Words First, Medicine Later– On Empathy

Words First, Medicine Later– On Empathy

Aleksandra Bubera

Interview published in Večernje novosti on June 20th 2010.

Empathy is the ability to understand others and to sympathize with them.

Just how many times have you said or heard someone say: “I have plenty of my own problems, I can’t worry about other people’s too” … This has become something we say almost without thinking, and we don’t even realize how selfish or insensitive we sound. It is a fact that we live in a time where it isn’t easy to take a moment and think about other people’s feelings. Despite that, just try to remember how many times you yourself were in a situation that you wished for someone to share your problems, your worries and your feelings with. If we understood how much it means to listen and to say a kind word, maybe we’d better understand empathy, which is something this society desperately needs. And it has always been a part of society. Even Hippocrates described it, in a single sentence “Words first, medicine later”! Our guest for our Život Plus(Life Plus) column is Aleksandra Bubera, M.D., psychiatrist and psychotherapist. She is here to tell us more about empathy, the ability to understand each other.

– Empathy is the ability to feel how another person feels in a given situation. Sympathy or compassion,  is an emotion which signals that we find other people’s feelings important, and that they themselves are important to us, which affirms a friendly relationship between us. Feelings that result from empathy and compassion are vicarious feelings. “Vicarious” meaning a representative, deputy, apostle. So, in a way, we can be other people’s representatives and be there for them.

Are we born with empathy, or do we develop it throughout life?

– We need socialisation in order to feel empathy and compassion. This means that we’re not born with these abilities, but that they are learned, i.e. empathy is developed throughout life. Small children, for instance, aren’t socialised. They function by following their needs and whims, and when they are quite young they feel no compassion for other people, animals… Their parents need to teach them: “It’s not OK to hit the kitten, the kitten is hurting, just as you hurt when someone hits you”.

How feasible is it to develop the ability for compassion with others at a time when people have increasingly less time for one another?

 – The modern way of living is quite different from communities in the past, when the ability for compassion was greatly nurtured and valued. Nowadays, children are brought up differently than back then – they are taught to care about themselves, their own wishes and needs more than about other people’s. Back in the day, people followed the biblical principle “Thou shalt love thy neighbour as thyself”, and the common interpretation was that one should make sacrifices for others. In contrast, nowadays that same sentence is narcissistically interpreted as “I come first, then after about 350 empty slots, everyone else.” Both interpretations are exaggerated. A realistic standpoint would be to take care of yourself first, but not to the extent that other people suffer for it (if they already don’t benefit from it). The circumstances and human society are constantly changing, but that shouldn’t be an excuse for indulgence, selfishness, narcissism and excessive hedonism.     

What ways are there to develop empathy?

– Building empathy must always begin with us and our impressions. We need to imagine how we would feel if we were in a certain situation, and it is our parents who start training us to do this. This is so callen “naïve” empathy, because it teach us about us, not other people, but that’s how we start. One of the functions of fairy tales, games, stories and poems for children is giving a child the ability to imagine situations that happen to other people, what they do, what they might feel and how they might think. It would be good to teach our children emotional literacy, first within the family, and then in kindergartens and schools. To do this, we must be emotionally literate ourselves to begin with. We need to teach children to understand themselves. We also need to teach them to take a step back from their own perspective and understand and accept that other people are sometimes quite different from them – that they have different wishes, reasoning and feelings from their own. If we ourselves understand it, and if we teach our children clearly, this won’t be a mystery to them any longer. It will become an automated activity, like riding a bike. Luckily enough, adults can also learn to be emotionally intelligent, emotionally literate and empathetic. There are many books, trainings and educational workshops that deal with people, feelings and relationships between people in various ways. For anyone interested in these topics, I’d like to recommend some books: Emotional Literacy; Intelligence with a Heart by Claude Steiner, Emotional Intelligence by Daniel Goleman, Emocije(Serbian only)  by doctor Zoran Milivojević

Is it true that people with developed empathy have higher quality romantic relationships?

