If I Understood You, Would I Have This Look on My Face?

by Alan Alda

  This process of allowing something you receive from another person to transform into something else is one of the most interesting experiences in improvising. It’s a delightful moment of creativity. You’re manipulating an imaginary object or acting out an emotion, and suddenly you see it changing into something else. You don’t consciously put the new thing there; you accept what the other person gives you and then, as you lend your body to it, you see it becoming something else.

  In a way, as the young musicians did this, they were practicing Yes And. You accept what you get from the other person, and then let it grow into something else. You keep moving things forward. You don’t cut off the flow. You build on what the other person offers you. You give them a green light instead of a stop sign.

  Then came the game I had been waiting to try on them, one I had never been able to do with scientists. I asked them to pick up their instruments and form a circle. This time, they were to make an emotional sound with their instrument—the idea wasn’t to play an emotional tune, just to try to make the sound of an emotion—using their violin, viola, or cello to make a kind of abstraction of emotion, even if it was an ugly sound.

  Some couldn’t help playing snatches from the string literature that were associated with certain emotions, but I would bring them back to just making sounds.

  Soon they were receiving an emotion from the person next to them, letting it morph, and then using their instrument to toss a new emotion to the next person: the sound of anger, turning into the sound of love, becoming the sound of disgust. I wanted to see if the sense of transformation and spontaneity they had been allowing to happen using their bodies would somehow show up later in their playing if they tossed emotions using their instruments.

  But first, we played word games, because after all, I had been asked to help them with speaking to an audience when they were onstage announcing the piece they would play.

  I asked them to sell something in gibberish while the rest of the class tried to figure out what the product was, just picking up clues from the pitchman’s body language and tone of voice.

  In another game, they would sit in a chair and try to figure out what their emotional relationship was to someone—just from reading clues in the way that person told them about their favorite book or movie.

  I noticed that the shyest one there, the Korean girl, was starting to leap up and join in every time she had the chance.

  After three hours, they faced the audience again. They announced their piece of music and played the first thirty-two bars. The Korean girl was beaming. This time, she seemed glad to face the audience. In fact, all of them were more at ease and sometimes even playful introducing their pieces. But the shock for me—and it was a happy shock—was that almost all the kids seemed to be playing the music with more freedom, even more joy. I wanted to make sure I wasn’t hearing things. I turned to Itzhak.

  “Am I kidding myself, or did they actually play a little better?”

  “They did,” he said. “Except for him…” He pointed to one of the students. “He was amazing to start with.”

  That’s okay. I was happy with nineteen out of twenty.

  IMPROV ALL AROUND

  Life, of course, is an improvisation. You don’t know what’s coming next. Your partners on the stage of life will always say something that throws you a curve. “I’m not happy anymore. I need some space.”…“We’re thinking of giving your job to your assistant.”…“I’m not going to college. I’m getting a tattoo and going to Africa.”

  What do you say? “No, this isn’t possible; it’s not going to happen?” It’s not only possible, it’s what is.

  As hard as it is to keep the conversation going when your child wants to drop out of college, an even harder thing to react to is when someone demands something while pointing a gun at you. This happened to my friend Larry Gelbart. Larry brilliantly wrote most of the first four years of M*A*S*H and was one of the most creative and empathic people I’ve known, but one act of empathy stands out.

  Larry was coming home late one night to his house in Beverly Hills when someone stepped out of the bushes and leveled a gun at him. The man wanted money, jewels, whatever was in the house. He told Larry to unlock the door.

  Larry let him into the house. Then what did he say? You can’t do this? How dare you? This is an outrage?

  He looked at the young black man, a kid really, and said, “You don’t need to do this. You’re too smart. What if I help you get a job?”

  The conversation probably took longer than that, but I remember it this way because it startled me so much when Larry told me.

  The kid put away the gun and the next day Larry got him a job.

  Yes And.

  But a story like this raises a question. Was Larry just lucky that he had this ability to connect with the young man, to sense what he was feeling? What if Larry didn’t have an abundant, natural supply of empathy? Are we stuck with whatever measure of empathy we come into the world with?

  In our work with scientists, not only is one of our core assumptions that a deep awareness of the other person is at the heart of good communication, but we also believe that empathy can be increased.

  But what if empathy is something you either have or you don’t? Are we born with a capacity for empathy that remains pretty much the same throughout life, or can it be enriched and deepened? Can people be trained to have more empathy?

  When I met with Helen Riess, she told me how she had realized the importance of empathy in her own work when she and her patient were both hooked up to a machine monitoring their emotions. And then she told me how that prompted her to train other doctors to be more empathic with their patients.

  I had two big questions: How does she go about it?

  And does it really work?

  CHAPTER 11

  Training Doctors to Have More Empathy

  Once Helen Riess realized she had been missing her patient’s emotional ups and downs, the experience changed the way she related to patients, and it changed the way she trained other doctors to care for their patients.

