Emotional Empathy and Its Relationship with Perceived Stress

Abstract

Empathy is essential in the health care context as it affects diagnosis, care, adherence, and treatment effectiveness. In addition to influencing the doctor-patient relationship, it impacts the quality of life of professionals, as does stress. There are studies on the link between empathy and stress, and some conclude that stress decreases empathic disposition. Others propose that burnout is associated with empathic hypertrophy. From this, the question arises to know the way in which empathy and stress are related in the university population. To this end, a correlational study was carried out on 651 students from the National University of Mar del Plata (Argentina). Among the findings, a positive association between the level of perceived stress and emotional empathy stands out.

1. Introduction

Empathy is a human capacity that allows us to understand the emotional states and thoughts of other people and is a fundamental attribute for life in society. In the context of health care, the empathetic disposition of professionals affects the quality of diagnosis, care, adherence, and treatment effectiveness [1]. The measurement of the level of empathy in university students of careers linked to health has been studied in various countries and universities [2, 3, 4, 5]. Although the results of these studies are not conclusive, some research has shown that empathy levels tend to decrease in the last years of academic training [2, 3, 4, 5, 6, 7]. Faced with these results, there are authors who affirm that the decline in empathy may be associated with the level of stress to which students are subjected [4, 5, 6, 8]. However, there is no agreement in scientific studies on the effect of stress on the empathic disposition, so in the present work, the general objective was to determine and describe the relationship between empathy levels and perceived stress levels of the students from the National University of Mar del Plata. Based on the background information consulted, it was hypothesized that there is a relationship between self-reported levels of empathy and the level of perceived stress, such that higher levels of perceived stress are significantly associated with lower levels of empathy.

2. Theoretical framework

2.1 Empathy

In literature, Lipps is usually mentioned as the founder of the concept of einfühlung, translated into English by Titchener as empathy. However, the one who began using the term einfühlung was Vischer [9, 10, 11] to explain the way in which people experience inanimate objects, in the field of philosophical aesthetics, and the way they understand the mental states of others [10]. Even before Vischer, the verb einfühlen had been used by Herder [11] when describing the God-given ability of humans to recognize everything in nature in analogy with oneself, in order to understand the inside of it [11].

Lipps’ great contribution was to take the term einfühlung and systematize it [12] to, on the one hand, describe the process by which an art object causes phenomena of internal resonance in those who contemplate it [9, 11] and, on the other hand, to try to solve the problem of how we come to know other people’s minds [9]. Einfühlung, then, would be the way in which one inhabits one’s own subjectivity while reaching out to someone else’s [13]. According to Lipps [14], empathy is an innate and involuntary response to the expression of someone else’s emotion.

Over time, the discussion on the concept of empathy led to the distinction between its cognitive and emotional components. Hogan [15] considered empathy as a noncognitive social intelligence, while Davis [16] analyzed it based on four separate but related components: perspective taking, fantasy, empathic concern, and personal distress.

The concept of empathy was studied from different points of view. Some authors started from the approach of Dymond [17] who considered that an empathic person is the one capable of understanding and predicting the thoughts and feelings of another, through imagination. Others paid attention to the emotional response produced by exposure to someone else’s emotional situation. From this approach, Mehrabian and Epstein [17] highlighted an important difference between the cognitive process of taking another’s perspective and the ability to respond to that empathically as this response not only implies the ability to recognize other people’s emotions but also to share them.

Eisenberg and Strayer [18] defined empathy as an affective or emotional response that arises from understanding the emotional state of another person. Although the authors prioritize the affective component, they consider that empathy involves cognitive components that allow the differentiation between one’s own emotional state and that of others [19].

In the literature review, it is common to find concepts, closely linked to each other, that are used as synonyms for empathy such as the theory of mind, mentalization, and perspective taking. All of them refer to higher cognitive functions and characteristics of human beings and involve the understanding of one’s own and others’ mental states.

Premack and Woodruff [20] defined the concepts of theory of mind and empathy practically as synonyms, referring to the former as the attribution of mental states of intention, purpose, knowledge, and belief (of oneself and others) and the second as the understanding of the other’s situation through the attribution of a purpose to him, specifically, empathy would be a theory of mind restricted to the purpose or intention of other people.

Frith and Frith [21] returned to the concept of the theory of mind to explain the process of mentalization, that is, the process through which inferences can be made about the mental states of others. This ability of the human brain usually occurs automatically, although it is also done deliberately through nonverbal communication (facial expressions, and body movement, among others). Mentalization also enables perspective taking, defined as the ability to infer what another person believes about the world, from their point of view.

For its part, Baron-Cohen [22] defines empathy as the ability to identify what another person thinks or feels and to respond to it appropriately.

