Professional Distress and Meaning in Health Care - Why Professional Empathy Can Help (Ekman, 2015)

Social Work in Health Care
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Professional Distress and Meaning in Health Care:

Why Professional Empathy Can Help
Eve Ekman PhD, MSW & Jodi Halpern MD, PhD
To cite this article: Eve Ekman PhD, MSW & Jodi Halpern MD, PhD (2015) Professional Distress
and Meaning in Health Care: Why Professional Empathy Can Help, Social Work in Health Care,
54:7, 633-650
To link to this article: http://dx.doi.org/10.1080/00981389.2015.1046575
Published online: 28 Aug 2015.
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Download by: [NUS National University of Singapore] Date: 05 November 2015, At: 21:30
Social Work in Health Care, 54:633–650, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 0098-1389 print/1541-034X online
DOI: 10.1080/00981389.2015.1046575
Professional Distress and Meaning in Health

Care: Why Professional Empathy Can Help
EVE EKMAN, PhD, MSW

Osher Department of Integrative Medicine, University of California San Francisco,
Downloaded by [NUS National University of Singapore] at 21:30 05 November 2015
San Francisco, California, USA
JODI HALPERN, MD, PhD

Bioethics, Joint Medical Program, University of California Berkeley, Berkeley,
California, USA
For human service care providers working in hospitals, balancing

the motivation for interpersonal engagement with patients along-
side self-protective emotional boundaries is a familiar struggle.
Empathy is a critical, although not thoroughly understood, aspect
of patient care as well as an important ingredient for feeling work
satisfaction and meaning. However, empathy can lead to feelings
of sympathetic emotional distress and even burnout. This article
uses an illustrative case study from a medical social worker in the
emergency room to explore these themes of empathy, burnout, and
the search for meaning in work. The discussion examines areas for
further empirical study and intervention to support care-provider
empathy and avoid burnout.
KEYWORDS burnout, empathy, human service work, meaning in

work
INTRODUCTION
Neuroscience has demonstrated that human brains are hardwired for empa-
thy, especially when there is a display of intense negative emotions such as
pain and suffering (Iacoboni, 2009; Ickes, Funder, & West, 1993; Levenson &
Ruef, 1992). Our brains “feel” the pain we witness (both physical and
Address correspondence to Eve Ekman, PhD, MSW, Osher Department of Integrative

Medicine, University of California San Francisco, 1545 Divisadero Street, San Francisco, CA
94115. E-mail: eve.ekman@ucsf.edu
633
634 E. Ekman and J. Halpern
emotional) through our mirror neuron system. This mirrored, sympathetic

mental pain, also described as emotional resonance, can precipitate sympa-
thetic distress or act as a precursor to the natural proclivity to empathy,
altruism, and compassion (Batson et al., 1991; Iacoboni, 2009; Iacoboni &
Lenzi, 2002). Hence, our capacity for feeling the pain of others offers both a
susceptibility to share suffering as well as an opportunity to respond with
compassion (Baron-Cohen, 2011; Batson, Lishner, Cook, & Sawyer, 2005;
Hatfield & Rapson, 1998; Hein & Singer, 2008; Singer & Klimecki, 2014).
Workers in settings such as hospitals encounter many opportunities for
emotional resonance and empathy from struggling and suffering clients
(Davis, 1983). The opportunity to be empathic and act compassionately

