieve those goals. We decided to do a systematic review of 50 years’ worth of empirical, quantitative research on empathy. And our research covered 450 articles that met our criteria.

What Factors Predict Empathy in Health Care?

Basiouny: Let’s talk about the takeaways. You found that more empathy ends with better health care outcomes, and that five factors predict empathy. Can you take us through those factors?

Nembhard: Sure. The first is that provider demographics seem to matter. Those are things like the number of years a professional has been in their specialty. We also see that it varies by characteristics like gender and the specialty. Perhaps not surprisingly, studies suggest that primary care physicians and those in behavioral health tend to display more empathy than colleagues who are more on the surgical side or who have acute experiences with patients.

Other characteristics of Who is providing empathy can matter too. In that bucket, we find things like personality, whether somebody is an introvert or extrovert, their knowledge, their attitudes towards different people and the like.

The third category that we identified is how providers behave during their interactions. We pay attention to the fact that people talk in different ways and speak to people in different ways, and that certainly appears in the data. Providers vary in the way that they communicate, the tone they use, the words they use. They also vary in aspects like their body movement in the interaction. Are they closer to you or farther away? Do they create distance or not have distance? And whether they give adequate consultation.

The fourth bucket of things that we find are target characteristics. We’re referring largely to patients as the target of that empathetic interaction. It varies by the type of condition the person has or the disease that they’re battling. Some of the data would suggest that certain conditions are more likely to elicit an empathetic response than other conditions. Someone’s socioeconomic status — whether they have more income or less income — tends to influence the level of empathy that’s directed towards them.

The fifth category that we found in the literature is organizational context. Things that are organizational include how long is the visit that the patient has with their provider? In shorter visits, there’s less empathy typically found. The waiting time also is tied to perception of how much empathy there is.

The five categories are really interesting. I’m simply giving you the high-level [view]. Within each one of those categories, our research showed there are multiple factors.

What Interventions Increase Empathy in Health Care?

Basiouny: You also looked at some interventions that can increase empathy among health care givers. What are those interventions?

Nembhard: Once the field appreciated that empathy might matter, it started to think about ways to increase it. Most of those have been individual-level educational interventions, so things like training participants how to do a particular skill, like how to communicate well — in an empathetic way. We see some studies that focus on having a course, so a person goes through a series of lectures about how to be empathetic or what empathy behavior entails. Sometimes there are workshops where you’ll role play and get feedback on how you behave. Simulations, visuals, videos. The category that probably most caught my attention is treatment for empathy. There are studies that trial transcranial direct current stimulation — actually stimulating that part of the brain [associated] with empathy. There are a lot of options that are on the table for improving and increasing empathy, most of them educational interventions.

For us looking at the data, it was surprising that there were no studies of organizational interventions, because one of the factors that we found that was significant was organizational context. We know that organizations can matter. In some sense, the absence of organizational interventions may reflect the fact that we think of empathy as a human trait, so why make it part of the organization? You don’t need to be trained in empathy.

But if the provision of empathy benefits from having dedicated time and people and processes and leadership, then it totally makes sense that we need to direct greater attention to organizational interventions for improving empathy. My co-authors and I are now very much of the mindset that we need to have more empathetic systems and institutions that are structured in such a way that they create conditions for anybody to receive empathy, in a non-arbitrary way throughout their whole service of care.

We’ve seen that organizational interventions can work. We see it around patient safety. It used to be that you thought safety was the type of thing that a provider delivered to a patient. Innovation was the type of thing that an entrepreneur delivered. Yet now when we look at health care, it’s not unusual to see a chief patient safety officer or a chief innovation officer, or roles that are dedicated exclusively to ensuring those goals. Organizations are taking that route, rather than just training clinicians.

There are now role-based approaches centered on non-clinicians to deliver what is needed. We might want to move in that direction [for empathy too]. I think my colleagues and I would be excited to see more interventions that say, “OK, this is something that organizations need to be attentive to.”

How Empathy in Health Care Can Reduce Disparities

Basiouny: I want to ask you about two demographics, which are Black patients and Hispanic/Latino patients. We know those two groups have worse health care outcomes across a number of measures, whether it’s COVID-19, heart disease, or maternal mortality. Would greater empathy for those patients translate into better outcomes?

Nembhard: The simple answer is that it should. If you recall my earlier response to your first question about why does it matter, it’s largely about understanding people, their emotions, their needs, and where they are in their care in their state. If we were to have greater empathy, we would expect that there would be greater understanding such that the choices that are made and the conversations that happen in the course of care would be more attentive to the needs of the person. That means that they would get the communication they need, and it would be culturally competent.

If you need transportation, we would provide transportation, because we would understand the circumstances. We would understand and therefore make choices and make care plans that would allow people to be successful in their health care. I do think empathy is part of the process. If we want to reduce some of those disparities, we need to be better about understanding where people are.

Basiouny: This study is the first of its kind. What do you want to look at next?

Nembhard: The main motivation in taking on the last 50 years of research was that we wanted to be better prepared to do work that could make a difference. We’d love to be able to collaborate with a health system interested in trying and trialing a role-based organizational intervention. We think it’s time.

We’ve been doing the training of individuals for years, and we’re still not at the level we need to be. That appears to be insufficient to allow systematic empathetic health care. So, we would love to be able to study role-based organizational intervention. We’d love to see the field take off and other people think about other organizational interventions that might be used to build empathy.

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• Open access
• Published: 04 April 2022

The development of empathy in the healthcare setting: a qualitative approach

• Chou Chuen YU 1 ,
• Laurence TAN 1 , 2 ,
• Mai Khanh LE 1 ,
• Bernard TANG 1 ,
• Sok Ying LIAW 3 ,
• Tanya TIERNEY 4 ,
• Yun Ying HO 5 ,
• Beng Eng Evelyn LIM 6 ,
• Daphne LIM 6 ,
• Reuben NG 7 ,
• Siew Chin CHIA 8 &
• James Alvin LOW 1 , 2  

BMC Medical Education volume  22 , Article number:  245 ( 2022 ) Cite this article

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Healthcare professionals’ empathetic behaviors have been known to lead to higher satisfaction levels and produce better health outcomes for patients. However, empathy could decrease over time especially during training and clinical practice. This study explored factors that contributed to the development of empathy in the healthcare setting. Findings could be used to improve the effectiveness and sustainability of empathy training.

A qualitative approach, informed by aspects of grounded theory, was utilized to identify factors that enabled the development of empathy from the perspectives of doctors, nurses, allied healthcare workers and students. Twelve sessions of focus group discussions were conducted with 60 participants from two hospitals, a medical school, and a nursing school. Data was analyzed independently by three investigators who later corroborated to refine the codes, subthemes, and themes. Factors which influence the development of empathy were identified and categorized. This formed the basis of the creation of a tentative theory of empathy development for the healthcare setting.

The authors identified various personal (e.g. inherent characteristics, physiological and mental states, professional identity) and external (e.g. work environment, life experience, situational stressors) factors that affected the development of empathy. These could be further categorized into three groups based on the stability of their impact on the individuals’ empathy state, contributed by high, medium, or low stability factors. Findings suggest empathy is more trait-like and stable in nature but is also susceptible to fluctuation depending on the circumstances faced by healthcare professionals. Interventions targeting medium and low stability factors could potentially promote the development of empathy in the clinical setting.

Conclusions

Understanding factors that impact the development of empathy allows us to develop measures that could be implemented during training or at the workplace leading to improve the quality of care and higher clinical work satisfaction.

Peer Review reports

Introduction

Mercer and Reynolds [ 1 ] defined empathy in the medical context as the understanding of patients’ emotions, concerns and situations, communicating that understanding to the patient and acting on that understanding. Empathy improves diagnostic accuracy, patient satisfaction and compliance, and lowers psychological distress and medical complications [ 2 , 3 , 4 , 5 ]. Lack of empathy is correlated with physical, emotional, and work-related issues such as depression, burnout, sleep disturbance, and poor concentration, all of which could negatively impact patient care [ 6 ].

Despite extensive efforts to promote empathy through education, a decline in empathy has been observed among medical students, especially when they have spent more time interacting with patients [ 7 , 8 , 9 , 10 , 11 , 12 ]. This decline persists throughout residency and into their practice. Residents have been found to be less empathic and humanistic, and more cynical over time, while physicians from different specialties are at risk of compassion fatigue [ 7 , 12 , 13 , 14 ]. While a decline in empathy was commonly reported in American medical schools, recent studies observed conflicting empathy trends in medical schools and empathy trends in other parts of the world were inconclusive [ 15 , 16 ]. Consequently, this highlights a need to understand how clinical empathy develops among healthcare students and professionals.

Nezlek et al [ 17 ] believed that empathy should be considered both as a trait (a personal disposition that determines one’s ability to recognize, experience, and react to others’ emotions) and a state (the extent to which one empathizes with others in a specific event at a specific time). The same view was shared by Hojat [ 18 ] who considered empathy as neither a highly stable trait nor an easily fluctuating state, which was a result of a complex interplay of factors such as evolution, genetic dispositions, individual development, education and personal experiences. Hence, targeting these factors is thought to enable modification and development of empathy.

Many factors can affect an individual’s empathy level, such as gender, personality, career choices, common experience with patients, education background, and work environment. Females have been shown to have personality traits that lower stress levels [ 11 , 19 ]. Medical students who prefer specialties with a more human touch [ 10 , 11 ] have higher levels of empathy. Sharing common experiences with patients allowed healthcare professionals to empathize more with patients [ 20 ]. Medical education which focused more on science than humanities, and trainee distress are thought to lower empathy levels [ 7 , 20 , 21 , 22 ]. Work experience and work environment could either positively or negatively influence empathy levels [ 23 ] while stress and burnout have been shown to lower empathy levels [ 5 , 24 ].

Unfortunately, little is known about how these factors influence empathy at the trait and state levels. In social science, childhood experiences have been shown to have a long-lasting impact on individual trait empathy [ 5 , 25 ]. On the other hand, cognitive load impedes empathy experience and reduces empathic responses [ 26 ], which is highly applicable to healthcare professionals as they constantly face massive workloads and responsibilities, thus affecting how they experience and exhibit empathy. While empathy research in healthcare has focused mainly on the experience of healthcare students and research on empathy interventions has focused solely on the success of these interventions, few have evaluated the development of empathy in healthcare workers [ 7 , 8 , 27 , 28 , 29 , 30 , 31 ]. Hence, the aim of this study is to qualitatively understand the underlying construct of empathy both as a trait and state in healthcare professionals and students, and determine what are the factors that may influence the development of empathy in the heatlhcare context.

Research design

The research design was informed by the constructivist approach to grounded theory [ 32 , 33 ] in which the aim was for researchers and participants to co-construct the theory on the development of empathy. A qualitative approach was adopted for this study as it was considered the most appropriate way to uncover and understand the meaning of empathy from the ‘emic’ perspective (i.e. the contexts, lives and meanings of those involved). This approach was also important considering that little is known about the theory of change whereby various factors influence the development of empathy of those experiencing empathy in the clinical setting. In view of practical constraints faced by the study team, approaches in grounded theory were adapted for the purpose of data collection and data analysis. Ethics approval for this study was granted by the National Health Group Domain Specific Review Board (DSRB), reference number 2018/00020.

Data collection

Data was collected from care providers consisting of physicians, nurses, multidisciplinary teams, as well as medical and nursing students. While grounded theory would employ theoretical sampling to focus on and support a constant comparative analysis of data, this study adapted the sampling approach whereby clinicians on the study team made a strategic a priori decision based on their expertise to sample from various groups who would provide the most information-rich source of data. Healthcare professionals from various hospitals, medical students from a medical school and nursing students from a nursing school were invited via email to participate in the study. Participants were informed of the study details and written informed consent was obtained. Data was collected from 60 participants via 12 homogeneous focus group discussions (FGDs). Each FGD lasted approximately two hours. All FGDs were conducted in English and hence translation was not required. The demographic information is presented in Table 1 .

The FGDs were conducted in pairs by a female research officer (MK) with either a male medical doctor (LT), or male research fellow (CC) in rotation. All have practice experience in qualitative research and interviewing. MK and CC also had educational qualifications in psychology. Being a clinician, LT was able to reflexively use his knowledge of clinical practice to facilitate discussions in the clinical context whereas MK and CC approached the interviews from an outsider “naïve” position, thereby reducing the possibility of biasing the responses. For each FGD, one researcher would keep notes of the conversation to aid the interpretation of transcripts. Prior to the start of the FGD, each participant was provided with an information sheet containing details about the study and the research team introduced their roles in the study. Only researchers were present at all data collection settings except at the nursing school where the site investigators (part of the study team) were present to provide logistical support. These procedures in place adhered to common best practices to ensure trustworthiness in qualitative research [ 34 ]. Participants had no contact with the research team prior to study commencement.

The initial guided questions were broad and developed based on existing literature on empathy.

These questions focused on beliefs, thoughts, emotional feelings, behaviors and experiences and served as a guide to encourage participants to share their personal stories about their experiences of empathy especially in the clinical context and emerging themes were explored [ 33 ]. Examples of such questions included:

What are your personal experiences of empathy in the care of patients?

What are some of the things doctors or nurses do when they show empathy?

Do you think empathy levels in someone can be changed? Or is it inborn, meaning it cannot be taught?

Some questions were focused on more, or were included during subsequent interviews, as investigators felt that they were important issues that had surfaced during earlier interviews. This required the investigators to be sensitive and open to the views being shared. Examples of such questions included:

Limited time to see patients is a factor that can influence empathy levels? What are your views on this?

Some people are able to maintain their level of empathy despite personal or work related problems. Why do you think this is the case?

Stressors at work can impact empathy levels. What is your view on this?

Negative case discussions were also encouraged as it allowed for emerging theories to be developed and modified while cases that did not fit led to generating of new knowledge [ 34 ]. Examples of such discussions included asking participants to discuss the negative consequences of having no empathy and possible negative effects that could result from having empathy. To ensure that the groups sampled were adequate, the investigators reviewed their field notes and logic diagram following each FGD to aid the assessment of saturation.