On the other hand, there are integrative models of empathy that address the complexity of the construct and combine modes of automatic affective experience and controlled cognitive processes, such as the recognition and understanding of other people’s emotional states. From this perspective, Davis [23] presented a framework to explain empathy as a set of constructs that connect an individual’s responses to the observed experiences of others. The constructs are four: antecedents, processes, intrapersonal results, and interpersonal responses.

Antecedents refer to characteristics of the observer, the observed subject, and/or the situation that can influence the empathic process. The processes include the particular mechanisms by which empathic results are produced, which can be cognitive or emotional, and are divided into three classes according to the degree of cognitive effort and the sophistication necessary for their operation: noncognitive processes, simple cognitive processes, and advanced cognitive processes. Intrapersonal results involve internal consequences, which occur in the observer during the empathic experience, but which do not necessarily manifest themselves in his or her behavior. These results can be cognitive, affective, or motivational. Finally, interpersonal results refer to behavior directed toward the observed subject.

As can be seen, the concept of empathy is not easy to define. It is a construct as complex as it is necessary for life in society. At this point, it is worth clarifying that the conceptualization provided by Davis [23] has been adopted for the interpretation of the results of this study.

2.2 Stress

The term stress derives from the Greek stringere, which means to cause tension, and it began to be used in the fourteenth century to account for adversity [24]. However, it gained importance as a concept in the field of physics, thanks to Hooke, at the end of the seventeenth century, and in the nineteenth century, it began to be applied in the field of medicine with the contribution of Cannon [25] who stated that stress is an alteration of homeostasis in adverse conditions for the organism.

In the area of health, stress has historically been studied and defined from different perspectives, placing emphasis on the stimulus [26], on the response [25, 27], or on the interaction between environment and person, giving a predominant place to the active role of the subject through the cognitive evaluation that mediates between the stimulus and the response [24, 28, 29, 30, 31, 32].

Some authors [26] postulate that there are certain situations that cause discomfort or can alter the body as they require adaptation and, sometimes, imply a change in the way of life.

On the other hand, the definitions of stress as a response refer to the processes that are activated in the person as a reaction to an environmental stressor. These perspectives have prevailed in biology and medicine and refer to a state of stress. Although the most representative author of this type of definition is Selye [27], a few years earlier, Cannon [25] considered stress as an alteration of homeostasis in adverse physical conditions (cold, lack of oxygen, and low sugar level) [24] and focused his attention on what he called the fight or flight reaction, that is, the mobilization of bodily resources to sustain an attack or flee from danger [30].

In 1936, Selye developed a multiple stress model and extended Cannon’s notion of homeostasis, with the presentation of the general adaptation syndrome (GAS), by including hormonal responses [33]. Selye’s model includes the physiological response of the organism and the consequences at the organic level that prolonged or excessive exposure to stress can produce [34].

A third position conceptualizes stress not only as a stimulus or a response but also as a process of interaction between the person and the situation. Along these lines, the transactional theory of stress [24] states that stressful experiences derive from the transactions between the person and their environment. The individual perception of the stressor and the social and cultural resources available to the person determines the level of stress. This definition takes into account not only the nature of the event or environment but also the characteristics of the person, emphasizing the relationship between them. Lazarus and Folkman [24] changed the way we think about stress by focusing the analysis on the concept of cognitive evaluation, that is, the process of evaluating a situation in relation to its impact on personal well-being. In the words of the authors “people and groups differ in their sensitivity and vulnerability to certain types of events, as well as in their interpretations and reactions,” not every situation is equally stressful for all people and their forms of evaluating and responding to demands are, in effect, unique.

3. Background

There are studies carried out on a population of medical residents in which they analyzed the link between the level of stress or burnout and empathy. They found that doctors with burnout, especially those who score high on the depersonalization dimension of the Maslach scale, report poor care for their patients [35]; that personal distress erodes empathy [36, 37]; that stressors such as the prevalence of sleep, somnolence, and changes in mood are reflected in a deprivation of empathy [38]; and that stress deteriorates the quality of life of residents and this produces a decrease in empathy [39].

Between 1988 and 1989, Kliszez et al. [40] administered the Mehrabian and Epstein Emotional Empathy Scale and the Davis Interpersonal Reactivity Index (IRI) to 210 female and 143 male first- and final-year medical students at the University of Gdansk, Poland. Among the results, they found that women were more empathetic than men, both cognitively and emotionally. They also observed a decrease in emotional empathy in women and concluded that this was due to a defense mechanism to cope with stress. In the case of men, cognitive empathy increased; however, the authors explained that it may be due to emotional distance and resistance to environmental influences.

On the other hand, West et al. [41] stated that there is a vicious circle between personal distress, empathy, and medical errors as these errors can lead to personal distress, which contributes to deficits in patient care, and, in turn, it generates in the doctor the fear of making new mistakes, increasing his insecurity.