  The first thing she had to do, she told me, was help doctors understand that in fact it is actually possible to learn to become more empathic. She maintains that it’s not something you either have or you don’t. Rather, most of us come equipped with the mental hardware for it.

  She told me, “I introduce them to the neuroscience of empathy”—in other words, she teaches them how our brains are wired to receive the thoughts and feelings of others. Then she caught me by surprise with this: “Nowhere in medical school is this taught—the whole concept that there is Theory of Mind—that we can do a kind of mental time travel and enter the mind of others.”

  For therapists, entering the mind of the patient is regarded as central to treatment. Helen points out that the psychoanalytic theorist Heinz Kohut said that without empathy there is no treatment. There are countless papers in the literature cautioning therapists about the need for empathy. But for the medical doctors Helen was training, it was a novel idea that this was a tool of the trade. If they still carried little black doctor bags, empathy was unlikely to be in them.

  AFFECTIVE RESONANCE—RESONATING EMOTIONALLY

  The key to putting that empathy tool in the bag is making use of the brain’s ability to reflect what another person is going through. As Helen said, “There’s a temporary sharing—mapping—on the observer’s brain. That temporary sharing has helped us through evolution to survive, and it’s necessary for affective resonance.”

  I had a little trouble understanding what affective resonance is. She explained that it’s the feeling of connectedness we’re able to get with other people; for instance, “from looking people in the eye, from unconsciously having our bodies fall into sync with theirs. When we’re tuned in to someone,” she said, “these mirror functions happen almost automatically.” And in a way, we can have the sensation of sharing their emotions—resonating emotionally.

  In her class, He
len introduces doctors to this notion by having each of them tell a story to the person sitting next to them. Once they’re engaged, she brings the awareness of their connection to the surface. “Did the person you told the story to seem interested? How did you know?” The doctors usually say they could tell because the other person was nodding their head, making eye contact, laughing at their jokes. They have the experience of being listened to, and they become aware that they can listen more deeply to the person listening to them. This exercise reminded me of our version of the What’s the Relationship? game we do in improv sessions, and that I described in Chapter 5, where a scientist explains her work to someone who’s trying to guess his relationship to her just from the way she behaves. The focus is on connection—on reading the other player.

  THE PATIENT’S PERSPECTIVE

  When she works with doctors on how they talk with their patients, Helen Riess suggests something that sounded, to me, a little unusual. She recommends getting the patient’s perspective—by asking the patient, “What do you think is causing the problem?”

  This seemed like an odd thing to do. But apparently it’s been going on for some time among physicians who feel it leads to a deeper kind of contact with their patients. A few weeks after I met with Helen Riess, I was talking with a pediatrician who told me a story her professor had told her when she was in med school.

  “He was teaching us how to listen to patients,” she said. “He told us how when he was a young doctor there was a very difficult case that none of the residents could figure out. He was sort of the junior person on the team, and he thought, I’m not going to be able to figure it out if all my supervisors can’t figure it out. So I’m just going to talk to the patient and ask him what he thinks is going on. So he went to the station and said to the patient, ‘You know, no one can figure out what’s wrong with you. What do you think is wrong with you?’ And the patient, who had been turning his symptoms over in his mind, said, ‘Doc, I think I have malaria.’ ” For some reason, this had never occurred to the doctors examining him.

  The pediatrician telling me the story smiled. “And so they did the tests for malaria, and he had malaria.”

  Getting the patient’s perspective is what Helen Riess calls cognitive empathy: an important first step in the doctor’s ability to resonate emotionally with the patient. That emotional resonance, she says, helps us know whether the other person is at ease with us. Our sense of what they’re feeling is based on what we’re feeling, because, as Riess says, “most connections are mutual.”

  SELF-REGULATION

  Whatever brain circuits are at work at this point producing this sense of mirroring, the doctor has to avoid getting swamped by the patient’s emotion and sinking into “affective quicksand.” Self-regulation has to take place: You know what the other person is going through because you recognize their emotion in yourself, but you don’t have to act out that emotion. You take responsibility for regulating your own feelings.

  EVEN MORE EMPATHY TRAINING

  As I read more research, I saw that Helen Riess wasn’t the only scientist teaching empathy with techniques similar to those of improvisation. At Boston College, Thalia Goldstein and Ellen Winner wanted to know if students would become more empathic if they were given acting training. Since actors have to step into the shoes of another person, the researchers wondered if experience in acting would lead to growth in empathy and Theory of Mind.

  To test this hypothesis, they did two studies, one on elementary school students and the other on high school freshmen. All the students were given standard empathy and Theory of Mind tests before and after the training, to see if the training had any effect.

  It did.

  Both groups of students trained in acting showed significant gains in their empathy scores. Adolescents showed even more progress than younger kids: They had significant gains not only in empathy, but in a test of Theory of Mind, as well. Control groups that had been given other kinds of arts training, such as training in music or visual arts, showed no such improvement. Only theater training did it.