with clients is at the root of why many providers are drawn to interpersonally
challenging service work. This work can allow professionals to naturally feel
good about helping others—importantly, these feelings can make challenging
work feel meaningful instead of stressful (Batson & Shaw, 1991; Brickman,
1987; Keltner, 2009). However, when one does not have the ability to ade-
quately help or respond (e.g., due to limited follow-up resources or lack of
time in the day), the experience can lead to feelings of sympathetic distress
(Freudenberger & Richelson, 1980; Klimecki, Leiberg, Lamm, & Singer, 2012;
Zammuner, Lotto, & Galli, 2003). Thus, when the workers continually feel
they lack efficacy to adequately respond to the needs of clients, this escalates
the distress and can lead to feelings of emotional exhaustion and burnout
(Freudenberger & Richelson, 1980; Maslach, 1982).
Empirical research shows that practicing empathy is crucial for care pro-
viders downstream. Through empathy, they can provide effective and humane
treatment (Chaudhry et al., 2010). In medical settings, empathic care toward
patients increases adherence to medical treatments, builds trust, improves
satisfaction with care, and improves overall patient health outcomes (Krasner
et al., 2009; Riess, Kelley, Bailey, Dunn, & Phillips, 2012). The conventional
training for medical professionals warns that opening up to the emotions and
feelings of the patient can create stress. This is simply a limited view of
empathy, more akin, in fact, to simple emotional contagion (Hatfield & Rapson,
1998). In emotional contagion, there is a convergence with the emotions of the
other, as though these feelings were “contagious” (Hatfield & Rapson, 1998).
Chronic stress is an obstacle for professional well being that has been
studied across many human service work environments (Lambert, Altheimer,
& Hogan, 2010; Lazarus & Folkman, 1984; Maslach, Leiter, & Jackson, 2012).
Sixty-nine percent of all employees report that work is a significant source of
stress and 41% say they typically feel tense or stressed out during the workday
(American Psychological Association, 2009). A growing number of studies
among medical professionals in the last decade have identified rising rates
of burnout (ref). This burnout is associated with diminished empathy. How-
ever, education and trainings to support these professionals needs more
conceptual development and strategies before it is implemented among
Professional Distress and Meaning in Health Care 635
workers in the field. Appropriate development of education requires a theo-

retical, conceptual, and direct understanding of the problem. This article uses
a medical social work case study as the lens to examine the interpersonal
demands of human service work and to build a conceptual framework for the
relationship between empathy, stress, and meaning for the consideration in
the development of future training and assessment.
PROFESSIONAL EMPATHY
We propose a distinction between basic or general empathy and a profes-

sional empathy. Professional empathy in human service settings usually
includes a much higher degree of emotional demands than the everyday
empathy. With basic or general empathy (e.g., with a distressed friend)
there is less need to regulate emotional resonance. A natural caring response
arises. In comparison, human service care providers must economize emo-
tional resources and consider appropriate responses to manage a full caseload
of clients who require attention. The practice of professional empathy entails
a cognitive shift which moves the focus from witnessing and feeling with the
suffering of the client to curiosity about the circumstances and leads to a
behavior or interaction of empathy (Halpern, 2001, 2003).
The practice of professional empathy can be defined with three often over-
lapping attributes: affective or emotional resonance, cognitive appraisal, and a
motivation to act, guided by this cognitive-affective understanding (Halpern, 2001,
2007). These three attributes support emotional responsiveness to build trust,
identification of the client’s needs as separate from the provider, and interpersonal
engagement that facilitates social rewards and feelings of meaning in work.
The key to a balanced professional empathy is maintaining a clear
awareness of the distinction and separation between the suffering of the client
and one’s own experience (Halpern, 2001). The professional’s ongoing
awareness that a patient or client is experiencing suffering that the profes-
sional can never fully grasp engenders both genuine interest in listening to
and learning more about the patient’s predicament, while also establishing
appropriate boundaries (Eisenberg, 2000; Halpern, 2001, 2007).
PROFESSIONAL EMPATHY AND MEANING
Many care providers are drawn to emotionally engaging human service work
because they are naturally empathic and seek the intrinsic rewards of helping
others. That was the motivation for my work as an emergency room social
worker (Ashforth & Humphrey, 1995; Freudenberger & Richelson, 1980). The
built-in social rewards from helping clients are more reliably rewarding than the
extrinsic financial- or status-based sources of success for promoting sustainable

well-being (Brickman, 1987; Keltner & Haidt, 1999; Wallace & Shapiro, 2006).
Satisfaction and meaning within a human service job include the align-
ment of one’s personal values, motivation, and objectives with those of the job
role and a feeling of personal efficacy in achieving these values and objectives
(Leiter & Maslach, 2009; Porter, Steers, & Boulian, 1973; Csikszentmihalyi;
1973). The human service job role can be an ideal location to connect to core
motivations and values if the worker feels efficacy; however, without that
efficacy, the work can feel emotionally draining (Brickman, 1987). Supporting
the personal efficacy of workers is a critical component to reducing stress and
connecting workers with a feeling of purpose and meaning.