– It is. When you can accurately feel what is happening inside another person, you can understand them well and correctly. This lowers the chances of misunderstandings. In contrast, when you don’t have this ability, you tend to interpret other people, their feelings, reasoning and actions according to what you yourself would feel and do, and not as it really is. The ability to see the world through other people’s “lenses”, and not only through your own, provides a rich source of hues in the spectre of human relationships.       

Plenty of research has shown that empathy is an important trait of successful business people. If it is important, how come there’s an unwritten rule that emotions should stay out of business and the business environment? 

– To put it more precisely, the rule should read that objectivity is always better than subjectivity when it comes to business. Not bringing emotions into work is impossible, unless you’re a person completely cut-off from your emotions. That’s a rather unhealthy person, a robot. Our experience confirms the results of research that empathetic, emotionally and socially intelligent people are more successful at work than people who are not. As every job, to a lesser or greater extent, consists of communication and cooperation with others, the ability to assess how others feel in their own skin, what bothers them, what they wish for allows for easier and better communication with them. This also entails motivating them to cooperate in a way that is beneficial for everyone.

Why is empathy particularly important in a tense work environment?

– It helps us stay out of unnecessary conflicts and also helps us react adequately. Business people are expected to be at the top of their game, to understand the core of things and relationships between people. However, everyone expects the other person to be ready and able to understand and adapt. This is why there’s a recent trend of investing in HR and training in the field interpersonal skills, not just professional competencies. Some of the areas covered are communication skills, both verbal and non-verbal, becoming more sensible for different ways in which people communicate their feelings, etc.

It is important to differentiate empathy from pity. What’s the key difference?

– Pity is feeling sorry when something bad happens to a person. It is a form of love, and not, as we often tend to perceive it, an expression of contempt or animosity. When a person doesn’t want pity, it’s often because they think it is a form of animosity or gloating over their adversity. Or they believe that this kind of compassion is reserved for people not worthy enough or capable enough to fight with the battles that life brings them. Pity is, in fact, compassion for someone we’re close to who is suffering. That person is someone we see as worthy, and that’s why it’s important to us how they feel. So, when we feel pity for someone, it’s quite the opposite of feeling contempt. The person we sympathize with is one we perceive as worthy. Empathy is broader term and includes emotional understanding of all emotional states of others, not just pity.

How can one show empathy?

– Empathy can be shown verbally and non-verbally. The better people know each other, the fewer words are needed.  A hug, a look or holding someone’s hand can be enough. But in case we don’t know a person well, or don’t know them at all, it’s best to check with them whether we’ve understood the meaning of what they said and how they feel.

How important is empathy in everyday communication?

– It’s important in all relationships, and since most of us communicate with a great number of people during the day – at work, at home, in public transport, during vacation and leisure – we practically need it in every waking moment.

If empathy is the ability to put ourselves into another person’s position, to understand their feelings – is it possible to be too empathetic? – By definition, empathy is realistic, so we can’t overdo it. We can only overdo it by taking too much on as a result of knowing how someone feels and then coming to a conclusion that we must do something about it. If no one asked us to do anything, if we do more than is up to us, and meddle in things that we should stay out of, we’ve got ourselves tangled in a so-called “psychological game”. If don’t become aware of it, at best we’re going to end up feeling pretty uncomfortable. However, if we can really understand why someone feels the way they do, we’re probably going to have the ability to estimate which actions to take, and which not to take. So, I’d say “yes” to empathy as I don’t think we can overdo it since it’s precise and realistic.  



Interview with MD Aleksandra Bubera, psychiatrist and psychotherapist, with journalist Branislava Laćarak, published in Večernje novosti daily papers 29.03.2014.

Hypochondria is often thought of as a condition of enormous fear of an illness, which is not important enough to be dealt with more seriously. To what extent is hypochondria a really serious condition and how much can it affect one’s life? Is this condition only “in one’s head” or can it cause some specific problems to a person?

  • Hypochondria implies excessive preoccupation with physical symptoms, health and illness due to pathological fear that a person suffers from a serious illness. Hypochondria was known even in ancient Greece, while the term has been used in medical practice since 16th or 17th century.