Data analysis

Investigators met after each FGD to compare their memos, identify key themes generated by participants, compare findings with previous FGDs, and revise questions based on new themes that emerged. Upon completion of every two FGDs, the audio recordings were transcribed ad verbatim by one of two investigators and counterchecked against the recordings by LT. The investigators subsequently met regularly over a period of 12 months to compare codes and to form themes. Differences in opinion were mediated till a consensus was reached. This “immediate analysis” approach is an important part inspired by grounded theory [ 35 ] as it allowed the investigators to identify similarities and differences in the data. Additionally, it also informs the manner through which questions were developed and raised in each subsequent round of data collection.

Coding occurred in three stages [ 36 ]. First, open coding was conducted from the onset to generate as many ideas as possible regarding how empathy was described by participants, and whether the components of empathy could be categorized into the four domains postulated by the investigators. Axial coding then determined how the various codes related to each other throughout the dataset (e.g. factors related to childhood, environment, workplace, stress affecting empathy). Finally, selective coding involved the investigators selecting central core categories of ‘between and within person changes’ and ‘development over time’ and relating the codes to these categories. To support this whole process, diagrams of how the factors influenced participants’ empathy were constructed to identify the relationship between factors and categories after each FGD. A coherent theory of ‘empathy development’ was drafted by the 6 th FGD. This theory was further refined throughout the study until data saturation and this was achieved by the 12 th FGD.

Participants on the whole considered empathy as both a trait and state. Although there were innate qualities that determined empathic tendencies and responses, these could also be learned and developed over time. Environmental and personal factors later in life are important determinants and these factors can be categorized according to difference in resistance to change which we termed ‘stability factors’ of which there are three levels: high, medium, and low. High stability factors form the foundation of an individual’s trait empathy (e.g. childhood experience, parental values and religious values). Their impact on one’s empathy, for instance, how one responses and reacts to others’ emotions, is long-lasting and less amenable to change. Low stability factors are those that are highly situation specific (e.g. unexpected stressors faced at work) whereby the impact is to cause momentary fluctuations in empathy levels. Medium stability factors are those that tend to be persistent and enduring in one’s environment (e.g. one’s job scope) and arguably have the potential to influence empathy levels over the long run. These factors often represent the environmental and personal constraints that exist for an extended period of time, and can influence one’s ability to empathize over the long run. The interaction between these factors and how they define empathy are presented in Fig.  1 . All factors which influenced empathy, along with their representative quotes are listed in Table 2 .

High stability factors moulds trait empathy

Empathy development model in healthcare setting

High stability factors were often the first thoughts that came to the participants’ mind when asked where they derived their sense of empathy from. Participants believed that individual baseline empathy determined their tendency to empathize with others and was shaped by inborn characteristics and early life experiences. The influence of high stability factors on empathy was persistent and fairly stable. Some participants felt that factors which occurred at the later stages of life, such as empathy training in schools, may not be able to fundamentally change an individual’s trait empathy level and response:

“[…] everybody is born with a certain personality type. And whatever nurture you get beyond that is still working on the baseline that you’re already inborn [born] with, and nurture might not be able to overcome what nature has already given you”. 20-FGD4.

As different individuals have different upbringing and early life experiences, high stability factors also seemed to explain the differences in empathy levels among individuals.

“I think it depends on the person’s upbringing and the environment they grew up in ‘cause [because] throughout my life I’ve seen a lot of people who are able to put themselves in other people’s shoes and some who just aren’t.” 59-FGD12.

Medium stability factors can have enduring effects empathy levels

Medium stability factors can have an important influence on empathy levels, despite less permanent impact than that of high stability factors. These include current belief and value systems, education and training, group influences, work experiences and culture, supervisory influences, and the professional identity that one adopts. In the clinical context, values in medical practice guides how one understands or appreciates another person’s behavior and situation, which in turn influences their empathy level and response. Additionally, factors such as emotion regulation, coping capabilities, perspective-taking, self-reflective ability, as well as verbal and non-verbal communication skills, allowed healthcare professionals to feel, understand, and communicate better in response to patients’ emotions and reactions.

Participants also shared that religious teachings or other forms of educational training could benefit in helping one empathize with others. Tools and frameworks from educational training helped in relating and communicating affectively, for instance, what to say and do in certain scenarios faced by the patients. Interestingly, with more life experiences, healthcare professionals found it easier to relate to the lived experiences of patients. Work experiences could also improve emotional maturity, knowledge acquisition, coping strategies and communication skills:

“… empathy also comes from your experience, as all of them have mentioned earlier, like the kind of experiences you’ve been through which allows you to put yourself in the shoes of these patients which you’ll be seeing, and also having that experience of [for example] like say breaking bad news to this patient multiple times, I would learn how to do it better, and improve myself like maybe the fifth [time] and by- compared to the like one hundredth time I’ve done it, so I think if I had to choose one I think empathy is something that yes, as- there’s a basal level of like inborn like empathy, but it can definitely be developed and honed, so that you are able to like connect with your patients better.” 25-FGD5.

Most participants felt that it was easier to empathize with patients when they had more experience. Participants also shared various examples of how work responsibilities, standards and guidelines, culture, supervisors, surveillance, and reward structure affected empathy levels, as shown in Table 2 . Despite the stress and various challenges that came with the role of providing care, participants highlighted that their professional identities spurred them to maintain empathy even in difficult times, and they did this by contemplating what it meant to be a healthcare professional as well as prioritizing work and responsibilities of patient care.

Although participants felt that the impact of high stability factors was harder to alter, empathy levels could still change over time through interactions with medium stability factors. In some situations, they could override the influence of high stability factors, as mentioned by one participant:

“Parents teach us [to] always be nice to people, do things nicely. But when we step out to the world, we see like the world is not actually friendly. We try to be nice to people but they just shut us out. So it’s a different kind of empathy, and what triggers this empathy in us is experiences. How we see things, how we mature ourselves and for example if we have a situation at hand, how we handle it, how we show our feelings, is different from what our parents would teach us. And depends, either we ourselves would want to follow what our parents have taught, or we want to change and adapt to it.” 47-FGD9.

Similar to high stability factors, there are inter-individual differences in medium stability factors. At the same time, these factors of influence do change over time (e.g. transitioning from medical school to the clinical setting resulted in changes in work responsibilities and expectations). Hence, medium stability factors could account for both interpersonal (between individuals) and intrapersonal (within an individual at different time points) differences in empathy level.

State empathy fluctuates due to low stability factors

While trait empathy is relatively stable, one could still experience transient fluctuations in the experience and expression of empathy due to the presence of low stability factors. These factors often acted as short-term barriers or facilitators that determined how healthcare professionals felt or expressed empathy in a given situation:

“… how much innate empathy you have and then your experiences, and then how that leads to how much empathy you feel, but how much you express depends also a lot on the circumstances of the practice, and how much time you have.” 28-FGD5.

Low stability factors in individuals ranged from physiological states, such as being tired or hungry, to psychological conditions, such as stress and anxiety. Occasionally, situational imperatives and demands such as in the case of a medical emergency, made it challenging to feel or express empathy. Negative interactions and poor rapport between healthcare professionals and patients or family members (e.g. rude demands from family members) that affected mood could also hamper empathic response whereas positive interactions have been reported to have the opposite effect.

With prolonged negative interactions, participants shared that healthcare professionals in certain conditions might become ‘desensitized’ or even experience burnout, leading to avoidance behavior as a coping strategy, with negative consequences on empathy levels. However, high and medium stability factor can have protective effects and buffer against some of the negative interactions. As one participant shared in response to negative experiences faced by healthcare professionals, possessing strong trait empathy and a supportive work environment might protect individuals from the effects of stress or burnout, and help individuals maintain their empathy level:

“It’s tough. I mean if you got it you got it. May [Maybe] you got a very strong empathy, I think you can keep that. […] Maybe situation supports them; maybe the environment supports them to be there.” 38-FGD7.

Understanding empathy in the clinical setting allows trainers and mentors to focus on factors which will positively influence empathy development in clinicians. Our study showed concurring opinions among students and healthcare professionals with regard to empathy development in clinicians. The key findings suggest that the factors affecting empathy development can be categorized into high, medium, and low stability factors, which explains the inter-individual and intra-individual variations in the experiences and expressions of empathy.

In line with past research, high stability factors such as inborn personal characteristics have been shown to influence empathy [ 11 , 37 , 38 ]. This is also the case for other factors identified such as childhood influence from family members and parenting style [ 39 , 40 ]. As highlighted by the participants, social interactions during childhood including school experiences could also determine an individual’s emotional and prosocial tendency development [ 5 , 25 ].

Medium stability factors were also found to be important in the development of empathy. As with prior research, the findings suggest that empathy development could be influenced by whether one’s values prioritizes the welfare of others [ 41 ]. The relationship between religion and empathy was another area of interest among researchers. In line with what other studies have found, while religion seemed to have an influence on prosocial behaviors, the relationship between religion and empathy was affected by how individuals interpreted religious teachings [ 42 , 43 ]. Similarly, culture was also found to have an influence on empathy [ 44 ]. As culture often dictates communication norms, this determines the ability to build trust between patients and healthcare professionals as well as the perception of empathy in healthcare settings [ 45 ].

Factors attributable to the erosion or development of empathy during medical school training and clinical practice which were reported in previous studies were also found in our study. The inability to relate to patients due to lack of life experience or contact with patients, negative encounters with patients, heavy workload, desensitization, burnout, stress, hostile work environment, training, and work culture could lower empathy level. On the other hand, emphasizing the value of empathy during training or in the work culture, interactions with a role model and supervisor, and conducting communication training could improve empathy [ 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 ].

Our findings on the effects of low stability factors generally mirrored previous studies where mental state, situational stressors, and interpersonal interactions were found to influence empathy [ 7 , 24 , 48 , 49 ]. Similar to an exploratory study by Pohontsch et al. [ 50 ], we found that negative mood, work stress, lack of time, and negative interactions with patients, inhibited empathy although our study included not only students but also healthcare professionals. Other than one study in the healthcare setting that the authors are aware of, extant evidence is limited regarding the effects of physiological state (e.g. mood, hunger, fatigue) on empathy and findings from this study add to the literature by suggesting they can have detrimental effects. Thomas et al. [ 48 ] showed that well-being correlated positively with empathy whilst poor sleep impacted the capacity of mental health nurses to provide empathic and compassionate care [ 58 ]. Such effects on empathy were also reported in our sample. Supporting the well-being of trainees and clinicians, as well as investing in a healthy work-place culture that includes measures to protect healthcare professionals from verbal abuse, could therefore be important.

Overall, findings from this sample suggest that empathy tended to be more trait-like and stable in nature but is also susceptible to regular fluctuation depending on the circumstances healthcare professionals find themselves in. The stability of their effect has been studied mostly in the field of social and developmental psychology. The work of Knafo and colleagues [ 59 ] demonstrated the influence of genetic and environmental factors on empathy development at an early age. Empathy was found to be a stable disposition determined by genetics but could change due to both genetic and environmental factors. The environmental variables shared by children could explain empathy stability while non-shared environmental variables determined the change in empathy. Taylor et al. [ 60 ] showed that the long-lasting impact of personalities, parental guidance, and experiences on empathy at an early age were able to predict future prosocial behaviors. In addition, Greenberg et al. [ 61 ] showed that people who experienced traumatic events when they were young tended to have higher levels of empathy at adulthood.

Implications for practice

Our tentative theory of empathy development provides a framework to understand potential targets for empathy interventions. While targeting high stability factors may not be possible in an attempt to change trait empathy, developing the manner healthcare professionals/students understand, relate and respond emphatically to patients in medical or nursing schools as well as other clinical settings can be achieved and sustained by targeting both medium and low stability factors. Attempts to improve empathy in medical schools, nursing schools, and clinical practice over the years have largely been focused on social skills and perspective-taking [ 30 , 31 , 62 , 63 ]. A recent longitudinal study of Japanese medical students showed that communication skills education could improve empathy, but the effect was short-lived [ 64 ]. The challenge with focusing on social skills alone was that it often felt forced into a teaching curriculum as individuals were not always able to feel authentic empathy in simulated settings [ 46 ]. Shapiro et al. [ 65 ] was more successful in creating a sustainable positive effect by targeting different factors such as communication skills, coping techniques, well-being enhancing strategies, and exposure to patients; these are some of the factors outlined in our proposed model which adopted a more experiential approach in a real-life setting.

Our theory of empathy development is holistic and highlights that healthcare professionals should be equipped with the necessary skills, experience, and guidance to react empathically in the clinical setting, and that their work environment has to be conducive to minimize the effect of low stability factors. For example, forming healthcare students’ and professionals’ professional identity at an early stage and regularly reinforcing the identity, creating a supportive work culture, training and education, supervisory guidance and peer influence, and even developing a monitoring system that rewards empathic behaviors could help eliminate the effect of low stability factors on empathy.

Strengths and limitations

The strength of this study involves understanding views from a sample of doctors, nurses, multidisciplinary team members, medical students and nursing students and findings is therefore not narrowly confined to only one group, which is quite typical for qualitative research. In addition, this study was conducted in a multi-cultural setting with participants from different ethnic groups, religious beliefs and work setting (acute hospital, community hospital, home care and schools). With findings echoing those found by scholars in the field of empathy, this suggests that the theory of empathy development is applicable in the international community as it provides a framework to understand potential targets for empathy interventions.

One limitation was that as mentioned in the method section, theoretical sampling was not used. This would be expected for any study that adhered strictly to grounded theory. The sampling procedure therefore was guided by strategic a priori decision based on the expertise of the clinicians in the study teams that was in part guided by situational constraints and access especially with regards to the doctors and nurses. As there were more participants coming from ‘high-touch’ clinical setting such as palliative care and geriatrics, future studies may need to consider whether views about empathy from other settings such as the emergency department may differ. As identified in this study, participants felt that empathy levels may be affected in highly demanding clinical situations such as an emergency.