The potential for meaning and motivation to cope with stress has been
studied among family care providers. The generation and maintenance of posi-
tive emotions can be protective against stress (Epel et al., 2004; Folkman,
Chesney, & Christopher-Richards, 1994; Folkman & Moskowitz, 2000). These
positive emotions are associated with a reconnection to underlying personal
values, and an ability to connect a feeling of meaning to the work itself (Folkman
& Moskowitz, 2000). This meaning-based coping can be a natural response to
challenging work and/or can be developed through the culture of a workplace.
Surprisingly, studies show that physicians working with dying patients and
those in severe pain—hospice physicians and pain management teams—
showed less “compassion fatigue” then other medical subspecialties (Kearny
et al., 2009). Compassion fatigue is closely associated with burnout for those
working in close relationships with patient in human service care settings
(Adams, Boscarino, & Figley, 2006). Importantly, in these settings, physicians
are immersed in a culture that, unlike the usual medical culture, acknowledges
caregiving as requiring meaning, self-care, and conscious attention to grief and
interpersonal support. Studies with mental health providers also suggest that
self-care and a culture of connectedness can help these providers sustain well-
being and compassion (Coster & Schwebel, 1997; Harrison & Westwood, 2009).
CASE STUDY, PART ONE
The year 2006 marked a 10-year high in incidents of violence and homicides
in San Francisco. One of the authors, Ekman, was a newly minted medical
social worker at the city’s only level-one trauma center emergency room; this
case study will be presented through her voice. I provided daily emotional
support to severely injured and dying victims of gun violence and their
families alongside my other duties of counseling substance users and victims
of domestic violence and providing referrals for the homeless and the men-
tally ill, as well as patients with other nonmedical acute psychosocial needs. I
did not feel that my training had prepared me to cope with the emotional
demands and complexity of the job day after day. The following (disguised)
case study from the emergency room (ER) is broken up in two parts in the
article. The first part illustrates the nature of my experience with interpersonal
work and the emotional challenges that face all frontline human service care
providers, and the second part of the case study provides an opportunity to
examine additional circumstances that led to challenges in my feelings of
efficacy and a sense of meaning in work.
Just before four p.m. on a warm summer Saturday, a 25-year-old Latino
male arrived in the ER with multiple gunshot wounds to his abdomen; I
followed the gurney from the ambulance bay to the trauma room with the
medical team. The patient was unconscious, very pale and limp, and his T-
shirt was drenched in blood around his midsection. The charge nurse briefed
me that the patient would soon be intubated, and there was no way to know
if he would survive his injuries at this stage. Finding close family was
immediately necessary. The paramedics told me the shooting had been in
the Bayview neighborhood, and there had been family members there and a
large crowd at the scene. The crowd and family were likely on their way.
The overwhelming majority of gun violence is concentrated in a few
neighborhoods near the hospital; friends and family from these communities
knew to come to the ER to wait for news. The prevalence of death resulting
from this violence created a cumulative trauma and anxiety among the
crowd of 20–40 who arrived. The institutional police (IP), were stationed at
the front door of this emergency room. They were wary of these crowds who
occasionally became agitated and whose actions could even escalate to
violence waiting for news. Arrests by the IP of frustrated, mourning friends
and family were unfortunately common. Part of my role during these inci-
dents was to help the IP to manage the crowds by identifying the four closest
family members to come inside the unit to the ER family room and providing
frequent updates to the crowds outside. In this case, by the time I had left the
trauma room and walked to the ER entrance, the mother, younger brother,
uncle, and pregnant wife of the victim were pushed forward from the mount-
ing crowd outside.
I brought them into the small family room, only a few feet away from the
trauma room where their loved one was in the process of receiving lifesaving
treatment. The uncle, mother, and wife had been on the scene to see the
patient’s limp body being pulled onto a gurney. The younger brother was very
agitated; he had been across town and wanted to see the patient NOW. The
uncle tried to calm the brother to no avail. I explained that the injuries were
quite serious and that he was in good hands. I knew at any moment they
needed to be prepared for the worst news, but they could also potentially be
waiting for hours, maybe days, to know any conclusive outcome on whether
their loved one would survive his injuries.
For the next three hours, I ferried cautious medical updates to the family
in the family room and to the crowd holding vigil outside the ER entrance.
The trauma room was packed with fully trauma-suited doctors and nurses
whose focus would not stray from the myriad lifesaving procedures being
applied to the patient. I had to wait and watch until a moment arose when I
could ask for an update. During this trauma room information gathering, I
felt my presence was an unwelcome reminder that the body on the gurney
was connected to fearful family members just outside the door who may later
require an announcement of death or debilitating injury. I had been shut out
of the room by doctors or residents in prior cases who did not want “any
interference.” This lack of access had led to desperate hours of waiting and
had intensified fears among family members. A cultivated patience and
delicacy was required to diffuse these feelings. Just outside the trauma
room, the family members were in various states of despair. I alternately

