When Empathy Turns Sour

One of the most common concerns that I see working in healthcare is when a patient's family member acts out of empathetic anxiety for the patient. This is especially common in cases where the patient's condition is not as such treatable, but only "manageable," because it feels hopeless and will result in greater invalidity. 

For instance, a patient has diabetes and is not compliant with his dietary recommendations or foot care routine. He develops a toe infection, which then leads to a limb amputation. The family member (usually a child, but it need not be) feels pain seeing her father in pain. Her father's pain and discomfort is now her pain. Perhaps she feels it even more acutely than her father does. 

But now she is anxious: why is Dad still not listening? Why does he continue to eat chocolates and other goodies? The child becomes more and more frustrated. Her anxiety shoots through the roof: who will take care of her father if loses his other limb? Will his health become worse? What if he dies? 

The child then starts scolding her father: stop it, you are going to get worse, this situation is your fault to begin with, listen to the doctor!! The child starts to feel that her father's irresponsibility is not just harmful to her father, but to her as a child. If you were a good parent, you would start eating right and taking your medications consistently! Don't you see how much you are hurting me? Don't you care about me? I will have to take care of you for the rest of your life! This is for your own good! 

Depending on the capacities of the patient, he might respond with similar frustration, or simply feel a sense of indignity. Why? Because the child is trying to take away his autonomy! But on what basis? Is it really only because that is what is best for the father? Isn't there a just a teensy little bit of selfishness in his child's anxiety over him? 

Sometimes a family member is so concerned about a patient that he starts acting against the patient's best interests. It need not even be due to resentment, but simply lacking a third-person perspective. The healthcare team says: "Mum has to walk after her surgery, even though it hurts her to do so; this is best for her long-term health." But the son cannot stand to see his mother grimacing with every step. It hurts so much that he encourages his mother to stay put, even though this is to her detriment. He may not blame Mum, but he advises her on the basis of his pain, not her well-being. 

All right, so sometimes family anxiety and empathy conflict with patient well-being and patient autonomy. So what? Some people are just made that way, right?

I don't think that's right. I think we sometimes force family members to be convert their baseline empathy into resentful empathy by making empathy the main form of connection they have with their family member: if you love someone, you empathise with them. We tell them that they are not actually obliged to their unwell family member. The patient is responsible for herself--and if the patient loses responsibility, then the state is responsible for her. The nursing home or healthcare team will decide what's best for her (even if legally a family member is the decision-maker). Technically, dear family, you have no obligations to your parent. Don't worry about it! I mean, worry a bit--that's natural--but don't worry too much. (This is the official line, even if there is judgment when family members don't step up from individual healthcare providers.)

Of course, the family member is now left in a conundrum: she is being told that the patient is not her responsibility (so don't be anxious!), so how should she relate to her sick family member? Is her relationship just the same as how you would feel towards a sick stranger: altruistic assistance, or otherwise indifference? But that will never happen! She does love the patient! It is not altruism. Love has made it incumbent on her to care and to care for. 

But how should this love manifest itself? As empathetic anxiety. Of course, a person is naturally anxious when a loved one is sick. But the family member I am criticising is overly empathetic and therefore overly anxious because this is the form of official connection that she has: her love has to be based in anxiety, not in obligation. The sense of obligation transforms into an anxiety that is empathetic. The sole connection that she has to her family member is her deeply empathetic anxiety over her. And obviously this empathy is unbearable, because you have no autonomy or authority over the person's life. If it were actually your own pain, you could take steps to stop it. But you can't stop Dad from eating chocolates! So you have to stay anxious. Or maybe you become a tyrant and stop him, and hate yourself and him for making you tyrannical. 

If we kept family members' instinctive sense of obligation, I think we would do better. Obligation makes people anxious, sure, but not empathetically anxious. Your anxiety is entirely different since you are not delusional that you are being empathetic about it. You are concerned about how the additional responsibility will affect your welfare: will your obligations become overwhelming? Will you be able to sustain them? Obligation is another form of linkage that does not have to do with empathetic concern, although it is linked to love. You can fulfill your obligations without feeling your mother's pain as your own. The fact is, your welfare is not always identical to your loved one's welfare. Sometimes the two conflict! But that's why it's an obligation.

That is not to say that if people feel obliged, they won't feel empathetic (or vice versa). But I think that people begin to re-imagine their anxieties and resentments over their obligations as empathy. And they think that this intense empathy is somehow necessary for love!! So of course they won't get rid of it! If they stop feeling the patient's pain, it would mean they no longer love them! This is just a terrible conceptual and emotional situation to put someone in. And I find that it can be really quite cruel and undignifying to the patient herself.

 (The interesting exception here, I think, is mothers and children: many mothers seem to be able to take on a great amount of empathetic concern without lashing out. But that should not be presumed, since many mothers are also, quite naturally, resentful.)

So I think we should keep caregivers somewhat obliged, as they naturally are inclined to be. Obligations are sustainable because you can fulfill them while being emotionally distant from a person. They are not based in empathy. You may resent an obligation, but it is hard to resent the actual person who is the subject of your obligations: that person did not create the pre-existing moral obligation on you. 

In contrast, much of ill-health can be seen as a direct result of people's small and big choices. Constant empathetic anxiety will eventually result in people lashing out and it will make their love miserable.

(I keep the term "family member," and not "caregiver," here because there are lots of caregivers who do not feel this anxious empathy. Nurses, PSWs, etc. The anxious empathy is rooted in love.)

-- MM, October 2021