Another limitation of this study is that the use of FGDs may have induced socially desirable responses from participants. For the healthcare professionals, there is a possibility that what was shared may not be truly reflective of their personal views since the sessions were conducted in the presence of fellow colleagues from the same institution. Likewise, the study team also felt that the role of religion was not fully explored in the FGDs as there were instances participants did not feel comfortable or appropriate sharing their personal views on religion in the presence of other fellow medical professionals and associates.

To a large extent, empathy is an inborn trait and fundamental to being human. However, it is dynamic, constantly evolving, and develops under the influence of various personal and situational factors. Our proposed theory of empathy development consolidates the factors influencing empathy and describes their involvement in influencing empathy over time both intra-personally and inter-personally. With a clearer understanding of how empathy develops in the healthcare setting, quality of clinical care in the future may be improved as healthcare providers could implement measures during training or at the workplace, to encourage empathy and compassion in healthcare.

Availability of data and materials

The authors declare that the data supporting the findings of this study are available within the article.

Abbreviations

Focus group discussion

Mercer SW, Reynolds WJ. Empathy and quality of care. Br J Gen Pract. 2002;52(Suppl):S9–12.

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Acknowledgements

The authors would like to thank Khoo Teck Puat Hospital, Tan Tock Seng Hospital, Yong Loo Lin School of Medicine (National University of Singapore), Lee Kong Chian School of Medicine (Nanyang Technological University), and Nanyang Polytechnic for their assistance in recruitment. Additionally, the authors wish to thank Ms. Isabelle Lim, Geriatric Education and Research Institute, for contributions to research administration support.

This study was funded by Geriatric Education and Research Institute’s Intramural Fund (reference number: GERI/1616).

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LT is the principal investigator of the study who made significant contribution to study design, investigation, analysis and reviewing of this manuscript. MKL made significant contribution to study design, investigation, analysis, study administration and writing this manuscript. CCY made significant contribution to study design, investigation, analysis, and reviewing this manuscript. BT made major contribution to reviewing this manuscript. SYL, EL, DL, and YYH made major contribution to study investigation. TT, SCC, and JL made major contribution to study design and investigation. RN made major contribution to study design. All authors have read and approved the manuscript.

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YU, C.C., TAN, L., LE, M.K. et al. The development of empathy in the healthcare setting: a qualitative approach. BMC Med Educ 22 , 245 (2022). https://doi.org/10.1186/s12909-022-03312-y

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What is Clinical Empathy?

Jodi halpern , md, phd.

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The author thanks Oxford University Press for permission to use material from Halpern J, From Detached Concern to Empathy: Humanizing Medical Practice, Oxford University Press, 2001.

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Patients seek empathy from their physicians. Medical educators increasingly recognize this need. Yet in seeking to make empathy a reliable professional skill, doctors change the meaning of the term. Outside the field of medicine, empathy is a mode of understanding that specifically involves emotional resonance. In contrast, leading physician educators define empathy as a form of detached cognition. In contrast, this article argues that physicians' emotional attunement greatly serves the cognitive goal of understanding patients' emotions. This has important implications for teaching empathy.

There is a long-standing tension in the physician's role. On the one hand, doctors strive for detachment to reliably care for all patients regardless of their personal feelings. Yet patients want genuine empathy from doctors, and doctors want to provide it. 1 , 2 Medical educators and professional bodies increasingly recognize the importance of empathy, but they define empathy in a special way to be consistent with the overarching norm of detachment. Outside the field of medicine, empathy is an essentially affective mode of understanding. Empathy involves being moved by another's experiences. In contrast, a leading group from the Society for General Internal Medicine defines empathy as “the act of correctly acknowledging the emotional state of another without experiencing that state oneself.” 3

It goes without saying that physicians cannot fully experience the suffering of each patient. However, the point of saying that the physician does not “experience that state oneself” is, presumably, to emphasize that empathy is an intellectual rather than emotional form of knowing. This assumes that experiencing emotion is unimportant for understanding what a patient is feeling.

This recent definition is consistent with the medical literature of the twentieth century, which defines a special professional empathy as purely cognitive, contrasting it with sympathy. Sympathetic physicians risk over-identifying with patients. Further, all emotional responses are seen as threats to objectivity. Influential articles in the The New England Journal of Medicine and the Journal of the American Medical Association in the 1950s and 1960s argue that clinical empathy should be based in detached reasoning. 4 , 5 Blumgart, for example, describes “neutral empathy,” which involves carefully observing a patient to predict his responses to his illness. The “neutrally empathetic” physician will do what needs to be done without feeling grief, regret, or other difficult emotions. 4

Blumgart's description recalls the early twentieth-century writings of Sir William Osler. In his 1912 essay, “Aequanimitas,” Osler argues that by neutralizing their emotions to the point that they feel nothing in response to suffering, physicians can “see into” and hence “study” the patient's “inner life.” 6 This visual metaphor of projecting the patient's “inner life” before the physician's mind's eye underscores the stance of detachment. Viewers stand apart from what they observe. This contrasts markedly with the ordinary meaning of empathy as “feeling into” or being moved by another's suffering.

The concept of a detached physician accurately viewing a patient's emotions persists throughout the twentieth century. In their classic 1963 article, “Training for Detached Concern,” Fox and Lief describe how physicians believe that the same detachment that enables medical students to dissect a cadaver without disgust allows them to listen empathically without becoming emotionally involved. 7

DETACHED CONCERN IS NOT THE SAME AS EMPATHY

Physicians recognize that they cannot genuinely overcome all emotions. Yet, they strive to view patients' emotions objectively. The model of detached concern presupposes that knowing how the patient feels is no different from knowing that the patient is in a certain emotional state. When used to refer to impersonal knowledge about a state of affairs, such as the workings of bodies, the term “knowing how” is interchangeable with the term “knowing that.” Knowing how the stomach puts out gastric acid is the same as knowing that histamine cells stimulate the release of certain hormones. Accordingly, knowing how a patient feels would be the same as knowing that, in fact, she is sad versus anxious.

However, the function of empathy is not merely to label emotional states, but to recognize what it feels like to experience something. That is why empathy is needed even when it is quite obvious what emotion label applies to a patient. Consider the following example of mine from several years ago. The medical team called for psychiatry to consult on a patient with Guillan-Barre syndrome who was depressed and refusing treatment. When I first came into the patient's room, I noticed a flicker of interest in his eyes as he greeted me. He was completely paralyzed from the neck down. He greeted me by struggling to whisper a few words through his tracheotomy tube. The nurse gently adjusted his tube. I felt uncomfortable viewing his immobile body splayed on the bed, hearing him struggle.

I spoke to him in a quiet, gentle way. As I spoke, he became withdrawn, literally looking away to end the conversation. I felt ashamed at imposing on him. Yet, when I thought about the shame, which led me to retreat, I wondered if this shame was also an emotion that came from resonance with him. Here he was, a powerful man, now suddenly paralyzed and exposed to all of his caregivers. My gentle approach to him clearly backfired—did he sense pity? I tried to change my tone, to see how he responded. I asked him, directly and assertively, what was bothering him about how we were treating him. He looked right at me and then began an angry tirade about how disrespected he felt. This engagement was the beginning of an effective therapeutic alliance.

In another incident, reported by a pregnant patient to me, a physician discussed with her what she might expect during labor and delivery. Noting that the woman seemed anxious, he immediately reassured her that she had options for pain relief, and went into a detailed exposition of these options. He noted afterward that the patient was still anxious, and asked her directly what was making her anxious. Despite recognizing her physician's sincere concern, the patient did not answer, and changed obstetricians.

According to the patient, she felt increasingly panicked as the doctor tried to reassure her about pain relief, hearing about being “tied” to an intravenous line, and then about how she might feel numbness and be unable to push secondary to medication. This patient had been a rape victim, and deeply feared being restrained and losing control. She believed that by the doctor continuing on and on in a cheerful way as he described these options, he signaled to her that he did not recognize how terrified she felt. His reassurances felt generic, and she did not feel able to express her fear without him pausing and recognizing her in some nonverbal way.

What is fascinating about juxtaposing these 2 cases is that in both, the physicians are genuinely concerned about the patients and ask essentially the same questions. Yet, in the former case, emotional attunement guides the timing and tone, whereas in the latter, this appears not to be the case. A recent study reported in the Journal of the American Medical Association observed patient-physician interactions and noted that nonverbal attunement led physicians to pause at moments of heightened anxiety, at which times patients disclosed information. If physicians did not do this, patients did not share vulnerable information, despite the physicians asking the patients appropriate and accurate questions. 8

This study reminded me that as a beginning psychotherapist I learned to avoid directly asking “how are you feeling?” because people rarely gave full responses. Instead, I learned to trust my own emotional cues to shifts in patient's emotions to guide me to pause silently or repeat a few of their words when I sensed anxiety or sadness. Patients told me much more.

SPECIFIC WAYS THAT EMOTIONS CONTRIBUTE TO EMPATHY

The importance of nonverbal attunement seriously undermines the “detached concern” model of empathy. However, what remains to be clarified is what exactly such attunement involves. If engaged empathy (herein referred to simply as empathy) requires experiencing emotions in parallel with each patient, this would be absurdly demanding (even for psychotherapists). Further, general internists do not have the time that psychotherapists do to focus on emotions.

One key point of this article is that empathy does not require that physicians vicariously experience and introspect about patients' emotions. The physician's attention should not be unduly diverted to introspection. The whole point of empathy is to focus attention on the patient. A listener who was busy having his or her own parallel emotions and introspecting about them would have the wrong focus.

Emotional attunement operates by shaping what one imagines about another person's experience. In trying to imagine what the patient is going through, physicians will sometimes find themselves resonating. This is not an additional activity to imagining, but rather a kind of involuntary backdrop to it. Further, resonance is not a special professional skill, but a part of ordinary communication. While listening to an anxious friend, one becomes anxious, while talking with a coworker, one feels heavy, depressed feelings. Importantly, attuning to patients does not always involve resonating with strong feelings, but often is a subtle nonverbal sense of where another person is emotionally.

The special professional skill of clinical empathy is distinguished by the use of this subjective, experiential input for specific, cognitive aims. Empathy has as its goal imagining how it feels to be in another person's situation. Outside medicine, imagining how an experience feels is similar to daydreaming or fantasizing. An emotion or mood sets the tone of the imagined scenario. In clinical practice, the challenge is to use skillful attunement, not in leisurely fantasy, but in multiple, rapid, ordinary clinical interactions. For example, if a patient says that she has stopped taking her medication, empathy involves taking cues from her tone. This patient may be angry about sexual side effects, or she may be upbeat, and see the medication as unnecessary because she doesn't feel sick, or she may see the medication as useless because she feels hopeless about getting well. In each case, addressing the patient more or less appropriately depends upon attuning to the patient's emotions.

At this point, the busy physician reader might be wondering about the clinical utility of empathy when a physician can do a quick checklist review and cover the common reasons people stop taking medications. I do not disagree with this point. Most likely, there is no single question for which physicians need empathy to get an answer. Yet in the daily grind of medical practice, an empathic physician gains a source of information that is at least as efficient as having checklists for each psychological need of patients. Here are 4 ways that physicians can capitalize on their emotional responses to enhance medical care.

Empathy Involves Associative Reasoning

First, emotional attunement helps physicians appreciate the personal meanings of patients' words. Emotions guide thought by linking one idea to another in an “associative” way: in addition to thinking logically, we link ideas that have affective, sensory, and experiential similarities. What doctors say to patients has associative as well as logical meanings. For example, a patient may take the term “degenerative joint disease” to signify that she is falling apart. Of course, a detached physician can recognize this meaning of the word degenerative. Yet an emotionally attuned doctor has an additional source of noticing which words are particularly loaded for a particular patient. Alongside the logical meanings conveyed in conversations is an ongoing flow of associative or emotional meanings. By attuning to another person, one follows this flow with much more ease than if one were to try to get at all this meaning through asking questions and consulting checklists. (Gleaning meanings by associating involves all kinds of inaccuracies, so that at some point the doctor needs to check his or her understanding with the patient more directly.)

Associative listening need not be an added task. Physicians can make use of what they already notice but have learned not pay attention to. For example, a patient suddenly refused previously wanted life-sustaining treatment. She wouldn't talk to anyone, and wanted to be sedated and never wake up. She wound up telling me her painful story, but then became angry and said that asking her to talk was “the cruelest thing anyone had ever done” to her. Her striking words were an important clue to what I learned about her situation. Just a few days before, when she had just gotten out of surgery, her husband of many years had told her that he was leaving her. Patients' words communicate meanings that cannot be summarized on a preformed checklist.

Emotions Help Guide and Hold Attention on What is Humanly Significant

Second, physicians' emotions focus and hold their attention on what the patient is anxious about. Consider a physician who sees a patient who suffers from headaches and fatigue. When asked about her home life, the patient says that everything is fine. Yet, something about the patient's body language, perhaps an evasive gaze, worries the physician. By resonating with the patient's anxiety, the physician is more likely to slow down at this point in the history and gather more information.

The skeptic might ask, can't a detached but thorough physician notice the patient's gaze? The answer is yes, of course. However, it would be difficult for even the most thorough but nonintuitive physician to consciously observe and attend to the dozens of signals that have emotional import in each patient interview. Emotional attunement spontaneously directs attention to some aspects of patient's histories over others.

Neuroscientist Antonio Damasio 9 and philosopher Ronald de Sousa 10 describe this focusing and riveting of attention as necessary because human beings are so cognitively complex that events in daily life involve too many possible things to pay attention to. The cognitive tasks physicians face are at least as complex as the tasks of daily life, and logic alone cannot determine which matters are most important to pay attention to. Nonverbal attunement automatically directs attention to matters that have emotional significance to the patient. Of course, such intuitions in no way supplant thorough history taking and paying attention to other clinical clues. Rather, resonance offers short cuts, the paths of which still need to be rechecked in a systematic way.