held the hand of the mother, attended to the pregnant wife’s snack and water
needs, and managed the impatience of the brother. I escorted the brother out
of the side door for air when, in grief and frustration, he began punching the
walls of the family room. Hours later, at dusk, when I came outside with news
that the patient was going into surgery, the crowd had grown to about 30
people. A pastor, who was a family friend, brought me into a wide circle of
hands held to pray for the patient.
As demonstrated in the first half of this case study, within human service jobs,
the principal services provided are intangible and transcend a transactional
relationship (Yagil, 2008). The management of emotion to fit job roles is part
of emotional labor, which often requires the amplification of certain false
emotions and the internal suppression of (often negative) emotions (Hoschild,
1983; Zamuner et al., 2003). For example, the panic of a family member
whose son is critically injured may be very disturbing for the provider;
however, in order to support the family, the amplification of calm can be an
appropriate way to provide important updates and information. Additionally,
when encountering a patient whose acute illness, underlying mental health, or
state of intoxication is manifested through acting out through aggression or
unreasonable demands, it may be necessary to amplify courteous or comfort-
ing responses instead of responding with the felt irritation.
Emotion labor can be performed at a deep or surface level of acting
(Larson & Yao, 2005; Zammuner et al., 2003). Deep acting is an internalization
of the expected emotion and produces a more authentic emotional experi-
ence (Haller, Lispit, Yao, & Larson, 2005; Hayward & Tuckey, 2011). How-
ever, deep acting can distress the provider whose clients are suffering (Haller,
Lipsitt, Yao, & Larson, 2005). Surface acting manages the vocal and facial
expressions even while it operates on suppressing authentic emotions (Zam-
muner et al., 2005). Suppression is useful to manage inappropriate negative
emotions; however, it is not a fine instrument, and the chronic suppression of
undesired emotions can lead to the dampening or suppression of all emotions
(Gross, 2002; Gross & John, 2003; Zapf, Vogt, Seifert, Mertini, & Isic, 1999). In
the case study above, it was important to suppress the feelings of fear in front
of the crowd and family members and present a calm engaged affect. How-
ever, suppression alone could have felt like indifference or aloofness and
would have exacerbated the crowd’s anxieties and frustration. The suppres-
sion of fear still required the performance of concern and caring—empathy
with and for the needs of the family and friends.
The IP and medical staff in the trauma room staff needed the suppression
of urgency of the family’s concerns and fears and to be shown consideration
of their respective goals—safety and lifesaving. In this case, empathy was
required for the effective engagement for co-worker communication and
patient care.
While emotion labor is not intrinsically distressing, chronic amplification
and suppression can overshadow the consonant, authentic emotions (Hos-
child, 1983; Zammuner et al., 2003). Emotional labor helps conceptualize how
empathy fits in as an expected part of the job role. However, empathy is not
equivalent to emotion labor. Emotion labor does not connote the reading of
others; it describes the work of responding through emotions in the context of
the job. Empathy is needed for that to be done successfully, however, an
emotion labor that used suppression would not need empathy.
This next section of the case study illustrates further emotional labor and
additional elements of complexity that overwhelm feelings of efficacy. The
first half of this case study demonstrates successful emotion labor and empa-
thy in navigating both co-worker and patient family care.
CASE STUDY, PART TWO
An hour after the patient had been moved up to the surgery unit, I received a
call from the charge nurse to inform me that surgery was done, and the
patient was being moved to the Intensive Care Unit (ICU). This meant some
level of medical stability had been achieved. Through witnessing the emo-
tional suffering of his friends and family, I had become invested in the well-
being of the patient. Although I had relatively good news of his move to the
ICU, the delicate medical reality required that the update to the family be
sober so as to avoid raising their expectations.
I first went to the ICU to check on the patient and update the nurses on
the family waiting outside. The medically delicate move to the ICU can create
protectiveness among nurses who fear that families will unintentionally
interfere with procedures or medical equipment. Once the patient was firmly
secured to the life-sustaining machines, I brought the family inside. It had
been many hours since the patient had arrived by ambulance. His face was
now swollen, there was an intricate weaving of tubes from him to many
machines, and he had thin bandages over an open wound on his abdomen
that would be closed after the swelling reduced. I could barely keep myself
from overflowing with tears when I watched his mother and pregnant wife
grip each other and approach the bed weeping at seeing their loved one so
undone. I left them there to be with him, and they thanked me deeply for my
presence.
In my last hour of work, two gang task force police detectives, who were
often at the hospital to investigate gun violence and homicide, came to my
office to ask me to show them the patient. I brought them up to the ICU; the
nurse told us the family had left to get food. The detectives looked at the
patient’s swollen face, tattoos visible beneath the tubes and bandages, and
shook their heads meaningfully. I told them the family would probably return
soon if the detectives needed more information for the case. The detectives
said they knew this patient and his family well enough to predict that they
would have nothing to say to the police. They continued to tell me that the
patient had been responsible for at least half a dozen other men and their
families being brought to this ICU. His brother and uncle were involved in the
same gang as the patient and never talk to the police. They speculated that the
family were not out for food but out for revenge. Cynically, they suggested I
should leave work before more bodies arrived in the ER.
I felt my stomach drop and my heart sink. My feet were leaden, but I
managed to drag them out of the hospital and make my way home to a
sleepless night. I no longer felt good about the work I had done; the expressed
gratitude from the mother and the prayer circle I had joined with the patient’s
friends and family now felt somehow duplicitous. I had become submerged in
the emotions of the case, and it was dizzying to hold in my mind my intensely
sympathetic view of this man and his family alongside what the detectives
had said. The emotional hangover from this case made it difficult to return to
work the next day and for weeks to come. I noticed myself pulled back from
the friends and families of new patients who arrived as victims of gun
violence. My emotional detachment reduced my ability to support other
patients as well as my sense of efficacy and purpose.
Moral Complexity
An additionally challenging aspect to an already difficult case was the moral
complexity of caring for a victim who was also a victimizer. A critical compo-
nent to accurate and professional empathy is the ability to remove the need to
emotionally and personally identify with the object of empathy. This is a key
distinction between empathy and sympathy. Sympathy includes feelings of
pity but is limited to scope of being along side the suffering of another.
Empathy is more akin to investigating. A more practiced cognitive appraisal
in this case could have provided an adequate cushion from internalizing, and
feeling with the complex emotions related to the status of the victim. This
does not mean indifference or aloofness but rather a self awareness about the
separation between the suffering of others and suffering of one’s self.
Diminished Meaning
An especially unfortunate lingering symptom of this case was the desire to
emotionally detach from the job leading to feeling an overall loss of
efficacy and a lack of purpose. Without appropriate education and training
in empathy and emotional boundaries, a professional can easily feel emo-
tionally drained, spent, and overwhelmed in other patient cases, even
those without moral complexity. Education in the medical field focuses