It belongs to fear-related disorders and belongs to the class of neuroses, i.e., light mental disorders. When I say light, I do not mean the suffering that a patient experiences because of the disorder, but I mean the cause, course and the prognosis of the disorder that are easier to approach to and treat, often by psychotherapeutic methods in contrast to severe mental disorders. And because of this hypochondria should be distinguished from delusional hypochondriac ideas that occur in severe, psychotic disorders – delusional ideas are unrealistic and sometimes very bizarre such as, for example, when a patient is fully convinced that he[1] has stomach-ache because he has frogs in his stomach, or that he has cancer because of the influence of evil forces from an unknown planet. In such cases the patient usually suffers from a very serious disorder that requires long-term and inevitable medical treatment, while psychotherapy can sometimes be applied.

Like all other disorders associated with fear, hypochondria is a disorder that greatly affects the quality of life, and/or a person is in constant fear, preoccupied, convinced that he is very ill, which affects his daily routines and enjoyment. When diagnosed with hypochondria, this means that a patient has been fully examined and found to be free from any physical illness. However, although someone does not have a bodily illness, this does not mean that he cannot have sensory experiences. Every emotion, pleasant and unpleasant, due to a physiological body reaction to emotion, which actually prepares the body for action, is felt in the body as a set of sensations and can be misunderstood as a symptom of an illness.

What is it caused by, how does it occur and what can affect its development in a favourable manner?

  • The so-called “emotional illiteracy” (alexitimia), which implies that a person does not recognize emotions, that he does not know what they serve for and thus he does not relate (normal) body reactions to (most often unpleasant) emotions, is the primary cause of the development of disorders. A person feels an emotion that he does not recognize (it is usually a very intense and unpleasant emotion), the body physiologically reacts with the preparation for action, which is reflected literally on the whole body – heart, breathing, blood pressure, sugar level, oxygen and carbon dioxide, muscle tone, functioning of internal organs, glands with external and internal secretion, brain, etc., and then a person, being not aware of the emotions he has felt, does not recognize the emotion, but only recognises the body reaction. Since the body reaction to intense emotions is also intense and the person is only aware of that emotion, other than of the psychological mechanism that resulted in the body reaction – he concludes that something unusual is happening in the body, something that is a sign of an illness. For example, heart palpitation, tightness and abdominal pain, headache, sweating, numbing of arms and legs, heavy breathing, etc. This condition includes the development of the so-called “hypochondriac mentalisation” in a person, and/or a system of beliefs that the body, organ or organ system will surely “let” him down.

The development of hypochondria is favourably influenced by the environment and education that do not deal with emotions, which is often for many reasons: generations deal with survival rather than with quality of life, while dealing with emotional life belongs to the domain of a comfortable life zone, not survival, which of course also entails not paying attention to emotions, either to all of them or just to some of them, and if we are not emotionally literate ourselves, we can hardly teach our children, pupils, students to be emotionally literate.

To what extent does the environment contribute to a person becoming preoccupied overnight with illnesses (media, newspapers, TV, movies, series…)?

  • These disorders rarely develop “overnight”, although there are cases when we can precisely identify the situation when it all started.

For example, the case of a patient whose hypochondria has been treated for several years and he has been examined almost every week for a body illness in a precisely defined, always identical part of the body, while psychotherapy identified the event when he had an intense unpleasant feeling for the first time and related his intense body reaction with this feeling, other than with an illness.

After this, when he thought back, he realized that the pains in that particular part of the body appeared ALWAYS when he felt the same emotion, which had been completely suppressed due to a certain context and circumstances. More repetitions of the model “emotion – not recognizing – a body reaction – interpretation as a symptom” is usually needed so that a person could conclude that he is certainly ill.

It often happens that when someone around the person gets sick or dies of some severe illness, and especially if the deceased person was close and dear to him, the person begins to have certain symptoms that may point to the same or similar severe illness. Especially if the deceased person was a cousin, the person is afraid of the “genetic resemblance” and of becoming ill.