  Other studies have pointed to similar results. Training in improv and acting in general both lead to improvement on standardized tests designed to measure a person’s ability to connect with the state of mind of another person.

  But does this work in real life? That was the question I was most interested in. When we train doctors to have greater empathy, do they not only do better on tests, but do their patients actually get better? Will it pay off in better health for the patients?

  The answer is yes.

  A meta-analysis of 127 studies on how patients react to their doctors’ communication skills found that “expressing empathy and concern, providing information on the illness and its treatment, and encouraging patient participation in decision-making” made a real difference. The study found that those patients were “19 percent more likely to follow their physicians’ recommendations on medication, diet, exercise, and screening than those patients whose physicians communicated poorly.”

  And there were demonstrable improvements in the health of the patients. In studies with diabetics, for instance, when the patients rate their doctor as empathic, their cholesterol and blood sugar numbers improve. Flu patients get better sooner, and even the common cold doesn’t last as long and doesn’t feel as bad.

  Again, as in other research, gender plays a part. In a meta-analysis of twenty-three studies, female physicians visited with their patients 10 percent longer than male physicians did, and were more likely to ask questions about how their patients were feeling emotionally. The behavior of the patients of women physicians was more interactive. These patients spoke more, and disclosed more medical information to their doctors.

  As in other studies, these results probably have something to do with the observation that women tend to be better at picking up nonverbal cues. But across the board, regardless of gender, doctors who display empathy get better results.

  Even doctors themselves are said to benefit. One study has indicated that when senior medical people show empathy, there’s a kind of “emotional contagion” in the hospital and everybody feels better.

  I know. It sounds like it cures everything. But empathy does have a strong effect, even on malpractice suits. It reduces them appreciably.

  The letter I received from the dentist who gave me a smile-ectomy is still vivid to me. Every sentence expressed his concern, not about how I felt, but about whether or not I would sue. And that wasn’t an unusual stance of self-protection. For years, lawyers often advised doctors to “deny and defend” whenever the subject of malpractice came up. But the advice didn’t seem to help much. The number of malpractice suits stayed high.

  Lawyers may still be offering doctors that advice, but some hospitals are taking a different approach, one based on better communication. A few years ago, the University of Michigan began a program of encouraging doctors who had made a medical mistake to talk about it with their patient—admitting the error and even apologizing. From the lawyers’ point of view, expressing regret was a mistake in itself, but within six years, the number of claims and lawsuits dropped from 262 to 83.

  EVONNE KAPLAN-LISS

  There are dozens of reports of advantages that flow from this kind of personal connection—too many to ignore. But you can’t just tell people to be more empathic. It takes a skilled communicator to teach it—like Dr. Kaplan-Liss.

  For a young woman, Evonne Kaplan-Liss has had an extraordinary life. She was a child actress with a small part in the movie Annie Hall. At about nine, she auditioned to play the lead role in the Broadway musical Annie, and came in second to Andrea McCardle. In her teenage years, she needed medical attention and her doctors recommended an operation that was “state of the art.” She and her parents agreed to the procedure, assuming state of the art meant “best possible.” What they didn’t know was that, instead, the doctors were using the term to describe a procedure that had hardly ever been tried on children. “Stat
e of the art” just meant relatively new.

  It was a learning experience in poor communication that led to twenty-one surgeries over the next thirty years.

  Evonne studied journalism and became a journalist for a while, then switched to medicine and became a pediatrician. She now trains medical professionals across the country. Using her experience as an actor, journalist, doctor, and even a patient on the operating table, Evonne is a formidable speaker. After one of her talks, an anesthesiologist who works with cataract patients wrote her and said she had changed her practice with just one piece of advice from Evonne: “Don’t start off with all the details. Get to the bottom line. ‘You’re going to be fine. I’m going to make you comfortable. You’re not going to be in any pain.’

  “Previously,” the anesthesiologist wrote, “I would ask the patient if they ‘did okay with anesthesia’ and would immediately proceed into what they could expect. I felt like I was doing well because of the detail I was providing; who else spent the time doing that? (Aren’t I wonderful…)

  “Now,” she wrote, “I start the speech with, ‘I’m your anesthesia doctor and I’m here to keep you safe and comfortable.’ I swear to God, the patients visibly relax when I tell them this—and only then do I discuss the specifics.”

  This anesthesiologist has also asked the whole OR team to change the way they speak to patients. Evonne read to me from her letter: “For example, instead of saying ‘I’m going to drape your face,’ now we say, ‘I’ll be placing this light cover over your eye to protect it.’ ”

  Evonne looked up at me, her eyes flashing: “Right? What would you rather hear? ‘I’m going to protect your eye,’ or ‘I’m going to put a drape over your head?’ Which is what I heard twenty-one times.”