on concrete patient care without value placed on the intrapersonal experi-
ence of the provider. In social work, there are many concrete tasks of
discharge planning, follow-up medical mental health referrals, and there
are also many interpersonal tasks around grief, substance abuse, and crisis
counseling. However, the education and training for understanding, mana-
ging, and even building on the felt emotional experience and empathy of
the provider is absent.
The early education and training paradigm for psychoanalysts used the
development of emotional self-awareness as a fundamental skill for the
therapist to develop empathy. This empathy meant becoming a barometer
for the emotional experience of the patient without falling in to their experi-
ence (Kohut, 1959). Maintaining an effective yet appropriate empathy requires
cognitive and emotional skills. The foundation for these skills are well
described through contemporary neuroscience research.
Neuro-Architecture of Empathy
Neuroscience research began by examining empathy through emotional reso-
nance in lower brain regions. These lower brain regions correspond to rapid,
rigid, affective responses to the emotional valence of a situation (Hein &
Singer, 2008; Iacoboni, 2009; Zaki, Weber, Bolger, Ochsner, & Posner,
2009). Newer studies have suggested that empathy includes both higher and
lower brain regions: the higher brain regions are associated with executive
functioning, which facilitates cognitive perspective-taking (Decety, 2011; Dec-
ety & Jackson, 2004; Klimecki et al., 2012). The cognitive process of perspec-
tive-taking can help to distinguish the struggle of another’s situation from
one’s own; thus, the perspective taking can effectively “put the brakes” on
the emotional resonance before it devolves into sympathetic distress (Decety,
2011; Decety & Jackson, 2004; Halpern, 2001). A professional can become
preoccupied by sympathetic distress. In this state other important cognitive
functions, such as compassion, can be impaired. (Singer & Klimecki, 2014). A

