Guest Editorial – Stigma, Pity, and the Limits of Empathy

A few months ago, I was invited to speak to a group of medical providers in Oklahoma about best practices for the medical management of substance use disorders. My colleague, O’Nesha Cochran, a peer mentor, was also invited to present. Her talk was exceptional. She first shared her personal story of childhood neglect, sexual exploitation, drug use, and incarceration, and then explained how that history now helps her connect with others still struggling with trauma and substance use. That connection, she said, is vital to getting beyond the stigma and discrimination so often faced by drug users. She and other peers can tell a patient, “I know what you’ve been through. I understand what you’ve done. I get it. I see you.” And I know you matter.

After she finished speaking, an audience member asked what medical providers can do to reduce stigma during clinical encounters. O’Nesha’s reply surprised me, and I’ve been thinking about it ever since. “You need to stop feeling sorry for us,” she answered. “Don’t pity us. Look at us and know we’ve been through it and we’re still here.” If you can, she said, feel empathy. But leave the handwringing at home.

In his seminal work on stigma, the sociologist Erving Goffman wrote that stigma is relational. It is “a process by which the reaction of others spoils normal identity.” Stigma isn’t something that simply travels with a condition, like a label or a leech. It is something we actively create. I think what O’Nesha was saying was that while sympathy or pity may come from a caring impulse, it also sends the message that a person deserving of pity is not normal, or at least not as normal as the person who pities them.

I’ve known O’Nesha for years. She is brilliant and brave, incredibly funny, and has an infectious cackle and charisma that owns every room. I’ve seen her speak with administrators about racism in the hospital, comfort pregnant patients wild with fear about losing their babies to foster care, and hold an audience spellbound when she talks about her work. I have felt intimidated by O’Nesha. Often. But I’ve never felt sorry for her.

Maybe I would have, though, when she was younger, helpless against the abuse she was suffering, less imposing, and deep in her struggles, when she would have needed my support. Maybe, with good intentions, I would have met her story with sorrow and pity. And maybe, despite those good intentions, that pity would have harmed her.

I get that. I get stuck, however, when I think about the next step: empathizing. I don’t believe I could have empathized with O’Nesha back then, and I don’t think I can empathize with most of my patients now. Empathy is the ability to understand, share, and vicariously experience the emotions and perspectives of others. Like O’Nesha, so many of my patients have been through horrors. When I try to imagine what it must be like to face trafficking, to lose custody of my child, to live on the streets, to be continually vigilant and afraid, afraid, afraid, my mind jerks away reflexively, as if mentally touching a hot stove. Which, of course, was O’Nesha’s point; I’m afraid to even imagine those experiences. She and so many of my patients have survived them.

But I also think I may be doing them a disservice if I try to imagine those experiences, because I don’t know that kind of suffering. I haven’t experienced anything close to it. Yes, I have experienced grief, loss, and fear. Of course I have. I’m human. But not to that degree, and to believe that because I have experienced some suffering, I can empathize with those who have experienced extraordinary suffering seems at best self-indulgent, and at worst almost grotesque.

Leslie Jameson, in her brilliant book The Empathy Exams, offers some help here. She gets granular about empathy, calling it “a choice we make: to pay attention, to extend ourselves. It’s made of exertion, the dowdier cousin of impulse.” Empathy, she says, is a decision, and it is hard work. Pity is an impulse and easy.

I think that gets to the heart of what O’Nesha was advising in Oklahoma: Don’t be arrogant and don’t be lazy. Keep our impulses in check and refrain from differentiating and distancing ourselves through easy pity. It also offers a middle way; I may not be able to empathize, and sometimes may not even be willing to try, but I can and should still exert myself. I can do my job, and I can do it well. I can pay close attention to the person in front of me and recognize her suffering and resilience. I can respect the strength that has gotten her this far.

I can’t, like O’Nesha, say to most of my patients, “I get it. I know what you’ve been through.” But I can, like O’Nesha, let every one of them know, “I see you, and I know you matter.”