The ability to empathize with patients is vital to becoming a good clinician (1–3). Although many believe that the capacity for empathy is innate, medical educators have tried to develop exercises and techniques to foster empathy in clinicians (4, 5). Coulehan et al. (6) define empathy as “the ability to understand the patient’s situation, perspective, and feelings, and to communicate that understanding to the patient.” While empathy is important for all clinicians, it may be particularly critical for psychiatrists who must rely on their understanding of the patient’s internal experience in order to diagnose and treat their patients. Nevertheless, trainees may have a more difficult time learning to empathize with patients whose internal experiences are very distant from their own—for example, patients with hallucinations, delusions, or cognitive impairment (7). These differences might represent significant barriers to developing empathy with severely and persistently mentally ill patients, especially early in psychiatric training.
Medical educators have found that writing narratives can be a very powerful and effective method of fostering empathy with patients early in training (4). As Charon (8) writes, “Narrative competence permits caregivers to fathom what their patients go through, to attain that illuminated grasp of another’s experience that provides them with diagnostic accuracy and therapeutic direction.” Narrative writing exercises have been used with preclinical medical students, clinical medical students, and residents to nurture all parts of the doctor-patient relationship, including promoting self-reflection and developing empathy, professionalism, and trust with patients (5, 9–14). One form of narrative writing exercise, which involves writing autobiographical stories from the patient’s viewpoint, has been successfully used with junior and senior medical students (4, 13, 15).
One PGY-I psychiatric resident (SD) undertook a project in which she used a self-reflective exercise to help her to understand the severely and persistently mentally ill patients with whom she was working in a community mental health clinic.
During her rotation at a community mental health clinic, one PGY-1 resident at Columbia University elected to write narrative pieces about three patients of her own choice with whom she was working. She wrote the narratives during a weekly, 3-hour writing block that she built into her 3-month elective. She wrote these pieces in the first person, imagining that she actually was the patient during a normal day in that person’s life. She had a clinical supervisor for each of these patients (CM), with whom she discussed patient care for 2 hours per week as part of the clinical rotation. She also met weekly with a writing supervisor (DC), another psychiatry faculty member who did not have any interaction with these patients, to discuss her narrative writing. Each session with the writing supervisor lasted 1 hour during which the resident read one piece aloud and then the two discussed different aspects of the resident’s style of writing, choice of words, and story line to help the resident learn about her feelings about the patient. The goal of these sessions was left open-ended, but it was broadly conceived as a possible mechanism to explore countertransference.
The PGY-1 wrote three narrative pieces ranging from three to six double-spaced pages about three separate patients. Each narrative took roughly 3 hours to write.
After a few writing supervision sessions, it became clear that the resident had chosen to write about patients with whom she had had a difficult time developing a connection. The supervisor and the resident realized that in each situation, these narrative choices were different and gave clues about some aspect of that particular patient that helped the resident to empathize with the patient’s subjective experience. They called these “points of contact.” In each case, the resident felt that discovering these points of contact through writing helped her to connect to her patients and to promote empathy. In addition, she felt that the process improved her interviewing skills because she imagined her patient’s lives more completely, thus increasing her ability to ask them more meaningful questions.
Below are a few examples from the resident’s writing, with some related supervisory process:
Patient #1: This patient was a young, morbidly obese, Latino man with schizophrenia and a borderline low IQ who was depressed and paranoid and said little about his feelings. The resident wrote:
My music protects me. Or maybe it just distracts me. I don’t know. But if I can’t find my headphones, I can’t leave the house. There are too many people out on the streets who want to jump me … But when I listen to my music, I can make it…Yeah, I’m nervous when I walk out the door, but I listen to my songs, and I get caught up in the beat, and I’m walking to the beat, and I don’t think about them as much.
The resident had first written a third-person version of this narrative, and had then switched to the first person. When comparing the two versions, the supervisor and resident noticed that the sentences of the first person version were much shorter and choppier. They thought that it might be like the rap music the resident imagined that the patient was listening to. During this discussion, the resident noted that in their first session, the patient had offered her his headphones in order to listen to music that he had composed. The resident had liked the music and had imagined jogging to it. Thus, the music was their point of contact. Once she found this link, the resident was more able to empathize with his perspective and to ask him relevant questions that helped her to learn about him and to foster the therapeutic alliance.
