Social Intelligence: The New Science of Human Relationships

by Daniel Goleman

  How did his supervisor respond to this gesture of human kindness?

  She reprimanded him for wasting time and made sure her complaint was registered in his personnel file.

  “Our institutions are organized lovelessness,” as Aldous Huxley put it so bluntly in The Perennial Philosophy. This maxim applies to any system that regards the people who inhabit it solely from an I-It stance. When people are treated as numbered units, interchangeable parts of no interest or value in themselves, empathy is sacrificed in the name of efficiency and cost-effectiveness.

  Take a common predicament, the hospital inpatient who has been scheduled for an X-ray that day. He’ll be told first thing in the morning, “You’re going to radiology for an X-ray.”

  But he will not be told that the hospital makes more money (at least in the United States) from its outpatient X-rays than from those for inpatients, whose tests are paid for as part of a “bundled” payment from their insurance company. The hospital has to make do with whatever total amount is in that bundle—making that X-ray a potential money-loser.

  And so inpatients are last in line, waiting—often anxiously—for a procedure they believe could come in five minutes, but that may not take place for five hours. Even worse, for some tests patients must fast starting at midnight the night before; if the test is delayed until the afternoon, the patient gets neither breakfast nor lunch.

  “Revenue guides how services are handled,” one hospital executive told me. “We don’t consider how we would feel if it were us waiting. We don’t pay enough attention to patients’ expectations, let alone manage them as well as we could. Our operations and information flow are set up for the convenience of the medical staff, not the patients.”

  But our knowledge of the role of emotions in health suggests that ignoring patients as people, even in the interest of some vaunted efficiency, causes us to forfeit a potential biological ally: feeling human concern. I do not mean to argue for being “soft”: a compassionate surgeon still must cut, and a compassionate nurse must still perform painful procedures. But the cut and the pain hurt less when an air of kindness and concern go along with them. Being noticed, felt, and cared for alleviates pain to a meaningful degree. Distress and rebuff amplify it.

  If we are to shift to more humane organizations, change will be required at two levels: within the hearts and minds of those who provide the care, and in the ground rules—both explicit and hidden—of the institution. Signs of the desire for such a shift are abundant today.

  RECOGNIZING THE HUMAN BEING

  Imagine a doctor, a successful heart surgeon, who is emotionally detached from his patients. Not only is he lacking in compassion, but he is also quite dismissive, even disdainful of them and their feelings. A few days ago he operated on a man who had jumped out of a fifth-floor window in a suicide attempt and seriously injured himself. Now, in front of his students, all medical residents, the surgeon tells the patient that if he wanted to punish himself, he would have done better to take up golf. The students laugh—but the patient’s face reveals his anguish and despair.

  A few days later this same surgeon has become a patient. He feels a tickle in his throat and has been coughing up blood. The hospital’s throat specialist examines him, and as the scene unfolds, the surgeon’s face and actions reveal his fear, confusion, discomfort, and disorientation. The throat surgeon ends the examination by telling our hero that he has a growth on his vocal cords and will need a biopsy and other tests.

  As she leaves to move on to her next patient, the throat surgeon mutters, “Busy day! Busy day!”

  That tale was told by the late Peter Frost, a professor of management who undertook a campaign for medical compassion after his own experience in a cancer ward.2 The key element lacking in this scenario, Frost pointed out, is the simple recognition of the human being, the person struggling for dignity, even for life.

  That humanity too often gets lost in the impersonal machinery of modern medicine. Some argue that this mechanistic attitude leads to needless “iatrogenic suffering,” the anguish added when medical personnel leave their hearts at home. Even with dying people, insensitive messages from doctors can sometimes engender more emotional suffering than the illness itself.3

  This recognition has spurred a movement toward “patient-centered” or “relationship-centered” medicine, enlarging the focus of medical attention beyond mere diagnosis to include the person being treated and improving the quality of connection between physician and patient.

  The movement to enlarge the place of communication and empathy in medicine highlights the difference between attitudes that are espoused and their actual practice. The first principle of the Code of Medical Ethics of the American Medical Association admonishes physicians to provide competent medical care with compassion. Most medical school curriculums include a module on doctor-patient relationships; practicing physicians and nurses are routinely offered brushup courses on interpersonal and communication skills. Yet only in the last few years did the U.S. licensing exam for medicine begin to include an assessment of a doctor’s ability to establish rapport and communicate with patients.

  Part of the impetus for this stricter new standard is defensive. A much-discussed study of how doctors talk to patients, featured in 1997 in the Journal of the American Medical Association, found that impaired communication—rather than the actual number of mishaps—largely predicted that a given physician would be sued for malpractice.4

  By contrast, doctors whose patients felt more rapport sued them less. These doctors did simple things that helped: they told patients what to expect from their visit or treatment, engaged in small talk, touched them reassuringly, sat down with them, and laughed with them—humor builds rapport quickly and powerfully.5 What’s more, they made sure patients understood their comments, asked for their opinions, cleared up all their questions, and encouraged them to talk. In short, they showed an interest in the person, not just in the diagnosis.