Empathy Facilitates Trust and Disclosure and Can Be Directly Therapeutic

A third related contribution of empathy is that it facilitates patient trust and disclosure. Physicians express empathy not only by grasping the personal meanings of patients' words, but also by (automatically) matching patients' nonverbal style, for example, their vocal tones. When doctors attune to patients nonverbally, patients feel more comfortable and give fuller histories. 8

Further, there is a growing body of evidence suggesting that empathy directly enhances therapeutic efficacy. Engaged communication has been linked to decreasing patient anxiety, 11 , 12 and, for a variety of illnesses, decreasing anxiety has been linked to physiologic effects and improved outcomes. 12 , 13 An expert panel on how physicians deliver bad news concluded that patients cope better in the long term if their doctors are empathic. 14

The skeptic might ask why it matters whether physicians respond emotionally if they just behave empathically. My response to this is threefold: 1) The observational studies mentioned above show that patients sense whether physicians are emotionally attuned. 8 2) Patients trust physicians who respond to their anxiety with their own responsive worry. Trust has been associated with better treatment adherence. 15 3) It matters when and how physicians ask patients about their feelings, and empathic attunement guides physicians about when to ask questions, when to stay silent, and when to repeat important words.

Empathy Makes Being a Physician More Meaningful and Satisfying

Finally, empathy makes practicing medicine more meaningful. Many physician narratives attest to this. There is also some research supporting this claim, although there are alternative hypotheses that could explain the findings. For example, Roter et al. found that physicians with an engaged, psychosocially oriented communication style burn out less frequently than others. 16 Robert Coles, writing about William Carlos Williams as well as himself, says that during moments of empathic connection, the real meaning of medical practice is suddenly illuminated in terms of hidden personal meanings. 17 Physicians who allow their patients to move them enrich their own experience of doctoring.

IS EMPATHY PRACTICAL?

In conclusion, empathy is an experiential way of grasping another's emotional states. Empathy is a “perceptual” activity that operates alongside logical inquiry. So long as physicians continue to exercise their skills of objective reasoning to investigate their empathic intuitions, empathy should enhance medical diagnosis rather than detract from it. Further, empathy enhances patient-physician communication and trust, and therefore treatment effectiveness.

Once empathy is seen as depending on emotional responses, however, a critical problem arises. Emotions are generally outside people's immediate control. How can physicians reliably empathize with patients toward whom they naturally feel little or even negative emotions? Sometimes emotional resonance comes easily. However, busy, overworked physicians may find such responses absent.

One path to educating empathic physicians is by encouraging trainees to maintain their natural curiosity about their patients' lives. 18 Doctors learn to suppress curiosity in order to take rapid, standardized histories. Charon, Coles, and others have fostered curiosity by encouraging trainees to hear and then tell patients' first-person accounts of illness. 17 , 19 Once busy in practice, physicians previously trained to write narrative histories might listen more precisely to patients' words. The previously mentioned patient who was paralyzed told me that his treatments were “useless, a waste.” Repeating these words moved him to tears and moved me to imagine that he felt his own life had become “useless, a waste.”

There are several barriers to empathy. First, anxiety interferes with empathy. Time pressure is invoked as a concrete barrier to listening to patients, but probably functions more as a psychological barrier, making physicians anxious. This can be addressed in part by showing physicians that listening can make care more efficient. For example, it usually takes less than ninety seconds for a patient to speak without interruption at the beginning of an interview, and this helps set the tone for trust and disclosure. 20 More generally, to address the anxieties that accompany doctoring, the culture of detachment needs to shift, encouraging physicians to acknowledge and seek support for their own emotional needs.

A second barrier to empathy is that many physicians still do not see patients' emotional needs as a core aspect of illness and care. Research shows that doctors who regularly include the psychosocial dimensions of care communicate better overall. Physicians can be educated to perceive psychosocial needs as important. 21

A third barrier to empathy comes from the negative emotions that arise when there are tensions between patients and physicians. Physicians who feel angry with patients and yet find such feelings unacceptable face barriers to thinking about the patient's perspective. All physicians could be taught to tolerate and learn from their own negative feelings in the way psychiatry residents are taught to pay attention to counter-transference. 22 – 24 We need both theoretical and empirical work to address such barriers and to help elucidate the intermediary steps that physicians can take to practice medicine with genuine empathy.

Acknowledgments

The author gratefully acknowledges Helaina Kravitz, MD, for advice and comments on this work.

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Empathy through the Pandemic: Changes of Different Emphatic Dimensions during the COVID-19 Outbreak

Affiliation.

• 1 Department of Psychology, University of Campania Luigi Vanvitelli, 81100 Caserta, Italy.
• PMID: 35206623
• PMCID: PMC8872216
• DOI: 10.3390/ijerph19042435

Growing evidence suggests that empathy is a relevant psychological trait to face the challenges imposed by the COVID-19 pandemic, but at the present very little is known on whether this multi-dimensional construct has been affected by the pandemic outbreak differently in its separate components. Here, we aimed at filling this gap by capitalizing on the opportunity of having collected data from different self-report measures and cognitive tasks assessing the main dimensions of empathy immediately before the beginning of the global pandemic and about one year later. The results showed a detrimental impact of the pandemic outbreak on empathic social skills but not on both cognitive (perspective-taking) and emotional empathy that instead significantly improved. Thus, reduced empathic social skills could be a weakness to be targeted in psychological interventions to help people cope with the mental health challenges related to COVID-19 pandemic, whereas the ability of understanding another's mental states and emotions could represent a strength in dealing with the current long-lasting crisis.

Keywords: COVID-19; empathy; social cognition; social skills; theory of mind.

• COVID-19* / epidemiology
• Disease Outbreaks

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• Published: 12 May 2021

Affective empathy predicts self-isolation behaviour acceptance during coronavirus risk exposure

• Serena Petrocchi 1 , 2   na1 ,
• Sheila Bernardi 3 ,
• Roberto Malacrida 3 ,
• Rafael Traber 4 ,
• Luca Gabutti 5 &
• Nicola Grignoli 4 , 5   na1  

Scientific Reports volume  11 , Article number:  10153 ( 2021 ) Cite this article

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• Health policy
• Human behaviour
• Infectious diseases
• Psychiatric disorders
• Public health

Health risk exposure during the global COVID-19 pandemic has required people to adopt self-isolation. Public authorities have therefore had the difficult task of sustaining such protective but stressful behaviour. Evidence shows that besides egoistic drives, the motivation for self-isolation behaviour could be altruistic. However, the type and role of prosocial motivation in the current pandemic is underestimated and its interaction with risk exposure and psychological distress is largely unknown. Here we show that affective empathy for the most vulnerable predicts acceptance of lockdown measures. In two retrospective studies, one with a general population and one with COVID-19 positive patients, we found that (1) along with health risk exposure, affective empathy is a predictor of acceptance of lockdown measures (2) social covariates and psychological distress have no significant impact. Our results support the need to focus on altruistic behaviours while informing the public instead of on fear-inducing messages.

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Introduction.

Lockdowns (namely collective physical distancing or isolation during a health emergency) have been necessary, besides mass-vaccination, for flattening the curve of the COVID-19 infection worldwide 1 but have a detrimental impact on global mental health 2 . During the current pandemic psychological science has gained the spotlight 3 , offering valuable understanding on how public authorities can mitigate such a stressful condition and at the same time help individuals to manage risk while maintaining motivation for self-protective and prosocial behaviours 4 .

The impact of public health measures on individual well-being and psychosocial functioning was one of the factors investigated in the course of behavioural management during previous pandemics. Review of these studies revealed a negative psychological impact generated by physical isolation and quarantine 5 , 6 . This evidence from measures taken for mixed lists of diseases that are prioritized in the context of public health emergencies tends to be confirmed by research on confinement conducted during the COVID-19 outbreak 7 , 8 . It has been acknowledged that isolation in the current public health crisis is a major stress factor that will contribute to an increased risk of psychiatric illness 9 , 10 . Stress-related disorders such as PTSD, anxiety or insomnia were observed in the early phases of COVID-19 and could be considered an expression of specific health anxiety in reaction to the risk of contagion during the pandemic outbreak 11 . Such a COVID-19 fear reaction has been described as coronaphobia, an emotional state that might induce exaggerated help-seeking behaviours during the pandemic 12 . Depressive symptoms have also been observed 13 and their increase is expected if the physical distancing measures are maintained in the long term 14 . Maintaining physical distance over a long period would in fact increase loneliness, which is recognized as a risk factor for mental health and in particular for depressive disorders of the elderly and middle aged 15 .

This emerging evidence from literature has enriched the debate on what aspects may protect individuals from the negative side effects of lockdown during a pandemic and at the same time promote compliance with public health rules. People’s willingness to comply with preventive public health behaviours is in fact known to be associated with an interaction between risk exposure/perception 16 and various psychosocial factors 3 , 17 . Among the psychological factors modulating both risk perception and preventive health behaviours, prosocial values may play a central role 18 and empathy appears to be in the forefront. In fact engaging in those behaviours both protects oneself and at the same time the most vulnerable, who may be approached through the different constitutive components of empathy, in particular affective response (or sympathetic/empathic concern), the perspective-taking cognitive process and regulatory mechanisms necessary to distinguish self- from other-feelings 19 . Empathy, defined as a process of sharing another person’s emotion and understanding their emotional state, has been described in a recent narrative review as effective in intergroup conflict resolution and valuable for targeted group intervention 20 . A study conducted in the US during the COVID-19 epidemic peak 21 showed that compared to messages that induce fear, prosocial messages capable of arousing a positive emotional state have proved to be more effective in the willingness to accept self-isolation. Recent studies on the general population suggested that prosocial mental attitudes, such as affective empathy, might promote compliance to public health rules 22 , 23 , 24 .

Other research conducted during the COVID-19 outbreak indicates, however, that empathy levels might fluctuate according to anxiety linked to risk exposure/perception and modulate prosocial willingness 25 , 26 . Perceived risk may be relative to the individual (i.e. one’s health) or to third parties (i.e. being a danger to others), which can be experienced by both infected and non-infected individuals. Altruistic acceptance of risk has been previously identified as a factor reducing the psychological burden on healthcare professionals during a pandemic, in particular in diminishing post-traumatic and depressive symptoms 27 , 28 . Notwithstanding, empathic abilities are recognized from a developmental point of view as associated with emotional distress and could be seen as “risky strengths” 29 .

To our knowledge, there are no studies to date that have analysed whether people’s affective empathy, interacting with the level of risk exposure and health anxiety, influences compliance with public health rules during the current COVID-19 pandemic. Furthermore, none of the screened literature has investigated those psychological factors in people affected or hospitalized for COVID-19: such data are hard to obtain but greatly needed for better informing public health decision-makers. Therefore, the main aim of the present research was to explore whether several psychological factors (i.e. affective empathy, risk exposure condition, psychological distress) increase acceptance of the COVID-19 pandemic lockdown. To this end, the study was developed in two distinct phases. Through a retrospective design involving the general population under the mandatory lockdown for COVID-19, Phase 1 explored whether a high level of affective empathy is a determinant of the acceptance of the lockdown, controlling for psychological distress, health status and socio-demo characteristics (i.e. RQ1). Phase 2 added the evaluation of the risk exposure condition in terms of being part of one of three groups: COVID positive/hospitalised individuals (high risk) vs COVID positive/home isolated individuals (moderate risk) vs COVID negative/home isolated individuals (low risk). Specifically, Phase 2 tested whether affective empathy is a significant predictor of acceptance of the lockdown, even controlling for psychological distress and considering the three risk conditions (RQ2).

Regarding data collected in Phase 1, descriptive statistics for the socio-demo are reported in Table 1 .

Descriptive showed that, respectively, 59.6% and 50.7% of the participants reported low anxiety and depression symptoms under the cut-off score of 5. On the other hand, 40.4% of the participants reported from mild to severe anxiety symptoms and 49.3% from mild to severe depression symptoms.

Non-parametric comparisons between females and males of their affective empathy, depression, anxiety and acceptance of the lockdown were conducted. No differences emerged from these analyses. Results of the correlations revealed that younger participants showed less anxiety, depression and distress. Sex showed no relationships with the other variables, whereas the household composition was negatively associated with the acceptance of the lockdown. Participants who had a partner showed less depression, while those who had an occupation displayed less depression and anxiety. The question on general health was negatively correlated with the number of chronic diseases, affective empathy, depression, anxiety, distress and acceptance of the lockdown. Contrarily, the correlations between those variables and the number of chronic diseases showed a positive sign: affective empathy, anxiety, depression and distress were positively correlated with each other. Acceptance of the lockdown correlated negatively with general health, and positively with the number of chronic diseases and affective empathy. Table 2 shows details of the results.

Mediation analysis yields various similar results. First, an overall path led from affective empathy to acceptance of the lockdown. Secondly, depression, anxiety and distress were not significant mediators in the relationship between affective empathy and acceptance of the lockdown. In other words, individuals with high levels of affective empathy were inclined to accept the lockdown over and above the perception of psychological distress. Affective empathy was significantly related with anxiety and distress, but not with depression. Thirdly, the covariates (i.e. age, sex, household composition, general health, chronic diseases, occupation and education) were not significantly associated with acceptance of the lockdown. Younger participants showed greater anxiety, distress and depression. The unemployed showed greater depression, while lower levels of perceived general health were linked to higher anxiety, distress and depression. Figure  1 shows the graphical representation of the mediation analysis. The indirect effects were not significant, whereas the total effect (β = 0.51, SE = 0.05, LLCI = 0.41, ULCI = 0.62) and the direct effect (β = 0.53, SE = 0.05, LLCI = 0.42, ULCI = 0.63) were significant. These results confirmed that between psychological distress and affective empathy, the latter led to a greater acceptance of isolation as a behavioural norm to fight the threat of COVID-19.