Patient #2: This patient was a young African American woman with schizophrenia who had marked poverty of speech and blunted affect. Although during their interviews the resident felt that the patient was not explicitly sharing many of her thoughts and feelings, she did tell the resident that she was losing custody of her 3-year-old daughter, whom she visited once a week. The resident wrote:
I tuck my baby doll under her pink quilt, and I turn off the light. She clings onto my hand, and it takes all I have to peel her tiny fingers off of mine. I take a long last look at her—I want to be able to notice how she’s changed next week. I tell her I’ll be back real soon. That’s what I hope. That’s all I can pray for. That I’ll be back real soon.
In discussing the piece, the resident revealed that she had been moved by the story of the impending loss of custody. Through her writing, she realized that this was her point of contact with this remote patient. Allowing herself to imagine her patient’s feelings enabled her to feel more empathy toward her in their subsequent interactions. Interestingly, after reading the piece, the clinical supervisor (CM) also noticed increased empathy for the patient.
Writing imaginative narratives about her patients helped one PGY-1 psychiatric resident to connect to several emotionally distant patients. Beginning in the third person, she discovered for herself the way in which writing in the first person enabled her to “crawl into the patient’s skin” more easily. She “found herself” writing about things that she had not emphasized in her meeting with her patients. She and her supervisor discussed these “points of contact,” helping her to better understand both her feelings about her patients and each patient’s subjective experience. Thus, by allowing herself to imagine things about her patients’ lives, the resident unearthed ways in which she had connected to the patients without even realizing it. As Marshall and O'Keefe (13) noted, writing in the first person changes the signifiers of “him/her” to “I/me,” reducing the distance between the clinician and the patient and giving the writer of the patient’s story a stronger investment in the patient’s future and the outcome of the medical care. While most trainees understand the idea of feeling sympathy toward their patients, it is the concept of empathy, or as Zinn (16) writes, “understanding an individual’s subjective experiences by vicariously sharing that experience while maintaining an observant stance,” that is fostered in this exercise.
In addition to fostering empathy, this resident’s experience provides some evidence that narrative writing may offer other benefits to psychiatric residents. It promotes self-reflection and nascent exploration of countertransference by giving residents permission to take time to think about their patients’ lives. While the concept of countertransference is usually somewhat undeveloped in new trainees, this exercise provides a forum in which to begin to explore how similarities and differences between their lives and their patient’s lives may affect their interaction. Using writing to explore countertransference was undertaken by Bhuvaneswar et al. (17), who incorporated the process of journal writing into a psychiatry intern’s emergency psychiatry rotation. Narrative writing in particular may also help residents to think of their patients as whole people, rather than just collections of symptoms (14). It may also help them to become better interviewers by allowing them to use their imaginations to think of the next question to ask, develop hypotheses about our patients’ motivations, and try out formulations. Thus, encouraging students to imagine things about their patients can have an important role in developing them into creative thinkers who are curious about themselves and their patients.
Despite these potential benefits, there may be limitations to the use of narrative writing for psychiatric residents. This resident elected to write narratives; this might not be as readily embraced by all trainees, especially if it were a required course rather than an elective. In addition, this type of exercise inherently exposes the resident’s countertransference, and thus supervisors would have to be extremely sensitive to this, particularly if it were done in a group. It is essential that the participating supervisors emphasize the ways in which these narratives are, of course, fictions, and are thus not to be confused with their patients’ histories. Trainees should be able to recognize that their own imaginings of a person’s life are colored by their own feelings and experiences and that they can learn about themselves through their imaginings. Careful supervision from experienced teachers is of the utmost importance in this type of project.
This exercise could be conducted individually or in a group setting in which group members learn from each other’s experiences. While this writing was done about severely and persistently mentally ill patients, it could easily be adapted for residents working with any type of patient population. We believe that this exercise allows trainees to imagine their patients as complete individuals, promotes self-reflection, and helps develop more empathic clinicians.
At the time of submission, Dr. Deen and Dr. Cabaniss reported no competing interests. Dr. Mangurian is a mentor for an APIRE/Janssen Research Scholar and will receive $500 in honoraria for this role.