compassionately informed response provides care to the patient and efficacy
to the provider. Additionally, the ability to reflexively examine our emotional
resonance supplies meaningful context about emotional cues from patients.
Cognitive appraisal of our own emotional experience as it arises can help us
manage our emotional response.
The Importance of Emotional Awareness

We hypothesize that the skillful application of professional empathy is a

balance and begins with the cognitive appraisal to inform emotional self-
awareness, insight into the subjective experience, and context of our emo-
tions. Developing insight about one’s emotional state promotes the ability to
set valuable emotional boundaries which do not avoid the emotional cues of
patients but recognize the important distinction between self and other to
guide one away from getting lost and distressed in the emotional experience
of the patient. Importantly, this subtle cognitive shift moves the provider from
“feeling with” to observing. An openly engaged, curious listening stance in the
context of good boundaries can make challenging interpersonal work not
only more rewarding but can also increase feelings of efficacy, both of which
may help prevent feeling chronic stress and burnout (Decety, Yang, & Chen,
2010; Halpern, 2001; Riess et al., 2012).
MINDFULNESS AND EMOTIONAL AWARENESS

Mindfulness-based trainings have been at the forefront of well-being and
stress reduction interventions and wellness in the last decade. They specifi-
cally teach skills that can lead to successful regulation of emotions without
suppression (Keng, Smoski, & Robins, 2011). Mindfulness practices have
been found to reduce stress, depression, and anxiety, and to increase
activation in brain regions responsible for regulating attention and positive
affective states, including empathy and other pro-social emotions (Davidson
& McEwen, 2012). Mindfulness-based programs build on the core skills to
create a space of reflection between stimulus and response. This is an ability
to create some space between thoughts, emotions, and the natural state of
the mind (Kabat-Zinn, 1990). This realization of emotions as they arise is a
metacognitive awareness, recognition of thoughts and emotions, and, with
practice, helps create more opportunity for choosing strategies of response
instead of simply suppressing, avoiding, or getting caught in the experience
of the emotion.
DISCUSSION AND FUTURE DIRECTIONS
Physical labor jobs have nationally mandated physical therapy interventions

and training, but emotional labor jobs do not provide emotional training
interventions. Professional and workplace-based trainings rarely address the
empathic burden of the job role and instead promote well-being and stress
reduction in the workplace by suggesting already overcommitted human
service care providers to make time for “self-care,” in the form of exercise
and eating well (Ashforth & Humphrey, 1995; Lambert et al., 2010).
We propose through this article that maintaining and/or (re)connecting
to the meaning of human service work could be a moderating factor against