Additionally, a group of researchers [42] conducted a systematic review of work with medical students and residents where they studied the decline in empathy. They analyzed different theories and highlighted that some aspects of the formal/informal curriculum, such as the limited time dedicated to patients [3, 6], the learning environment [43], and inadequate professional models [43, 44, 45] would contribute to the decline in empathy. On the other hand, these same factors could trigger distress or exhaustion in students, which would also significantly influence levels of empathy [36, 37, 38, 39, 41].

For their part, Brazeu et al. [46] analyzed the levels of empathy, burnout, and professional climate in 127 fourth-year medical students, residents, and faculty. They observed that the greater the exhaustion, the lower the professional climate scores. Against this, the authors explained that this strong negative correlation may indicate that burnout leads to less desirable professional behaviors or that less professional learning environments may contribute to student burnout.

Along the same lines, Passalacqua and Segrin [47] found that perceived stress is positively associated with exhaustion and, in turn, exhaustion is also positively and significantly associated with decreased empathy, that is, those residents with signs of burnout showed a marked decrease in empathy at the end of their shift.

In accordance with this, Gleichgerrcht and Decety [48], in a sample of 7,584 respondents, observed that there is a decrease in two subscales of the IRI, empathic concern, and perspective taking, in those doctors with burnout or stress.

In Brazil [49], a study was carried out with 1,350 medical students from different years and from various institutions, whose hypothesis was that students with a better perception of quality of life are more attentive to the needs of patients and, therefore, more empathetic. Furthermore, the authors postulated that those students with burnout or with a low perception of well-being may present lower levels of empathy. They could not confirm their first hypothesis, but they could confirm the second as their results confirmed higher levels of emotional exhaustion and depersonalization in the last years of training and postulated that this could be a possible explanation for the low empathic disposition of the students.

von Harscher et al. [50] took some of this background and sought to understand the relationship between empathy and burnout in medical students in Florida, United States. For this, they carried out a longitudinal study and used the Davis Interpersonal Reactivity Index and the Maslach Burnout Inventory in 353 participants. They found that there is a link between burnout and empathy, but not just any type of empathy. Specifically, they found significant values between the emotional exhaustion (AE) and depersonalization (D) subscales and the empathic concern (PE) subscale. Those students with high levels of PE presented lower values of AE and D, while participants with high levels of personal distress (MP) obtained higher scores of AE and D, that is, a higher level of burnout. Finally, the authors returned to work carried out by Nielsen and Tulinius [51] who found that too much empathy can generate high levels of exhaustion, a phenomenon known as compassion fatigue.

4. Methodology

4.1 Design

An ex post facto, non-experimental, descriptive, cross-sectional, and correlational study was carried out.

4.2 Participants

We worked with regular students from the National University of Mar del Plata, and a non-probabilistic, convenience, and quota sample of 651 students in total was obtained. A total of 101 students from psychology, 103 from nursing, 100 from occupational therapy, 118 from architecture, 93 from law, and 127 from social work were selected. For data analysis, those cases that completed all the items of the two administered instruments were considered, so the final number of participants was 552 students. Participation was voluntary and subject to the informed consent of the participants.

4.3 Instruments

A brief questionnaire was created with the objective of collecting demographic, socioeconomic, and academic information. To assess perceived stress, the Spanish adaptation [52] of the reduced version of the Perceived Stress Scale (PSS) [53] was administered. This is a self-report scale that evaluates the level of perceived stress during the last month with a five-point response scale, where 0 corresponds to never and four corresponds to very often. Finally, to evaluate the level of empathy was administered the Spanish adaptation by Mestre Escrivá et al. [54] of the Interpersonal Reactivity Index (IRI) developed by Davis [55]. The instrument is composed of 28 items, divided into four subscales of seven items each: fantasy denotes the tendency to identify strongly with fictional characters from books, plays, and movies; perspective taking measures the ability or tendency to take other points of view when dealing with other people; empathic concern evaluates the tendency to experience feelings of warmth, compassion, and concern for others, in negative situations or experiences; and personal distress indicates the emotional response, feelings of discomfort, in the face of adverse situations of other people [16, 55]. The questionnaire is self-administered, the person must mark the degree to which each item describes him or her, using a five-point Likert-type scale, where 0 represents does not describe me well and four represents describes me very well [55]. It should be noted that when using the Spanish adaptation, the psychometric properties of the instrument were analyzed, and it was observed that they did not present the internal consistency expected or reported in previous studies. In addition, a principal components analysis was performed using Varimax normalization with Kaiser as a rotation method, and it was observed that several of the items did not correspond to their respective subscale. Therefore, the decision was made to eliminate the items that loaded outside the respective scales and that did not contribute significantly to each factor. The results presented below were analyzed based on the modified instrument based on the data collected in the university population of Mar del Plata, which has seventeen items distributed in four subscales.