  Time is a key ingredient in such care: these office visits ran about three and a half minutes longer than those of doctors who were more likely to be sued. The shorter the visit, the more likely a malpractice claim. Establishing a good rapport takes a few minutes—a troubling observation given the increasing economic pressures on doctors to see more patients in less time.

  Even so, the scientific case for rapport-building grows ever stronger. For instance, a review of studies found patients’ satisfaction to be highest when they felt a doctor was empathic and gave useful information.6 But patients’ sense that a doctor’s message was “informative” stemmed not just from what information was imparted but from how. A tone of voice that showed concern and emotional engagement made a doctor’s words seem more helpful. A bonus: the more satisfied the patients, the better they could recall the physician’s instructions and greater their compliance.7

  Beyond the medical case for rapport, there is also a business one. At least in the United States, where the medical marketplace grows ever more competitive, “exit interviews” with patients who have decided to quit their health plan reveal that 25 percent leave because “I didn’t like the way my physician communicated with me.”8

  Dr. Robin Youngson’s transformation began the day his daughter was rushed to a hospital with a broken neck. For ninety days he and his wife agonized while their daughter, just five, lay tied down to a bed, able to see only the ceiling.

  That tribulation inspired Dr. Youngson, an anesthesiologist in Auckland, New Zealand, to begin a campaign to alter his country’s legal code of patients’ rights. He wants to add the right to be treated with compassion to every patient’s existing rights to dignity and respect.

  “For much of my career as a doctor,” he confesses, “I reduced the human being in front of me to a ‘physiological preparation.’” But that I-It attitude, he now realizes, diminishes the full potential for a healing relationship. His daughter’s hospitalization, he says, has “brought me back to my humanity.”

  To be sure,
there are good-hearted people throughout any medical system. But the culture of medicine itself all too often stifles or destroys the expression of empathic concern, making caring into a victim not just of cost and time pressures but also of what Dr. Youngson calls “dysfunctional styles of thinking and belief of physicians: linear, reductionistic, overly critical and pessimistic, intolerant of ambiguity. We think that ‘clinical detachment’ is the key to clear perception. Wrong.”

  In Dr. Youngson’s diagnosis, his profession suffers from a learned disability: “We have utterly lost compassion.” The main enemy, he says, is not so much the hearts of individual physicians and nurses—his own colleagues readily commit to kindness—but the inexorable press toward relying on medical technology. Add the relentless fragmentation of medical care, in which patients are shuttled from specialist to specialist, and the squeeze on nursing staff, in which one nurse covers ever more patients. Patients themselves often end up as the single person in charge of overseeing their medical care, whether they are equipped to do so or not.

  The word “heal” comes from the Old English hal, “to make whole, or mend.” Healing has a broader meaning than simply curing a disease; it implies helping a person regain a sense of wholeness and emotional wellness. Patients need healing along with their medical care—and compassion heals in ways that no medicine or technology can.

  THE CAREGIVING FLOWCHART

  Nancy Abernathy was teaching a seminar for first-year medical students on interpersonal and decision-making skills when the worst happened: her husband, just fifty, died of a heart attack while cross-country skiing in the woods behind their Vermont home. He died during her winter break.

  Suddenly bereft, raising her two teenagers on her own, Abernathy struggled through the next semester, sharing with her students her own feelings of bereavement and loss—a reality they would face routinely in the families of their patients who died.

  At one point Abernathy confided that she was dreading the next year, particularly the class that included showing photos of everyone’s family. What pictures of her own family, she wondered, would she bring, and how much of her grief would she share? How could she avoid weeping as she told of her husband’s death?

  Even so, she signed up to teach the course the next year and bade her current students good-bye.

  The next fall, on the day of that dreaded class, Abernathy arrived early, only to find that the room was already partly full. To her surprise, the seats were occupied by her students from the year before.

  All second-year medical students now, they had come simply to lend their presence and offer their support.

  “This is compassion,” Abernathy testifies, “a simple human connection between the one who suffers and one who would heal.”9

  Just as they share a mission of caregiving, those who give the care need to look after one another. In any human service organization, staff-to-staff concern affects the quality of caring they can give.

  Staff caregiving is an adult version of offering a secure base. It can be witnessed in the mundane mood-lifting interactions that go on in any workplace in the course of a day, from simply being available and lending a sympathetic ear, to stopping to listen to a complaint. Or it can take the form of giving respect or a word of admiration or a compliment, or by appreciating someone’s work.

  When people in the helping professions get little or no sense of having a secure base in those they work with or for, they become more susceptible to “compassion fatigue.10 The hug, the listening ear, the sympathetic look all matter, but they are too easily lost amid the din of frenetic activity typical in any human services setting.

  Careful observation can produce a map of the give-and-take of such caregiving. Indeed, a virtual flowchart for caregiving resulted from three years of observations by William Kahn, who cast an anthropological eye over the small daily exchanges among the staff of a social service agency.11 The agency’s mandate was to provide homeless children with an adult volunteer who would be companion, mentor, and role model. Like many nonprofits, the agency struggled with too few funds and too little staff.