Mediation Analysis, Phase 1. Note: for readability purpose, only significant paths between covariates and the other variables have been drawn. a  = .08, * = p < .05; ** = p < .01; *** = p < .001.

Since the research had a retrospective design, reverse models were tested. Model 1 tested whether anxiety was significantly directly associated with acceptance of the lockdown and through the mediation of affective empathy. Models 2 and 3 tested similar relationships of affective empathy and acceptance of the lockdown with distress and depression, respectively. Figure  2 shows the results of the three models. Affective empathy was a significant mediator in the relationships between psychological distress variables and the acceptance of the lockdown, whereas no direct effects were found between psychological variables and the outcome. The indirect effects were significant for Model 1 β = 0.10, SE = 0.03, LLCI = 0.02, ULCI = 0.16, and Model 2 β = 0.17, SE = 0.03, LLCI = 0.05, ULCI = 0.19, but not for Model 3. The total effects and direct effects were not significant. The reverse model describes a bidirectional relationship between affective empathy and distress in determining the acceptance of the lockdown.

Mediation analyses, reverse models, Phase 1. Note: The covariates are not listed for readability purpose. * = p < .05; ** = p < .01; *** = p < .001.

Regarding data collected in Phase 2, descriptive statistics for the socio-demo are reported in Table 1 . Preliminary ANOVAS showed significant differences on distress, depression and anxiety when the three groups of participants were compared (i.e. COVID positive/hospitalised individuals; COVID positive/home isolated individuals; COVID negative/home isolated individuals). The post hoc comparisons using the Duncan test indicated that the mean scores of distress and anxiety for the COVID positive/hospitalised individuals were significantly higher than the scores of the COVID negative/home isolated individuals. However, the scores of the COVID positive/hospitalised individuals and COVID positive/home isolated individuals did not differ significantly. As for depression, the scores of the three groups were all significantly different from each other, with the COVID positive/hospitalised individuals showing higher scores. Table 3 gives details of the results. Similarly, the ANOVAS comparing the three groups of risk showed significant differences in affective empathy and acceptance of the lockdown. The post hoc test revealed that the mean score of both variables was significantly higher in the COVID positive/hospitalised individuals and COVID positive/home isolated individuals than in the COVID negative/home isolated individuals; the COVID positive/hospitalised individuals and the COVID positive/home isolated individuals did not show a significant difference. See Table 3 for details.

Non-parametric comparisons between females and males on their affective empathy, depression, anxiety and acceptance of the lockdown were conducted. No differences emerged from these analyses. Results of the correlations revealed that younger participants showed less depression. sex showed no relationship with the other variables, whereas the household composition was negatively associated with the acceptance of the lockdown. The question on general health was negatively correlated with the number of chronic diseases, depression and anxiety. Contrarily, the correlations between depression, distress and number of chronic diseases showed a positive sign. Affective empathy, anxiety, depression and distress were positively correlated with each other. The acceptance of the lockdown positively correlated with age, affective empathy, depression, anxiety and distress, and negatively with household composition. Table 4 shows details of the results.

The three tested models showed a good fit with the data, χ 2 (2) = 107.57, p < 0.001, CFI = 1, RMSEA = 1, for the model with anxiety, χ 2 (2) = 140.89, p < 0.001 CFI = 1, RMSEA = 1 for the model with depression, and χ 2 (2) = 98.50, p < 0.001, CFI = 1, RMSEA = 1 for the model with distress. In all three models, the higher the objective risk the greater was the anxiety, depression and distress experienced by participants and the higher was the affective empathy. Affective empathy was a mediator in the relationship between objective risk and acceptance of the lockdown. Therefore, individuals with high levels of affective empathy perceived the lockdown as necessary for overcoming COVID-19. Finally, there was a direct effect of risk on the acceptance of the lockdown: the worse the risk, the higher the perception of acceptance of the lockdown. The three indirect paths from objective risk through affective empathy confirmed the above results, β  = 0.17, p  = 0.016 for anxiety, β  = 0.17, p  = 0.016 for depression, and β  = 0.15, p  = 0.03 for distress. The corresponding total effects were significant as well, β  = 0.36, p  < 0.001 for anxiety, β  = 0.35, p  < 0.001 for depression, and β  = 0.34, p  = 0.001 for distress. The indirect paths from objective risk through the psychological variables were not significant, β  = 0.02, p  = 0.25 for anxiety, β  = 0.03, p  = 0.15 for depression, and β  = 0.004, p  = 0.84 for distress. The total effects, considering anxiety, depression and distress, were significant ( β  = 0.21, p  = 0.01 for anxiety, β  = 0.21, p  = 0.01 for depression, and β  = 0.19, p  = 0.02 for distress). See Fig.  3 for details of the models.

The models tested, Phase 2.

Given the cross-sectional design of our study, the risk exposure condition could be a moderator variable in the relationship between empathy and acceptance of the lockdown. We tested this relationship and found a significant model, F(5 191) = 33.93, p < 0.001, R2 = 0.47, however the test of the highest order unconditional interactions was not significant, F(2 191) = 2.85, p = 0.06, Rchange2 = 0.01, meaning that the interaction terms between empathy and risk conditions did not add any significant part of the variance in the explanation of the outcome and that the subsequent results should not be considered.

The emerging evidence from literature has stressed that lockdowns can exert a detrimental effect on an individual’s mental health. Thus, the question for public health professionals and experts is: what aspects may protect individuals from the negative side effects of lockdown during a pandemic and, at the same time, promote compliance with public health measures? This question leads to the need to understand how individuals are motivated to protect themselves and others 30 , 31 . The results of the present research contribute to the debate by providing answers related to the role of affective empathy, objective risk exposure and the psychological impact of lockdown during a pandemic.

Phase 1 found that the more an individual experienced affective empathy regarding the most vulnerable people, the more they perceived the lockdown as an effective measure and the more they experienced anxiety, depression or distress. However, the psychological impact of COVID-19 was not associated with the acceptance of the lockdown. Even the presence of chronic diseases, which could be considered a proxy for objective health risk condition, was not associated with the acceptance of the lockdown. In other words, individuals with high levels of affective empathy were inclined to accept the lockdown over and above their perception of psychological distress and their risk condition. This is consistent with previous studies showing that affective empathy is a prosocial attitude increasing adherence to physical distancing and hygiene measures during the pandemic 22 , 23 , 24 . Moreover, our results show that the role of a prosocial disposition, like affective empathy, is more effective than other negative psychological outcomes such as anxiety/worry and emotional distress. These are recognized in the literature as related protective behaviours in the pandemic 32 .

Phase 2 added the evaluation of the risk exposure condition in the forms of being included in one of the three groups: COVID positive/hospitalized individuals vs. COVID positive/home isolated individuals vs. COVID negative/home isolated individuals. Therefore, Phase 2 considered a more accurate measure for testing the risk exposure condition of the three different groups of participants according to their COVID-19 exposure and symptomatology. The aim was to test whether affective empathy remained a significant predictor of the acceptance of the lockdown, considering the specific risk exposure condition related to COVID-19 infection and psychological distress. The results demonstrated that, as expected, being COVID positive/hospitalised individuals was associated with greater anxiety, depression and distress. These results are consistent with international literature 9 , 11 and those from the same geographical region as our study 33 . Moreover, even though the risk exposure condition was significantly associated with the acceptance of the lockdown (i.e. the higher the risk the greater the acceptance), affective empathy was still a significant predictor, even controlling for psychological distress. We expected that the risk exposure condition would play a role in determining both psychological distress and the acceptance of lockdown. The originality of this research is given by confirmation that individuals who expressed concern for the vulnerable (i.e. affective empathy) were more willing to accept the lockdown measures that are known to create distress, even taking into account their risk exposure.

According to the evidence of our research, we would propose some practical implications regarding how to direct public health communication. One possibility is that communication at a time of health crisis may induce people to protect themselves and others through fear. Simple public health messages focusing on health risk may induce fear of contagion but may also have detrimental consequences for psychological distress and collective well-being, without increasing adherence to self-protective behaviours necessary to contain the virus spread. Evidence from the use of fear as a means in communication is inconsistent and often highlights a boomerang effect 34 .

A current debate acknowledges the importance of reducing the psychological impact related to uncertainty and fear of infection experienced during a pandemic. More complex messages targeting a peer group sharing risk awareness that focuses on the protection of the vulnerable could be envisaged. In doing so, communicators should express their empathy, demonstrating concern and understanding regarding the impact of the pandemic on individual lives 35 . The results of the present research are to be placed within this debate, with the potential to add several practical considerations.

Evidence collected during the present pandemic shows that messages focussing on the collective threat (i.e. family or loved ones, community) promote the intention to comply with public health rules (e.g. face covering 36 or eliciting clickthroughs on official information 37 ). Moreover, compared to messages that induce fear, prosocial messages capable of arousing a positive emotional state are more effective in inducing willingness to accept self-isolation 21 . In line with evidence collected in the same country as this study 33 , 38 , our results demonstrate that when the risk for an individual’s health and survival is high, the level of psychological negative impact is high as well. However, a negative psychological impact did not lead to a greater acceptance of the quarantine. In this sense, individuals might be more inclined to respect the lockdown if the communication stresses the risk for vulnerable people being infected by a virus that spreads at an exponential rate 39 ; this provokes their empathic tendencies (i.e. affective empathy). Our results actually demonstrate that affective empathy, along with risk exposure condition, is one of the possible mechanisms that reinforce the acceptance of measures that restrict individual freedom. Risk exposure condition, however, cannot be manipulated for communication purposes, whereas affective empathy can. Recent studies have shown that brief interventions aimed at the mechanism of psychological flexibility (and indirectly at values such as caring and supporting others) lead to increased prosocial behaviours in the laboratory and in everyday life 40 .

Therefore, as public health communication has more influence on people when individuals perceive that the communicator is empathetic 35 , similarly we propose to use a form of peer communication and to target the message by including calls for affective empathy. Such a call is particularly needed when considering a potential effect of a decline in empathy due to the persistence of the pandemic 26 . The target for this kind of intervention should be people with low risk because they are less likely to be inclined to adopt self-isolation measures. Sex and gender issues may influence COVID-19 effective risk exposure 41 and negative psychological impact or psychological and behavioural reaction during the pandemic 13 , 42 , and should be taken into account for targeted interventions. In particular, evidence shows that women score higher than men in trait empathy (measured by the Interpersonal Reactivity Index) during the pandemic and suffer more than men from depression, anxiety and trauma 43 . Furthermore, gender has been proved an influential factor in compliance with public health rules during the COVID-19 pandemic. For example, an experiment testing the effect of messaging on prevention measures showed that men are less prone to wearing a face covering and feel less at risk than women of being seriously affected by the coronavirus 36 . Such targeted risk groups, after training, could become official communicators. In this way they would strengthen a social connection that has been shown to be a major factor in mitigating the negative psychological impact of the lockdown 44 . Our proposal is in line with recent claims in this direction that highlight shared prosocial motivation as one of the global lessons to be learned from the COVID-19 pandemic 45 .

Our study opens different future perspectives in the field of prosocial human behaviour during pandemics. Replication of this study with a validated psychometric measure of affective empathy and acceptance of public health rules could improve the understanding of the psychological processes involved in the impact of such prosocial attitudes on mental health. Previous work on prosocial attitudes in healthcare professionals shows for example that perspective-taking (i.e. cognitive empathy) is preeminently protective of burnout risk if that cognitive process is not overwhelmed by emotional contagion (anxiety) in a threatening situation 46 , 47 . The protective role of cognitive processes of empathy on prosocial behaviour in interpersonal relations is in fact recognized in the current literature 20 and evidence gathered during the current pandemic tends to confirm this tendency. An online study of students and the general population found a positive correlation between trait empathy (measured by the Interpersonal Reactivity Index), particularly perspective-taking subscale, and social distancing tendencies 24 . Another recent online study on the general population conducted in Germany tends to confirm our data and shows how affective empathy, empathy for “loved ones” and moral norms are related to self-elicited social distancing behaviour 23 . The perspective-taking process at stake in empathy could also be linked to the subsequent process of distinction between self and the other (namely the “community” or “loved ones”). Identifying which cognitive or affective process is involved with an increase of prosocial behaviour, and how it will modulate psychological distress during risk exposure can be a major challenge for future studies aimed at informing public health communication during the current or future pandemics.

Data show that decreased psychosocial well-being is related to greater difficulty in adhering to physical distancing 48 . However, our results did not confirm these findings. In particular they did not show a reduced psychological impact for individuals with a higher acceptance of lockdown measures. This aspect needs to be investigated in further research with the aim of testing relationships among variables over time and establishing proper causal effects between them.

During a highly infective pandemic, we have learned the most important protective behaviours – respect the lockdown, wash your hands, cough in a tissue, keep distance, wear a mask, stay isolated if COVID-19 positive – but we have also realized that how communication fosters those behaviours is not yet fully defined. Our evidence discourages insisting on fear while informing the population, but rather suggests that inducing concern for the vulnerable (i.e. affective empathy) may be a way to promote adherence to behavioural measures of prevention and to target specific interventions to reduce the psychological burden.

In both Phase 1 and Phase 2, participants were asked to refer retrospectively to the period from 22 March to 11 May 2020 during the mandatory lockdown in Switzerland. From the end of February to the end of June 2020, the Swiss Federal Government implemented mandatory measures of quarantine and isolation. In Phase 1, participants from the general population replied to an online survey via QualtricsTM. They were recruited from 8 September to 15 October 2020. The research was repeatedly advertised on the Facebook page of the University. Participants did not receive any compensation and the questionnaire was completed in approximately 15–20 minutes.

In Phase 2, the data collection took place between 4 August and 5 October 2020. Patients were recruited through the local hospital database on COVID-19 cases provided by Ente Ospedaliero Cantonale (EOC). Individuals were recruited by phone and could decide between the paper–pencil questionnaire or the online version.