5. Results

5.1 Sample characterization

The participants were mostly women, between 17 and 72 years old, with an average age of 24 years and students between the first and sixth years. A total of 130 men also participated, between 17 and 57 years old, with an average age of 24 years and also students between first and sixth year. The final sample was made up of 86 psychology students, 84 nursing students, 84 law students, 101 architecture students, 89 occupational therapy students, and 107 social work students.

5.2 Correlation between the four IRI subscales and perceived stress levels for the total sample

To establish the degree of relationship between the levels of cognitive empathy (perspective taking and fantasy), emotional empathy (personal distress and empathic concern), and perceived stress, a bivariate correlation analysis was used (Table 1).

		Personal distress	Empathic concern	Perspective taking	Fantasy	PSS-10
Personal distress	PCC	-	,355(**)	,075	,230(**)	,438(**)
	Sig. (bilateral)		,000	,080	,000	,000
Empathic concern		,355(**)	-	,364(**)	,340(**)	,331(**)
		,000		,000	,000	,000
Perspective taking		,075	,364(**)	-	,228(**)	-,013
		,080	,000		,000	,765
Fantasy		,230(**)	,340(**)	,228(**)	-	,158(**)
		,000	,000	,000		,000
PSS-10		,438(**)	,331(**)	-,013	,158(**)	-
		,000	,000	,765	,000

Table 1.

Pearson correlation coefficient (PCC) for the four empathy subscales and levels of perceived stress (PSS-10).

**

The correlation is significant at the 0.01 level (bilateral).

Levels of personal distress were positively related to levels of empathic concern, fantasy, and stress (.000). In turn, empathic concern also correlated positively with perspective taking (.000). Perspective taking positively correlated only with empathic concern and fantasy (.000). Fantasy was positively related to all empathy subscales and to perceived stress at a level of .000. Finally, perceived stress correlated positively with both subscales of emotional empathy (.000) and with a subscale of cognitive empathy (fantasy) to a degree of .000, that is, the results confirmed the existence of a trend that indicates that students who obtained high values of emotional empathy and fantasy tend to score higher levels of perceived stress.

6. Discussion

When analyzing the relationships between the level of perceived stress and empathy, it was observed that the level of perceived stress was positively correlated with the two subscales corresponding to emotional empathy (empathic concern and personal distress) and with one of the subscales of cognitive empathy (fantasy). The degree of relationship between these variables was highly significant, which allows us to affirm that emotional empathy and the fantasy subscale are closely linked to the self-perception of stress. In the case of women, the strongest association is between perceived stress and emotional empathy, and to a lesser extent with fantasy. While in men, the correlation between stress and empathy was only observed with the emotional empathy subscales, especially with personal distress.

Based on these data, it can be considered that highly empathetic people, especially in their emotional aspect, are prone to suffering from stress. Although there are many studies that affirm that stress, specifically burnout, directly and negatively affects the empathic disposition [36, 37, 38, 39, 41, 46, 47, 48, 49, 56, 57]. Positions that propose the opposite are also found in the literature [50, 58]. von Harscher et al. [50] found a link between burnout and emotional empathy, specifically with the personal distress subscale, as those who scored high in that subscale also obtained high values in two subscales of the Maslach Burnout Inventory, emotional exhaustion, and depersonalization. Faced with this, the authors concluded, returning to the ideas of Nielsen and Tulinius [51], that too much empathy can generate high levels of exhaustion, a phenomenon known as compassion fatigue [59].

7. Conclusions

In this work, it was hypothesized that there is a relationship between self-reported levels of empathy and the level of perceived stress. It was expected to find that higher levels of perceived stress would be significantly associated with lower levels of empathy. However, it was observed that students with higher levels of stress also presented higher levels of empathy, especially in relation to emotional empathy. These results lead us to return to and reconsider what we know about the link between the variables studied here. As presented previously, several studies found a strong association between stress and empathy, highlighting the effects of stress on empathic disposition. But here we find something different, which makes us propose a different logic about this phenomenon. People with a high empathic disposition in their emotional component are vulnerable to stress.

In the field of health care, empathy is a fundamental attribute as those who come to its service generally do so in a state of vulnerability and, as mentioned, empathetic treatment by doctors, nurses, and other professionals facilitate diagnosis and treatment. But an excess in the empathic disposition of these professionals can have consequences for themselves. Therefore, we consider that undergraduate training should include programs for the development of cognitive empathy and doctor-patient communication skills on the one hand and, on the other hand, emotional regulation workshops and self-care techniques to prevent the effects of stress that their own practice (and emotional empathy) can generate.

Acknowledgments

The authors thank the university students who so kindly participated in this study voluntarily and anonymously with their time.

Conflict of interest

The authors declare no conflict of interest.