  Caring interactions are nothing special, Kahn discovered; rather, they are embedded in the daily life of any workplace. For instance, when a new social worker presented a difficult case at a weekly meeting, a more seasoned social worker listened attentively to his frustrations, asked probing questions, held back her most negative judgments, and said how impressed she was with the novice’s sensitivity. That was a natural display of multiple modes of caregiving.

  At another meeting, however, where the social workers’ supervisor was supposed to discuss their most problematic cases, things went very differently. The supervisor blithely ignored the purpose of the meeting, instead launching into a monologue on administrative issues that were of more concern to her.

  All the while she stared down at her notes, avoiding eye contact; left little opportunity for questions, let alone comments; and made not a single inquiry about what the social workers thought. She expressed no empathy for the social workers’ overwhelming case-loads, and when a question was asked about scheduling, she could not come up with the crucial information. Caregiving score: zero.

  As for the flow of caregiving at this agency, let’s start at the top. The executive director was fortunate in having a board of directors who enthusiastically supported him. His board president was a model secure base, listening sympathetically to the director’s predicaments and frustrations, and offering help and reassurances that the board would not abandon him, while giving him the autonomy to do things his way.

  But the executive director provided none of that caring to the overburdened social workers who did the main work of the agency. He never asked how they felt, encouraged them, or showed a wit of respect for their valiant efforts. His relationship with them was emotionally barren: he spoke to them only in the most abstract terms, oblivious to the frustration and outrage they expressed when given the rare chance. The result was only disconnection.

  Still, the executive director did offer some caregiving down the ladder—to his fund-raiser, who reciprocated. The two formed a mutual support society, listening to each other’s troubles, offering counsel and consolation. But neither of them gave a bit to anyone else at the agency.

  Paradoxically, the social work supervisor, who reported to the executive director, gave far more support to her boss than he did to her. This kind of reverse caregiving is surprisingly common, with subordinates offering unreciprocated care to their superiors. The upward flow resembles the dynamic in dysfunctional families, where a parent abdicates responsibility and instead reverses roles, seeking care from the children.

  The supervisor also reversed the flow with the social workers in her charge, giving them virtually no care but instead seeking it from them. For instance, in a meeting where one social worker asked the supervisor if she had as yet found out from another agency how they were to file forms reporting child abuse, the supervisor responded that she had tried but had had no luck. At that, another social worker offered to take over the task. The social workers took over many of their supervisor’s other duties, like scheduling, and shielded her from the emotional force of their own distress.

  The greatest volume of caregiving passed among the social workers themselves. Abandoned emotionally by their supervisor, faced with daunting pressures and fending off burnout, they tried to build an emotional cocoon around themselves. In meetings without their supervisor they would ask how each other was doing, listen and empathize, offer emotional and concrete support, and generally help each other out.

  Many of the social workers told Kahn that when they felt cared about themselves, they were more willing and able to be active caregivers in their work. As one said, “When I’m feeling like I’m worthwhile around here, I throw myself into the supervision” of the children in their charge.

  Even so, the social workers had a swelling emotional debit: they gave far more than they received. Their energy was being drained as t
hey worked with their clients, despite their efforts to replenish one another. Month by month they would withdraw emotionally from their work, burn out, and eventually leave. Over two and a half years, fourteen people quit the six social work positions.

  Lacking emotional refills, caregivers run on empty. To the degree that health care workers feel that others give them the emotional support they need, they will be better able to offer the same to their patients. But a burned-out social worker, doctor, or nurse has no emotional resources to draw on.

  HEALING HEALERS

  There’s another pragmatic argument for enhancing the place of compassion in medicine: in terms of cost-effectiveness, that inarguable standard for so many organizational decisions, it helps retain valuable staff. The data here come from a study of the “emotional work” done by health care workers, mostly nurses.12

  Those nurses whose work made them more upset lost track of their sense of mission and had poorer physical health—and most strongly wanted to leave their job. The researchers concluded that these problems stemmed from the nurses “catching” distress from the despair, anger, or anxiety of those they dealt with. This negativity threatened to spill over into the nurses’ interactions with others, whether patients or coworkers.

  But if a nurse had nourishing relationships with patients and frequently felt she improved their moods, she herself benefited emotionally. Things like simply speaking warmly and showing affection made nurses feel less psychological stress from their work, as did get-togethers for patients or staff. These more emotionally connected nurses had better physical health, as well as a sense of a meaningful mission. And they were far less likely to want to leave their jobs.

  The more a nurse confronts or stirs up distress in patients, the more distress she catches; the more a nurse makes patients and their families feel good, the better she feels. In the course of a day’s work, any nurse will surely do both, but the data suggest that the more times she primes good feelings, the better she herself will feel. And that ratio of positive-to-negative emotional interactions, to a great degree, is in the nurse’s own hands.