This research project was conducted in accordance with the protocol 49 , the Declaration of Helsinki, the principles of Good Clinical Practice, the Human Research Act (HRA) and the Human Research Ordinance (HRO), as well as other locally relevant regulations. The study was approved by the Cantonal Ethical Committee (N. 2020–01,460 /CE3679). Participation was voluntary and data collection was in an anonymous form. Participants received an information sheet and gave their informed consent for participation. Since the fact of evaluating their basic psychological status associated with lockdown might increase participants’ awareness of their mental health, a local public psychiatric organization number was included in the information sheet.

Phase 1 and Phase 2

Demographic. Self-reported information on sex (i.e. male/female), age, marital status (i.e. presence/absence of a partner), occupation (i.e. employed vs unemployed), household composition (i.e. number of individuals in the household), was collected through specific questions.

Previous health issues. Self-reported previous diagnosis of non-COVID-19 diseases was collected through specific questions, as a proxy for objective health risk condition. The following diseases were detected: high blood pressure, heart problems; migraines, epilepsy, neurological diseases, stroke; vision or hearing problems; mental disorders or illnesses; diabetes, thyroid or other gland disorders; chronic infections; tumours; kidney diseases; diseases of the lungs; digestive diseases; addictions (alcohol, drugs, medicines). One point was attributed each time the participants claimed to suffer from a chronic disease. The final score was calculated as a sum of the participants’ answers with higher scores indicating worse health conditions.

General Health . An item evaluating general health as reported by participants was administered (“How would you rate your overall health compared to others your age?”). Response options were on a 5-point Likert scale from 1 (“very bad”) to 5 (“very good”).

Affective Empathy . This was measured by means of three items developed and tested in six related studies 50 and then applied in a research on COVID-19 22 . These items were developed based on the empathic concern scale by Davis 51 . The items were back-translated and the specification “during the lockdown” was added at the beginning of each sentence. Therefore, the items applied in the present study were: “During the lockdown, I was very concerned about those most vulnerable to COVID-19”, “During the lockdown, I felt compassion for those most vulnerable to COVID-19”; “During the lockdown, I was quite moved by what could happen to those most vulnerable to COVID-19 infection”. Response options ranged from 1 (“strongly disagree”) to 5 (“strongly agree”). The items measuring empathic concern were mixed with three-filler items to reduce demand characteristics. The three items on empathic concern were averaged to create a final score (α = .84, rs > .63 [it was α > .81 in the original study 50 ]) with higher scores indicating greater affective empathy.

Acceptance of lockdown . Four items evaluating participants’ acceptance of physical isolation (lockdown) were administered 52 . The items were: “The lockdown was very effective in stopping the spread of COVID-19”; “So many people were affected by COVID-19 that lockdown reduced the risk of infection”; “COVID-19 is highly contagious, so lockdown was useful”; “I don't understand why people have ignored lockdown restrictions”. Labels ranged from 1 (“strongly disagree”) to 5 (“strongly agree”). The final score was created as a mean of all the items (α = .85, rs > .45) with higher scores indicating greater acceptance of the lockdown.

Psychological impact of lockdown. The psychological impact of lockdown was investigated with the Italian version of the NCCN 11-point Likert scale Distress Thermometer, without the Problem List 53 . Anxiety symptoms were investigated through the Generalized Anxiety Disorder 7-item Scale (GAD-7) 54 and depressive symptoms with the Patient Health Questionnaire-9 (PHQ-9) 55 . For GAD-7 and PHQ-9, participants indicated how often they had been troubled during lockdown by each symptom, using a four-point Likert scale ranging from 0 (“Not at all”) to 3 (“Nearly every day”). Two summative scores were created, with higher scores indicating greater anxiety or depression.

Participants

According to Fritz and MacKinnon 56 , the sample size was estimated a-priori with a given power of 0.80. We estimated that both the effect from affective empathy to psychological distress, and from psychological distress to acceptance of the lockdown would be halfway between small and medium. The combination of the two effects led to a sample of 162 participants, since we applied a percentile bootstrap method for calculation. A total of 418 participants started the survey, 79 of whom failed to finish. No differences emerged between those who completed the survey only in part and those who finished, with the exception of affective empathy (U = 5280, p = 0.039). Participants who completed all the survey showed higher affective empathy (M = 3.87, SD = 0.95) compared to those who completed only part (M = 3.54, SD = 0.90). Table 1 presents the description of the final sample.

The sample size was estimated similarly to Phase 1. The effect from risk exposure condition to affective empathy and from affective empathy to acceptance of the lockdown were set as halfway between small and medium. This combination led to a sample of 162 participants. The effect from risk condition to psychological distress was set as large, whereas the effect from psychological impact to acceptance of the lockdown was set as halfway between small and medium. The combination of these two effects led to a sample of 123 participants.

The database provided by EOC included 500 patients over 18 years of age who had tested positive for COVID-19 and been hospitalized in isolation in post-acute phase between 22 March and 11 May 2020 (group 1). There were also 310 patients over 18 years of age who had tested positive for COVID-19 and been isolated at home between 22 March and 11 May 2020 (group 2). A third group of participants included individuals from the general population who were in lockdown during the same period and negative to COVID-19 infection. 195 randomly selected participants of group 1 were contacted by phone, 100 responded to the call and 90 gave their verbal consent to participate in the study (response rate 90%). For group 2, 192 randomly selected participants were contacted, 102 responded to the call and 90 gave their consent (response rate 88%).

Two-hundred participants aged from 19 to 87 (M = 49.41, SD = 17.33; 109 women) took part in the research. Participants were classified in three groups according to their risk exposure condition: a) group 1, COVID positive/hospitalised individuals (n = 76), group 2, COVID positive/home isolated individuals k (n = 63), group 3, COVID negative/home isolated individuals (low risk). (n = 61). Table 1 shows demographics of the final sample.

Non-parametric comparisons between phase I sample and phase II low risk sample were performed to assure that the two groups of participants were comparable. The comparisons showed a significance in their levels of depression, U = 9.937, p = 0.042, with participants in phase I showing higher levels of depression (M = 6.8, SD = 5.4) than participants in phase II (M = 5.8, SD = 5.7).

Data analysis

Analyses were carried out with SPSS v.26 and Rstudio. The normality distribution of the main variables was checked. Missing data did not exceed 7% in phase 1 and 10% in phase 2. The structural validity of the scale was tested through Reliability Analysis (Cronbach’s alpha and inter-item correlations). The mediation analysis in Phase 1 was performed through PROCESS macro v3.5 for SPSS v.26. Non-parametric tests were performed to test whether differences emerged between participants who completed the survey only partially or entirely. The Structural Equation Model in Phase 2 was tested using LAVAAN package or RStudio. The following goodness-of-fit indices were used to evaluate model-data correspondence: the Chi-square value, the Comparative Fit Index (CFI), the Root Mean Square Error of Approximation (RMSEA), and the Standardized Root Mean Square Residual (SRMR). Given that the χ 2 value is influenced by the sample size, a model can be accepted when the CFI is higher than 0.90 and close to 0.95, the RMSEA is 0.08 or less, and the SRMR is 0.05 or less.

Limitations

Our study presents some limitation. First, a retrospective study has disadvantages such as memory bias and difficulty in analysing the temporal relationship among variables. However, especially for COVID positive/hospitalized individuals and COVID positive/home isolated individuals, the retrospective study was the only way to evaluate the state of mind of the participants without the risk of overwhelming them in already difficult circumstances (i.e. being COVID-19 positive). Moreover, participants in phase 1 are especially women and this affects the generalization of our results. Secondly, the estimation of the effects size applied to determine the sample size might have led to an underestimation of the required dimension. Since no previous research has analysed this topic, further research is needed to consider a larger sample, also in other countries, in order to achieve greater generalizability of the results. Thirdly, the measures are all self-reported, thus the answers might be biased or influenced by social desirability and the measures adopted have little demonstration of validity properties. Although the measure of affective empathy has been applied in several other studies 22 , 23 , 50 , 57 , there is little demonstration of its validity properties and further investigation should apply validated procedures to replicate our findings. Still, the measure of acceptance of public health rules is not validated, even though it has been applied elsewhere 52 . Although this can be considered a further limitation for the generalization of the results, to the best of our knowledge there were no validated measures in literature for this kind of construct at the time of data collection. Finally, our measures of empathy and acceptance of public health rules were limited respectively to affective empathy for others at risk for COVID-19 and acceptance of the lockdown measures for COVID-19.

Data availability

Data are available on request from the first author.

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Acknowledgments

The authors are grateful to all the participants in this study, particularly COVID-19 patients, for sharing their experience. Thanks to Tomaso R.R. Bontognali for scientific writing advice. The authors thank John Hodgson for proofreading this article.

This work was supported by the Ente Ospedaliero Cantonale Research Fund COVID-19 AFRI EOC 22519 and by the Cantonal Sociopsychiatric Organisation Scientific Fund for Psychosocial Medicine. The financial sponsor had no role in designing or conducting the research, in recruiting the participants, or in analysing and discussing the results. The authors declare no competing interests.

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These authors contributed equally: Serena Petrocchi and Nicola Grignoli.

Authors and Affiliations

Institute of Communication and Health, Università della Svizzera Italiana, Lugano, Switzerland

Serena Petrocchi

Laboratory of Applied Psychology and Intervention, Department of History Society and Human Studies, Università del Salento, Lecce, Italy

Sasso Corbaro Medical Humanities Foundation, Bellinzona, Switzerland

Sheila Bernardi & Roberto Malacrida

Cantonal Sociopsychiatric Organisation, Public Health Division, Department of Health and Social Care, Repubblica e Cantone Ticino, Mendrisio, Switzerland

Rafael Traber & Nicola Grignoli

Department of Internal Medicine, Regional Hospital of Bellinzona and Valleys, Ente Ospedaliero Cantonale, Bellinzona and Università della Svizzera Italiana, Lugano, Switzerland

Luca Gabutti & Nicola Grignoli

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All authors conceived the study. S.P., S.B., N.G. performed data collection. S.P. analysed the data. S.P., N.G. interpreted the results and wrote the manuscript. All authors contributed to the draft and revision of the paper and gave final approval of the version to be published.

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Petrocchi, S., Bernardi, S., Malacrida, R. et al. Affective empathy predicts self-isolation behaviour acceptance during coronavirus risk exposure. Sci Rep 11 , 10153 (2021). https://doi.org/10.1038/s41598-021-89504-w

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ORIGINAL RESEARCH article

Trait empathy modulates patterns of personal and social emotions during the covid-19 pandemic.

• 1 CAS Key Laboratory of Behavioral Science, Institute of Psychology, Chinese Academy of Sciences, Beijing, China
• 2 Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
• 3 Key Laboratory of Behavior and Cognitive Psychology in Shaanxi Province, School of Psychology, Shaanxi Normal University, Xi’an, China

The COVID-19 pandemic has caused profound consequences on people’s personal and social feelings worldwide. However, little is known about whether individual differences in empathy, a prosocial trait, may affect the emotional feelings under such threat. To address this, we measured 345 Chinese participants’ personal emotions (e.g., active, nervous), social emotions (i.e., fearful and empathetic feelings about various social groups), and their empathy traits during the COVID-19 pandemic. Using the representational similarity analysis (RSA), we calculated the pattern similarity of personal emotions and found the similarity between the positive and negative emotions was less in the high vs. low empathy groups. In addition, people with high (vs. low) empathy traits were more likely to have fearful and sympathetic feelings about the disease-related people (i.e., depression patients, suspected COVID-19 patients, COVID-19 patients, flu patients, SARS patients, AIDS patients, schizophrenic patients) and showed more pattern dissimilarity in the two social feelings toward the disease-related people. These findings suggest a prominent role of trait empathy in modulating emotions across different domains, strengthening the polarization of personal emotions as well as enlarging social feelings toward a set of stigmatized groups when facing a pandemic threat.

Introduction

COVID-19 as a public health crisis has posed a threat to public mental health and social harmony. It has been changing us greatly by adding uncertainty and loss of control to our lives, each of which is known to trigger emotional dysregulation and distress, such as depression anxiety ( Margetić et al., 2021 ; Tyra et al., 2021 ). It is no doubt that the public has been suffering from the personal domain of emotional burdens when facing such a threat. Differentiating from personal emotions which represent individuals’ subjective feelings of their own emotional experiences ( Thompson, 1991 ; Gilbert, 2014 ; Liu and Chen, 2021 ), the public’s social emotions——the feelings about other people and social groups——are influenced by the social isolation during the COVID-19 pandemic. For instance, accumulating research has revealed that people are afraid of and try to avoid a wide range of social groups, particularly the COVID-19 related people and groups, including healthcare workers, COVID-19 patients, people who recovered from COVID-19, and residents living in high-risk regions ( Bagcchi, 2020 ; Roberto et al., 2020 ; Abuhammad et al., 2021 ). Though pandemic has negative impacts on both personal and social emotions, so far, little is known about whether individuals may differ in the two domains of emotions in the context of threat.

It has been well-documented that individual and group differences in cognitive control, emotion-related traits, and biological sex can modulate emotions and the underlying supportive substrates ( Tamir et al., 2020 ). Among these factors, the prominent role of empathy in emotion perception ( Olderbak and Wilhelm, 2017 ), emotional regulation [e.g., cognitive reappraisal, and rumination, Knight et al. (2019) and Zaki (2020) ], and sharing others’ emotional feelings [e.g., sad and happy, Spencer-Rodgers et al. (2010) ] has been widely discussed. So far, little is known about whether such individual trait may affect personal and social emotions under the enormous ecological threat. The current study is set out to test whether and how trait empathy would affect individuals’ personal and social emotions during the COVID-19 pandemic.

