Chapter

Meeting the therapist: a look into trust, hope, empathy, and compassion mechanisms

Fabrizio Benedetti

in The Patient's Brain

Published on behalf of Oxford University Press

Published in print October 2010 | ISBN: 9780199579518
Published online February 2013 | e-ISBN: 9780191754661 | DOI: http://dx.doi.org/10.1093/med/9780199579518.003.0005
Meeting the therapist: a look into trust, hope, empathy, and compassion mechanisms

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1) In this chapter, several aspects of the doctor–patient interaction are considered, from the patient's trust and admiration towards the therapist to the doctor's empathic and compassionate behaviour. All these highly complex brain functions have been described from a neuroscientific perspective, and represent what is called social neuroscience, a branch of the neurosciences which investigates complex social behaviours. 2) Trustworthiness decisions are based on several environmental stimuli, first and foremost, facial expressions. The decision on whether a face is trustworthy or untrustworthy depends on the amygdala. This region increases its activity as the facial expression is judged to be untrustworthy, and vice versa. 3) Oxytocin is a hormone that has been found to stimulate pro-social behaviour. In particular, it is produced in the hypothalamus and then secreted by the pituitary gland, and is capable of increasing trust. This effect is likely to be due to the presence of oxytocin receptors with inhibitory action in the amygdala. As amygdala hyperactivity is associated to untrustworthiness, oxytocin may inhibit this effect when binding to amygdala neurons. 4) Although admiration differs from trust, these two emotions are related to each other. If one admires a person, he is likely to trust him. The opposite often holds true. Admiration and trust may represent a very important aspect of the therapist–patient encounter. There is experimental evidence that admiration engages two different neural systems, depending on the type of admiration. If it is related to someone else's psychological state, e.g. admiration for moral virtue, it recruits a network involving the inferior/posterior posteromedial cortices and the anterior middle cingulate, which are affiliated with interoceptive information. If it is related to someone else's physical state, e.g. admiration for virtuosic skill, it recruits the superior/anterior part of the posterolateral cortices most connected with lateral parietal cortices, which deal with exteroception and musculoskeletal information. 5) Sensory stimuli are particularly important during the doctor–patient interaction. For example, subtle differences in verbal communication may lead to different outcomes. Likewise, visual stimuli are crucial for nonverbal communication, whereby gestures and postures can communicate plenty of meaningful information. The mirror neuron system plays a crucial role in these functions. Finally, the somatosensory input, e.g. tactile, may contain important emotional information. For example, being touched by a beloved one while in pain may reduce the unpleasantness of the pain itself. 6) Hope is also a basic aspect of the therapist–patient interaction. It can be defined as a positive motivational state that is based on a sense of successful goal-directed energy and planning to meet goals. Two key elements take part in hope: expectation and motivation. With the former, the patient expects the future to be better than the present. With the latter, the patient adopts the adequate behavioural repertoire to do so. Hope and hopelessness may influence the course of a disease, and even mortality. Therefore, high levels of hope should always be induced in the patient. 7) The study of hopelessness, and related helplessness, has shown that both the serotoninergic and noradrenergic systems are involved. For example, there is a negative correlation between the activation of serotonin receptors in the dorsolateral prefrontal cortex and the degree of hopelessness. 8) One of the main characteristics of health professionals should be their empathic behaviour. Empathy is distinguished from sympathy or empathic concern or compassion. An emotion produced by empathy is isomorphic with the other's emotion. This is not necessarily true for sympathy or compassion. Nor is empathy necessarily linked to pro-social motivation, namely, the concern about the others’ well being. By contrast, pro-social motivation is involved in both sympathy and compassion. 9) There is evidence suggesting that at least two mechanisms mediate empathy: emotional contagion on the one hand and cognitive perspective-taking on the other. Whereas emotional contagion is thought to support our ability to empathize emotionally, that is, to share the other person's emotional feelings, empathic perspective-taking involves complex cognitive components, whereby one infers the state of the other person. This distinction is particularly important from a neuroscientific point of view. In fact, whereas cognitive perspective taking activates the medial prefrontal regions, the superior temporal sulcus, the temporal pole, and the temporo-parietal junction, empathizing with another person has been found to activate somatosensory and insular cortices as well as the anterior cingulate cortex. 10) As for admiration, there are two different neural networks for compassion. Compassion for social pain is associated with strong activation in the inferior/posterior portion of the posteromedial cortices, whereas compassion for physical pain produces a larger activation in the superior/anterior portion of the posteromedial cortices. 11) In order to suppress distress in everyday medical practice, health professionals, particularly those involved in invasive and painful procedures, have developed mechanisms of self-control that are aimed at reducing negative emotions while watching the suffering of their patients. For example, the somatosensory cortex of physicians who practice acupuncture shows less activation compared to naive subjects when observing animated visual stimuli depicting needles being inserted into different body parts. 12) A good interaction between doctors and patients may lead to positive therapeutic outcomes and this represents the basis of different placebo effects, which will be discussed in Chapter 6. Therefore, health professionals must always adopt empathic and compassionate behaviours, which are aimed at modulating the patient's brain through the activation of the neural mechanisms of trust and hope. Even a mere diagnostic procedure may produce positive effects if performed in the appropriate context. 13) On the other hand, a bad interaction between health professionals and their patients may lead to negative outcomes. For example, anxiety may be induced, and we have seen in section 3.3.3 that negative emotions amplify the perception of pain. Although anxiety-induced hyperalgesia is the best-known model to understand the link between negative emotions and the perception of a symptom (see section 3.3.3), symptoms other than pain can be amplified by anxiety and other negative emotions. 14) This chapter is of particular relevance to psychotherapy. In fact, in psychotherapy the therapist–patient interaction is at the very heart of the therapeutic outcome. Several authors suggest that psychotherapy works only through a benign positive interaction, and several studies support this notion. There are common elements in any form of psychotherapy, such as trust, belief, hope, motivation, expectations, and these may represent the key to successful outcomes.

Chapter.  22489 words.  Illustrated.

Subjects: Psychiatry

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