chronic stress and compassion fatigue for care providers (Chang, Noonan, &
Tennstedt, 1998; Duerr & Consulting 2008; Klimecki et al., 2012). The mean-
ing in this work directly relates back to empathy and the connection of
working with others. Hence, managing empathy can promote meaning and
reduce stress. Specific skill training in professional empathy could catalyze
positive feedback loops. These feedback loops could help care providers
regulate emotional arousal, connect more with clients, experience positive
emotion, and feel efficacy, all of which assist in the provider deriving more
meaning from work (Bakker, Demerouti, Taris, Schaufeli, & Schreurs, 2003;
Morrison, Burke, & Greene, 2007).
One piece of empathy education and training is to manage sympathetic
distress through the dynamic process of emotion regulation (Gross & John,
2003; Mendes, Reis, Seery, & Blascovich, 2003). There are natural variations
among an individual’s sensitivity to the emotions of these jobs: some people
find the emotional challenges of human service work easier to manage than
do others. However, anyone can benefit from training to develop greater
awareness of emotional demands including mindful awareness of emotions,
as described above.
Human service care providers and their clients could benefit greatly from
a training targeted at developing professional empathy through the manage-
ment of emotions for high-intensity interpersonal encounters, which are an
expectable part of the job role (Halpern, 2001; Hayward & Tuckey, 2011;
Riess et al., 2012). An interpersonal approach to workplace stress opens the
door for developing skills of emotional self-awareness (Folkman & Mosko-
witz, 2000; Goleman, 2006; Gross & Muñoz, 1995; Hayward & Tuckey, 2011).
The challenge is to identify specific skills that can help clinicians sustain
professional empathy. In particular, we consider how the three components
of professional empathy may link to teachable skills that manage emotional
resonance and corresponding sympathetic distress.
Emotion and empathy skills training is a stated priority in professional
medical education fields; however, the development, implementation, and
evaluation of this type of training has not yet been standardized (Adams
et al., 2006; Riess et al., 2012). Medical providers are especially appropriate
for this training because of their critical role in providing patient care (De Valk
& Oostrom, 2007; Riess et al., 2012). A Journal of the American Medical
Association article found that 60% of doctors report symptoms of burnout
(Krasner et al., 2009). A 2012 study on the empathy of physicians reported
that at baseline, 53% of physicians reported that their empathy for patients had
declined over the past several years, 56% said they lacked the time to be
empathic, and 29% reported burnout as the primary reason for their difficulty
in being empathic (Riess et al., 2012).
Empathy trainings to improve patient care among medical providers are
in the preliminary stages of development and evaluation, and this article
suggests a unique hypothesis about the connection between developing

professional empathy skills, meaning in work, and the reduction of stress.
Motivation and meaning are critical for sustaining engagement in human
service care work (Morrison et al., 2007). Providers can be helped to recon-
nect with the sense of purpose that made them go into human service work in
the first place through group discussions. People can also sustain a sense of
connection and meaning from engaging in specific practices. For example,
learning how to practice compassion-focused meditation can help providers
focus on their ongoing dedication to alleviating suffering as motivation for the
work (Duerr & Consulting, 2008; Gilbert & Irons, 2005; Neff, Kirkpatrick, &
Rude, 2007). Establishing one’s overarching motivation as an intention to
alleviate suffering can provide a buffer against feelings of impotence when
everyday actions feel futile or overwhelming.
Many human service care providers experience sympathetic distress and
chronic stress. They develop individual strategies to balance and manage their
levels of engagement throughout their careers (Folkman & Moskowitz, 2000).
Some of these strategies are sustainable while others, such as high degrees of
emotional suppression, will find temporary relief from sympathetic distress
but may lead the provider to suffer from detached emotional functioning
resulting in a lack of efficacy and meaning. This is not an “either/or” phenom-
enon: there can be fluctuations in chronic stress and coping across a career
span. For example, a new boss at work or a new baby at home can entirely
shift the appraised demands and resources within the professional setting. The
use of individually focused empathy skills can provide support to various
levels of human service care providers who have lost an ability to effectively
manage everyday work demands.
This article has integrated and synthesized emotion labor, empathy, and
stress research relevant to human service care providers to suggest profes-
sional empathy as a coping strategy to prevent and combat chronic stress and
promote well-being through reconnecting to motivation and meaning. The
case study was included to provide the real world example of where emo-
tional awareness can help support a professional empathy with patients as
well as colleagues. Professional empathy involves both inherent capacities
and cultivated skills; these skills are essential for building boundaries that
permit ongoing engagement with the emotional needs of others. We suggest