Empathy and Personal Emotions

Empathy—the capacity to share and understand others’ emotional states—is highly related to the subjective experience of emotions and mirroring others’ emotions ( Decety and Jackson, 2006 ). Prior studies found that people with high relative to low empathy could capture negative emotions more quickly and experience them more deeply ( Yan et al., 2016 ; Sun et al., 2018 ). Using facial electromyography, researchers further revealed that high (vs. low) empathy individuals induced increased corrugator supercilii activity in processing disgusting and fearful facial expressions, suggesting increased sensitivity of negative emotions in high empathy individuals ( Rymarczyk et al., 2016 ). These findings suggest that high relative to low empathy people show more emotional reactions (e.g., more negative emotions and physiological responses) to process emotional stimuli conveying threatening/negative information (e.g., fear). However, little attention has been paid to the role of empathy in the modulation of emotions under a pandemic threat. Recently, a few studies uncovered that when compared to low empathy people, high empathy people experienced more emotional disorders during the COVID-19 pandemic [e.g., anxiety, depression, and poor sleep quality, Guadagni et al. (2020) and Petrocchi et al. (2021) ]. Similarly, the association between empathy and negative emotions (e.g., anger) was replicated in an Eastern sample of 453 Chinese during COVID-19 ( Ma and Wang, 2021 ). So far, most of these studies have focused on the impact of empathy on negative emotions, e.g., vigor, depression, distress ( Guadagni et al., 2020 ; Van de Groep et al., 2020 ; Grignoli et al., 2021 ). Considering that positive emotions are of great significance in fostering subjective well-being ( Livingstone and Srivastava, 2012 ) and help promote psychological resilience when facing an ecological threat [e.g., Yamaguchi et al. (2020) and Gurvich et al. (2021) ], we are curious about whether empathy may help boost the public’s positive emotions to relieve stress. Furthermore, we are interested in whether empathy may modulate the positive and negative dimensions of personal emotions, the characteristics of the two dimensions (i.e., pattern similarity), and the relationship between the two dimensions.

The relationship (i.e., the ratio) of the two dimensions of personal emotions has been found to function as an indicator of psychological well-being ( Larsen, 2009 ). Toward a better understanding of the relationship between positive and negative emotions, researchers have proposed different theoretical models and debated for a long time [e.g., the bipolar vs. bivariate models, Larsen et al. (2001) ; Schimmack (2001) , and Ong et al. (2017) ]. The bipolar model holds the view that positive and negative emotions are opposite to each other, that is, positive emotions and negative emotions are mutually exclusive and opposite to each other, and an individual can experience only one of them at the same time ( Russell and Carroll, 1999 ; Liu et al., 2008 ). On the contrary, the bivariate model suggests that the two are not mutually exclusive ( Larsen et al., 2001 ), and they could coexist and negatively correlate with each other ( Liu et al., 2008 ). One possible account behind the debate could be that the sources (e.g., personal affairs and social contexts) that trigger individuals’ emotions are complex and diverse rather than singular. Considering that the complexity of determining the sources creates obstacles to understanding emotions and their patterns, it is worth mentioning that COVID-19, as a pandemic threat that has heightened the public’s collective emotions ( Stanley et al., 2021 ), could provide a shared social context and contributes to a group perspective for understanding the relationship between positive and negative emotions and its underlying characteristics (i.e., pattern).

A previous study has shown that when exposed to a stressful event (e.g., a stressful speech), individuals’ positive and negative emotions exhibited more polarization—a higher level of negative correlation ( Zautra et al., 2000 ). This finding suggests that a stressful event could lead to attentional narrowing, which may in turn influence personal emotional states to jointly help humans respond rapidly when facing threats ( Hermans et al., 2014 ). Considering that COVID-19 is a severe stressor that has posed psychological burdens ( Elbay et al., 2020 ; Gritsenko et al., 2020 ), we speculated COVID-19 might lead to a negative association between positive and negative emotions. Given that individuals with high (vs. low) empathy are more sensitive to negative social events ( Yan et al., 2016 ; Sun et al., 2018 ), we predicted that people with high (vs. low) empathy might be more likely to show more polarization in the relationship between the two personal emotions.

Empathy and Social Emotion

Although previous studies have shown that people felt fearful about people and groups related to the COVID-19 disease, such as fear of interacting with people suffering or recovered from COVID-19, toward people related to COVID-19 ( Bagcchi, 2020 ; Roberto et al., 2020 ; Abuhammad et al., 2021 ). Meanwhile, some studies have revealed that people would also have positive (or prosocial) feelings, i.e., sympathy, about people related to COVID-19 ( Li et al., 2020 ). The emotional feelings toward others mentioned above are real (or expected) emotional experiences and reactions that people generate in real (or imagined) interactions with others, which are referred to as social emotions ( Mercer, 2014 ). According to the previous research, we speculate that in the face of the pandemic, individuals’ social emotions toward disease-related groups are complex; that is, negative social emotions (fear) and positive social emotions (sympathy) coexist.

Previous evidence has shown that the psychological process of people’s social feelings toward others is closely related to their ability to empathize ( Schipper and Petermann, 2013 ). Based on the definition of the two components of empathy, cognitive empathy reflects an individual’s ability to understand others’ emotions, and affective empathy refers to an individual’s capacity to share others’ emotions ( Deutsch and Madle, 1975 ; Cox et al., 2012 ). High empathy people therefore may be better at sharing others’ emotions and understanding others’ situations. For example, high compared to low empathy individuals were more willing to offer money and time to assist people with difficulties ( Lay et al., 2020 ; Xiao et al., 2021 ). Moreover, empathy-related neural activity (i.e., medial prefrontal cortex) contributed to the subsequent empathic concern toward the victim in need ( Masten et al., 2011 ; Spencer-Rodgers et al., 2010 ; Perez-Bret et al., 2016 ). Consistently, high empathy people tend to predict high prosocial behavior under the COVID-19 threat ( Taylor et al., 2020 ; Lv et al., 2021 ; Seong-Wook et al., 2021 ). Accordingly, we speculated that individuals with high vs. low empathy might generate more prosocial emotions (i.e., sympathetic) toward people in need (e.g., COVID-19 patients) during COVID-19.

On the other hand, recent evidence suggests that empathy may account for people’s fear and avoidance of disease-related groups who may carry the virus during the COVID-19 pandemic. For example, people tried to identify people who might pose a potential infection risk when facing a pandemic threat ( Troisi, 2020 ). In line with this, high empathy people were observed to show more self-protection tendencies during COVID-19, such as engaging in physical distancing and wearing facial masks ( Sassenrath et al., 2021 ). It is assumed that more fear of the disease-related groups and increased self-protection focus among high relative to low empathy people are served as a protective mechanism, which supports keeping away from danger when facing the threat of COVID-19 ( Ramaci et al., 2020 ). Though the two seemingly contradictory aspects (i.e., fear and sympathy) of social emotions are related to empathy, so far, it remains unclear whether or to what extent empathy may simultaneously affect the two social emotions toward disease-related groups and their relationship under a pandemic threat.

The Current Study

The current study aims to examine the impact of empathy on personal and social emotions and their patterns under the threat of COVID-19. Previous research mostly focused on the mean or sum value of different items within the two-valence domains [i.e., calculate two values to represent positive and negative emotions, e.g., Gan and Fu (2022) and Matiz et al. (2022) ]. Thus, it may hardly capture whether individuals’ emotions, as well as their feelings about others, may differ in their pattern characteristics in terms of similarity ( Riberto et al., 2019 ). The above issues can be easily addressed by using representational similarity analysis (RSA)—a computational technique that utilizes pairwise comparisons of units to reveal the similarity pattern among a set of variables ( Haxby et al., 2014 ). Unlike the traditional linear correlation testing of two-dimensional values, RSA has been gradually used in understanding behavioral as well as neural patterns in the field of social psychology ( Brooks and Freeman, 2018 ), which helps uncover the pattern similarity and further provides direct comparisons across conditions ( Luo et al., 2021 ).

In the current study, taking advantage of RSA, our first goal was to examine the pattern similarity of the public’s personal emotions (i.e., positive and negative emotions) and the pattern similarity between the two types of emotions during the COVID-19 pandemic. To address this question, we measured Chinese positive and negative emotions (e.g., inspired, active, nervous, and scared) when they were facing the COVID-19 pandemic. Our second goal was to reveal the pattern similarity of the public’s social feelings toward a variety of social groups (e.g., disease-related people, people violating moral norms, and healthy people) during the COVID-19 pandemic. As for social feelings, we first focused on the two sympathetic and fearful feelings toward the COVID-19-related people and groups (e.g., people infected by COVID-19, people who were suspected patients of COVID-19, and people who have been recovered from COVID-19), which have been demonstrated to be stigmatized during this pandemic [e.g., Baldassarre et al. (2020) and Ransing et al. (2020) ]. In addition, we were curious about whether their feelings toward the other disease-related groups, such as people suffering from an infectious disease (e.g., AIDS) and people with mental illness (e.g., schizophrenic patients) may show more pattern similarity. Researchers believe that disease-related groups are usually viewed as social deviants who violate certain norms by the public ( Phelan et al., 2008 ). We, therefore, included people who violate the moral norms (e.g., robbers). Finally, we added non-disease people (e.g., healthy people, natives) as control. Last but not the least, the third goal of the study was to test whether people who differ in the prosocial propensity (i.e., trait empathy) may elicit dissimilar patterns of personal and social emotions to help policymakers understand collective emotions in the context of such a crisis. To address this, we measured participants’ trait empathy using a Chinese version of the Interpersonal Reactivity Index (IRI) Scale ( Zhang et al., 2010 ) and compared the pattern similarity of personal and social emotions between the high and low empathy people.

Materials and Methods

Participants.

We collected two waves of data during the recovery period of COVID-19 (one is from May 2 to July 12, 2020; and the other is in December 2021, the severity of the outbreak is similar to the former in terms of the number of locally confirmed cases in China), using convenience sampling method (via WeChat spreading) through the online platform like Qualtrics. 1 According to Meade and Craig (2012) ’s recommendation for detecting careless data, we ruled out data with wrong answers in the probe questions (e.g., if you notice this question, please select the option “6”; if you choose any other options, your data will be invalid) ( N = 32) and invalid data (only completed the informed consent part of the questionnaire) ( N = 21). We excluded 21 participants from Hubei Province, considering that their perceptions of COVID-19 related groups might be different from those who were from other Chinese provinces because the Hubei province had the most serious outbreak of COVID-19 in China during the period that we conducted this study, and people in Hubei had mostly experienced lockdown. Additionally, previous research has shown that people in the areas with severe epidemics have different risk perceptions of the COVID-19 pandemic than those from other areas ( Wen et al., 2020 ). The final sample was 345 (120 males and 224 females, mean age 25.13 ± 7.85 years). Before the survey, all participants were given informed written consent. The present research was approved by the ethics committees of the Institute of Psychology, Chinese Academy of Sciences the institute. The current research was from a big project on COVID-19 and mental health. The dataset of social emotion was from a previously published study ( Zhu et al., 2022 ). In the current study, we reanalyzed the data using representation similarity analysis to address the empathy modulation on emotions, which was not investigated by the previous study.

Measurements

Personal emotion.

Using an adapted Watson et al. (1988) ’s Positive and Negative Affectivity Schedule, we measured participants’ positive and negative emotions within a week during the pandemic on a 7-point Likert scale (1 = never , 7 = always ), which included four positive (i.e., interested, proud, inspired, active) and seven negative emotions (i.e., upset, irritable, nervous, hostile, jittery, guilt, scared). The selected items have been proven to be related to individual emotional states under the pandemic threat [e.g., upset, and sacred in Hennein and Lowe (2020) ; nervous in Wang et al. (2020) ]. The Cronbach’s α coefficients were 0.81 for the positive and 0.90 for the negative dimension.

Social Emotion

We measured subjective reports on the possibility of participants’ positive (sympathetic) and negative (fearful) feelings toward a variety of social groups on a 7-point scale (1 = not at all , 7 = extremely ). There were 15 social groups, including healthy people, natives, outsiders, Muslims, depression patients, recovered COVID-19 people, suspected COVID-19 patients, COVID-19 patients, flu patients, SARS patients, AIDS patients, schizophrenic patients, people with masks, people not wearing masks, and robbers. The above social groups have been extensively studied in previous studies on social feelings and attitudes [e.g., Thornicroft et al. (2009) ; Nyblade et al. (2018) , Javed et al. (2021) , and Reinius et al. (2021) ]. Hierarchical cluster analysis was adopted for grouping the 15 groups into three clusters: the disease, the control, and the social deviant ( Supplementary Figure 1 ). In the hierarchical clustering analysis, we used the hclust function in the corrrplot package of R ( Wei et al., 2017 ), which can directly perform hierarchical clustering and visualization of the results. Based on the cluster analysis, the following targets, including depression patients, suspected COVID-19 patients, COVID-19 patients, flu patients, SARS patients, AIDS patients, and schizophrenic patients, were incorporated into one unit as the disease cluster ( Supplementary Figure 1 ). Similarly, these groups (i.e., healthy people, natives, outsiders, people with masks) were clustered into one unit as the non-disease control cluster ( Supplementary Figure 1 ), and the remaining groups were labeled as the social deviant cluster. Considering the variances in the deviant cluster and our research scope, we mainly focused on the differences between the disease and the control clusters.

Trait Empathy

We used a Chinese version of the Interpersonal Reactivity Index (IRI) Scale ( Zhang et al., 2010 ) with nine items to measure participants’ ability to share and understand others’ feelings on a 7-point scale (1 = fully disagree , 7 = fully agree ) (e.g., “I try to look at everybody’s side of a disagreement before I make a decision”). This scale included the four dimensions as the original IRI scale ( Davis, 1980 ), including two cognitive empathy (empathetic concern, perspective-taking) and two affective empathy (personal distress, and fantasy) dimensions. We calculated the correlation of affective empathy (α = 0.71) and cognitive empathy (α = 0.76) and the two were correlated ( r = 0.49, p < 0.001). Therefore, we merged the four dimensions and calculated the mean score of the IRI scale for each participant. A higher score indicated a higher level of trait empathy. We then split participants into two groups: high (above-average, N = 171) and low empathy (below-average, N = 174) groups. The Cronbach’s α coefficient was 0.74.