that human service care providers cultivate empathy skills to help them
refocus from sympathetic distress to curiosity about another person.
The risk of not developing empathy skills is significant. Practicing chronic
emotional suppression may diminish work-related meaning and lead to
depersonalization. Striving for a sense of competence despite emotional
exhaustion, providers inadvertently cope by creating distance between them-
selves and patients (Halpern, 2007; Riess et al., 2012). This distance can
decrease efficacy due to impoverished interpersonal communication and
interaction (De Valk & Oostrom, 2007; Jackson & Maslach, 1982; Leiter &
Maslach, 1988).
Depersonalization is especially concerning in human service settings. It is
not only harmful for the human service care providers who lose touch with
their sense of identity in their work, but it can lead to mechanized, dehuma-
nizing responses toward their clients (Haslam, 2006; Keltner & Haidt, 1999;
Zimbardo, 1973; Foucault, 1977). Additionally, human service care providers
who lack effective emotional coping skills may cope in unhealthy ways,
including abusing alcohol and drugs (Jackson & Maslach, 1982).
Cultivating skills of professional empathy can be invaluable for those who
either have biologically higher tendencies to emotional overarousal and/or
those who have become worn down by persistent job demands and have
retreated from emotional engagement, thus diminishing efficacy in and mean-
ing from work (Bakker et al., 2003). This article explores research, theory, and
direct practice experience to consider a new conceptual model for the devel-
opment of education training and assessment that may yield new approaches to
helping human service care providers sustain empathy and achieve well-being.
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Social Work in Health Care

ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: http://www.tandfonline.com/loi/wshc20

Professional Distress and Meaning in Health Care:

Eve Ekman PhD, MSW & Jodi Halpern MD, PhD

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Professional Distress and Meaning in Health

EVE EKMAN, PhD, MSW

San Francisco, California, USA

JODI HALPERN, MD, PhD

For human service care providers working in hospitals, balancing

KEYWORDS burnout, empathy, human service work, meaning in

Address correspondence to Eve Ekman, PhD, MSW, Osher Department of Integrative

emotional) through our mirror neuron system. This mirrored, sympathetic

(Davis, 1983). The opportunity to be empathic and act compassionately

workers in the field. Appropriate development of education requires a theo-

We propose a distinction between basic or general empathy and a profes-

PROFESSIONAL EMPATHY AND MEANING

extrinsic financial- or status-based sources of success for promoting sustainable

connecting workers with a feeling of purpose and meaning.

CASE STUDY, PART ONE

room, the family members were in various states of despair. I alternately

CASE STUDY, PART TWO

those without moral complexity. Education in the medical field focuses

functions, such as compassion, can be impaired. (Singer & Klimecki, 2014). A

The Importance of Emotional Awareness

We hypothesize that the skillful application of professional empathy is a

MINDFULNESS AND EMOTIONAL AWARENESS

DISCUSSION AND FUTURE DIRECTIONS

Physical labor jobs have nationally mandated physical therapy interventions

to the meaning of human service work could be a moderating factor against

suggests a unique hypothesis about the connection between developing

permit ongoing engagement with the emotional needs of others. We suggest

Directions in Psychological Science, 9, 115–118. doi:10.1111/cdir.2000.9.issue-4

vioral and Brain Sciences, 25(1), 39–40.

Leiter, M. P., & Maslach, C. (1988). The impact of interpersonal environment on

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