Data Analysis

Distribution of personal and social emotions.

To examine the distribution of personal and social emotions, we first applied the Kolmogorov-Smirnov test. Next, we ran the Mann-Whitney U -test to examine the differences in the distribution of the two types of emotions between the high and low empathy groups.

Representation Similarity Analysis

According to previous research ( Luo et al., 2021 ), we first calculated the representation similarity matrix (RSM) on the personal and social emotions of all participants. Specifically, we calculated the representation similarity matrix (RSM) on the seven negative emotions (negative-emotion RSM) across all participants using the Pearson correlation coefficients. The same method was used for generating the RSM of positive emotions (positive-emotion RSM). Furthermore, to investigate the relationship between the positive and negative emotions, we calculated the RSM between the two emotions (positive-negative-emotion RSM). Then, we applied the Fisher r to z transformation to the RSM to ensure a normal distribution of the correlation coefficients. Similarly, we calculated the RSM of the positive (i.e., sympathetic feelings) and negative (i.e., fearful feelings) social emotions of the disease and the control clusters. Then, we applied the Fisher r to z transformation to the RSM of the social emotions. We then calculated the RSM of the personal and social emotions for the high and low empathy groups and tested the discrepancy in pattern similarity between the two groups.

Representational Similarity Analysis of Personal Emotions

We first analyzed the distribution of all emotions ( Supplementary Results and Supplementary Figure 2 ). Generally, participants experienced a low frequency of negative emotions but a medium frequency of positive emotions during the COVID-19 pandemic ( Figure 1A ). The RSM of the two personal emotions revealed that the positive and negative emotions were inversely correlated with each other in general ( Figure 1B ).

Figure 1. Results of personal and social emotions. (A) The histogram of positive (light red) and negative personal emotions (light green); (B) The representation similarity matrix (RSM) of personal emotions; (C) The histogram of sympathetic (light red) and fearful (light green) feelings for the disease cluster; (D) The histogram of sympathetic (light red) and fearful (light green) feelings for the control cluster; (E) The RSM of sympathetic and fearful feelings toward the disease and control clusters. * p < 0.5.

Representational Similarity Analysis of Social Emotions

We calculated the distribution of the social emotions of the disease, control, and deviant clusters ( Supplementary Results and Supplementary Figure 3 ). A medium-to-high rate of sympathetic feelings and a similar rate of fearful feelings were observed for the disease cluster ( Figure 1C ) and lower rates of the two social feelings were shown for the control clusters ( Figure 1D ). To further examine the pattern similarity of the social feelings, we calculated the sympathy RSM and the fear RSM ( Figure 1E ) for the two clusters separately. Results showed that the sympathy RSM was correlated with the fear RSM in the disease ( r = 0.39, p < 0.05) and control clusters ( r = 0.87, p < 0.05).

Personal Representational Similarity Analysis of Individuals With High vs. Low Empathy

First, the distribution results of personal emotions showed that the high (vs. low) empathy group reported a higher frequency of positive and negative emotions ( Supplementary Results and Supplementary Figure 4 ). Consistently, the independent t-tests on each personal emotion item showed that the high (vs. low) empathy group reported a significantly higher frequency of the following emotions: active, upset, nervous, jittery, irritable, scared (2.00 < ts < 3.35, ps < 0.05, Supplementary Table 1 ). We then calculated the RSMs of the personal emotions and found more pattern similarity of the negative RSM in the high (vs. low) empathy group [ t (20) = 3.19, p < 0.01, Figure 2A ]. No difference in the pattern similarity of the positive RSM between the two groups [ t (5) = 1.15, p = 0.30]. Moreover, the positive-negative RSM of the high empathy group was more dissimilar than that of the low empathy group [ t (27) = −12.90, p < 0.001, Figure 2A ], indicating that less pattern similarity between the two personal emotions was induced in the high vs. low empathy group during the pandemic.

Figure 2. High vs. low empathy in personal and social emotions. (A) The representation similarity matrix (RSM) of personal emotions in high and low empathy groups; (B) The RSM of fearful feelings toward the disease and control clusters in high and low empathy groups; (C) The RSM of sympathetic feelings toward the disease and control clusters in high and low empathy groups. * p < 0.05, ** p < 0.01, *** p < 0.001.

Social Representation Similarity Matrix of Individuals With High vs. Low Empathy

The distribution results showed that the high (vs. low) empathy group showed a higher rate of fear and sympathy for the disease cluster ( Supplementary Results and Supplementary Figure 5 ). Specifically, the independent t-tests showed that the high (vs. low) empathy group reported a higher rate of fear toward COVID-19 patients, AIDS patients, and Flu patients (1.98 < t < 2.53, ps < 0.05) and a higher rate of sympathy toward all disease-related people (2.05 < t < 3.93, ps < 0.05, Supplementary Table 2 ). Paired sample t -test showed that the high (vs. low) empathy group showed less pattern similarity in the fear RSM for the disease [ t (20) = −2.96, p < 0.01] and control clusters [ t (5) = −12.14, p < 0.001, Figure 2B ]. In addition, the pattern similarity of the sympathy RSM of the high (vs. low) empathy group was lower for the disease cluster [ t (20) = −3.14, p < 0.01, Figure 2C ] but not for the control cluster [ t (5) = −1.80, p = 0.13]. These results suggest that high empathy people may induce more dissimilar and mixed social feelings about the disease-related groups to help them better adjust when facing a pandemic threat.

Previous literature has revealed that individuals’ emotional reactions are related to trait empathy ( Powell, 2018 ; Thompson et al., 2019 ; Wearne et al., 2019 ). However, insufficient attention has been paid to the relationship between the trait empathy and different emotions when facing ecological threats. To fill this gap, the current study focused on the pattern similarity of personal and social emotions under the COVID-19 threat and demonstrated that trait empathy strengthens Chinese personal emotions and their social feelings toward a variety of social groups under the pandemic threat. First, people with high (vs. low) trait empathy felt more positive and negative emotions during the recovery stage of COVID-19. The two valences of personal emotions had less similarity in the high (vs. low) empathy group. Second, high (vs. low) empathy people reported more fearful and sympathetic feelings toward the disease-related people. Additionally, the pattern similarity of the two social feelings toward the disease-related groups had less similarity in the high (vs. low) empathy group. To be noted, the conventional analysis (i.e., directly comparing means of emotions) failed to robustly detect the group differences in personal and social emotions (see Supplementary Tables 1 , 2 ). However, the pattern analysis indeed uncovered a robust effect of empathy on modulating Chinese personal and social emotions, which suggests that pattern analysis may be a more powerful tool to capture the pattern of collective emotions under threats.

Previous studies found that there was no association ( Spencer-Rodgers et al., 2010 ) or positive correlation between positive and negative emotions in Asians (i.e., Chinese, Japanese) ( Scollon et al., 2005 ; Cassels et al., 2010 ). Differently, our results revealed that the two types of personal emotions were negatively correlated, which may be due to the context of the threat. More interestingly, we found that positive and negative emotions were more inversely correlated in high vs. low empathy individuals, suggesting that trait empathy may play a role in enlarging the polarization of the two personal emotions during the pandemic. Moreover, we found that the polarization was driven by the increased pattern similarity of negative emotions in low compared to high empathy individuals. Similarly, Tamborini et al. (1990) found that college students with high empathy traits reacted more strongly to the suffering stimuli when they were watching a horror film. What’s more, high (vs. low) empathy individuals were more sensitive to emotional stimuli (i.e., recognize the emotional state of others from their faces more accurately), especially the negative emotion (e.g., sad and fear) ( Chikovani et al., 2015 ). One possible explanation behind the pattern results of personal emotions is that high empathy relative to low empathy individuals may arouse a higher frequency of a wide range of negative emotions to keep alert when facing ecological threats.

As we have mentioned above, previous studies have found that high empathetic people are more sensitive to threatening stimuli ( Fossataro et al., 2016 ). In line with these studies, our results confirmed that Chinese with high compared to low trait empathy were more likely to fear people with highly infectious diseases and severe mental illness (e.g., COVID-19 patients, schizophrenic patients). The fear of the disease-related people can be explained by the pathogen aversion theory, which holds that aversion to possible pathogen sources serves as a psychological mechanism to protect us from infectious diseases. It is an adaptive ability to avoid potential infection risk by avoiding contact with disease-related groups under the pandemic threat ( Park et al., 2003 ; Oaten et al., 2011 ). From the evolutionary perspective, empathy helps individuals keep away from things that might harm them. For example, low empathy individuals have more difficulties in inhibiting substance-related addictions ( Preller et al., 2013 ) and behavioral impulsivity ( Tomei et al., 2017 ).

Compared with low empathy individuals, high empathy individuals reported higher levels of empathetic feelings toward the disease group. The reason could be that high empathy individuals could put themselves in others’ situations and understand their emotions, which may facilitate cooperation under threats ( Eisenberg and Miller, 1987 ; Morelli et al., 2014 ). Previous studies revealed that as a prerequisite for understanding others’ emotional states, high empathy relative to low empathy individuals had a higher ability in detecting and discriminating others’ emotions ( Spencer-Rodgers et al., 2010 ; Olderbak and Wilhelm, 2017 ). An ERP study found that high empathy individuals induced a larger neural activity in both early (300–600 ms) and late processing (600–800 ms) in discriminating emotional faces ( Choi and Watanuki, 2014 ). Meanwhile, high empathy individuals not only process emotional information deeply but also have different reactions to various targets. For example, high compared to low empathy people had a larger zygomatic activity to angry faces than happy ones ( Dimberg and Thunberg, 2012 ). This finding indicated that high empathy individuals elicited stronger physiological reactions (i.e., muscle activity) in response to others’ negative emotions. Consistent with this, high vs. low empathy people could recognize other people’s emotions more accurately, especially negative emotions (e.g., fear and sadness) ( Chikovani et al., 2015 ). Meanwhile, trait empathy is related to one’s positive feelings (e.g., subjective well-being) ( Depow et al., 2021 ) and promotes prosocial feelings (e.g., willingness to help others) ( Telle and Pfister, 2016 ). Consistent with these studies, our results suggest that Chinese with high empathy traits may experience more mixed social feelings when they think about interacting with disease-related groups under the pandemic threat.

In the current results, people with high empathy have complex social emotions toward disease-related people, that is, sympathy (other-oriented) and fear (self-oriented, based on their avoidance of infection). These results were consistent with the existing research that individuals with high empathy have high self-protection intentions and high other-protection intentions simultaneously at the behavioral level. Specifically, people with high empathy were more willing to take other-protective behaviors during the COVID-19 pandemic ( Pfattheicher et al., 2020 ). Meanwhile, some researchers found that the implementation of pandemic prevention measures in high empathy people was mainly driven by a high self-protection tendency [e.g., Rieger (2020) and Asri et al. (2021) ].

The current study has the following limitations. First, the current study revealed that high empathy relative to low empathy people reported more negative and positive emotions during the COVID-19 outbreak (in both personal and social emotions) but showed less pattern similarity in the positive and negative aspects of the two emotions. However, the underlying mechanisms of the group discrepancy in pattern similarity remain unclear. Taking advantage of neuroimaging technology, researchers could further address whether different neural substrates may be recruited to support the modulation of empathy on personal and social emotions. Additionally, the study was conducted during the recovery period of the pandemic. Although the findings have suggested that there are differences in the pattern similarity of personal and social emotions between high empathy and low empathy individuals during the COVID-19 pandemic, we need to take caution in understanding the moderation of empathy in the patterns of emotions in normal times. Future research is encouraged to manipulate different threat levels (vs. non-threat control) to test whether such moderation of empathy is specific to collective threats or not. Another limitation of the current research is that the factors affecting emotions are complex. Therefore, in addition to empathy, whether other factors can affect the pattern of emotions remains unsolved. Considering that individual and social emotions are also linked with other emotion-related traits [e.g., anxiety and neuroticism, Wang et al. (2019) ; Vinograd et al. (2020) , and Brookman et al. (2022) ], future work is encouraged to test whether other emotion-related traits or factors would affect the pattern of collective emotions under threats. Moreover, we only focused on two social feelings in this study. It would be interesting to examine the relationship of various social emotions, e.g., guilt, pride, embarrassment, and jealousy.

The current study highlights the role of empathy trait in modulating the patterns of personal and social emotions during the COVID-19 pandemic. People with high empathy showed more pattern similarity of negative emotions but less pattern similarity of social emotions about the disease-related people than low empathetic people did when facing such a threat. Our findings enrich the existing literature on understanding the role of empathy in mental health and social cognition in the context of threat.

Data Availability Statement

De-identified data and code of the present study are available upon request to the corresponding author.

Ethics Statement

The studies involving human participants were reviewed and approved by the Ethics Committees of the Institute of Psychology, Chinese Academy of Sciences. The participants provided their written informed consent to participate in this study.

Author Contributions

YM conceived of the project. YM and JZ designed the project. JZ implemented the experiments and collected the data. YH and JZ performed the analyses. YH, JZ, and YM wrote the manuscript. All authors discussed the results and approved the submitted version.

This work was supported by the National Natural Science Foundation of China (32071016), and CAS Key Laboratory of Behavioral Science, Institute of Psychology, Chinese Academy of Sciences (Projects 2019000050, Y5CX052003).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2022.893328/full#supplementary-material

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Keywords : COVID-19, threat, emotion, empathy, representational similarity analysis

Citation: He Y, Zhu J, Chen X and Mu Y (2022) Trait Empathy Modulates Patterns of Personal and Social Emotions During the COVID-19 Pandemic. Front. Psychol. 13:893328. doi: 10.3389/fpsyg.2022.893328

Received: 10 March 2022; Accepted: 12 May 2022; Published: 10 June 2022.

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*Correspondence: Yan Mu, [email protected]

† These authors have contributed equally to this work

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