Due to the overflow of unpleasant emotions (sorrow, fear, anger), which a person does not recognize as such and feels them in his body, which leads to the conclusion that something with the body is wrong, the person concludes that something terrible happens with him and that and he got sick.

Various traumatic events, such as the survival of one’s own severe illness or accident and various other traumatic events may also trigger this pathological cycle of the development of hypochondria.

The phenomenon of medical students who, while learning about a certain disease during their studies, start to “recognize” symptoms of the disease one by one, until finally they realize that they are not ill, but that they were only “immersed” in their studies about the disease, is also known.

Certain influence can be made by media effects to young people who do not yet have enough life experience, especially if they deal with a disease with sensationalism and in a very scary way.

What are the most frequent illnesses that persons suffering from hypochondria are afraid of?

  • Nowadays people are most often afraid of cancer, although they are also afraid of some other usually severe and hard-to-cure or incurable illnesses. Today they are often afraid of AIDS, which is most often associated with the feeling of guilt due to some sexual behaviour that a person considers inadequate.

People are also afraid of “bird” and “swine flu”, SARS, Ebola and similar severe infectious diseases.

Fears of diseases that were incurable at the time, such as tuberculosis, plague, cholera, etc., were more often present in the past.

Are the symptoms they feel and describe invented or realistic (heart pounding, dizziness, hand tremor…)?

  • Patients feel very realistic symptoms in the form of pains in various parts of the body – stomach ache, headache, chest pain, heavy breathing, heart palpitations, dizziness, sweating, trembling, they have an impression that they have temperature, weakness, fatigue, they have an impression that they have felt some lumps on various parts of the body, etc.

Therefore, they often undergo various laboratory tests, X-ray examinations, ultrasound examinations, CT scanning, magnetic resonance imaging, ergometry, spirometry, various “scopies” (bronchoscopy, colonoscopy, etc.) …

If doctors do not want to see and examine them, convincing them that a week ago they underwent an examination and that everything was fine and that they should not repeat it, they often get angry with doctors, because they feel doctors have no understanding and that they really feel physical symptoms and it must be a sign of a disease.

And, if they financially can afford it, they will change a doctor and the medical facility and undergo examinations from the beginning – and so on indefinitely.

At what age does hypochondria usually occur?

  • Most commonly it occurs during the period from late twenties to the fifties, although there are cases when it occurs in teens, as well as in mature age and in the old age.

What kind of people does it usually occur in (education, interests, physical and mental condition…)?

Hypochondria “does not choose” its victims. This means that persons susceptible to the development of this disorder cannot be profiled by education, interests and physical condition.

Generally speaking, persons who are emotionally illiterate or insufficiently literate are susceptible to hypochondria, and they interpret the emotional body reaction as a symptom of an illness, rather than as a normal physiological reaction of the body to emotion.

Therefore, the more we are in touch with our emotions and the more we know why we feel the way we feel, and which thoughts, situations or interpretation of the situations this emotion is connected with, the more we know what emotion we exactly feel, what it serves for, how to adequately demonstrate it and use it for such an action that will best contribute to adapting to the current life conditions, the less we will be susceptible to this and all other disorders related to somatization.

Somatization is a tendency not to recognize mental conflicts as such, but to manifest them in the form of physical disorders.

What are the signs indicating hypochondria and what should be done when it is recognized in someone? (Should an expert be consulted to obtain advice what to do next, where to go, who should a person talk to and what is your advice in this regard)?

When there is a persistent belief that a person suffers from a physical illness, regardless of having undergone numerous examinations that have not confirmed the existence of such illness, and of course, when a person does not believe physicians who claim non-existence of the illness, the person suffers from being preoccupied with the illness to the extent that various aspects of his daily routines are affected.

If these symptoms last six months or longer, a person can be diagnosed with hypochondria.

In this case, it is best to talk to a person and point out to him that all those difficulties may not come from a physical illness, but that there is a psychological conflict that he does not recognize and that it would be good to consult a psychotherapist, psychologist or psychiatrist.

In most cases, a person, if not sufficiently informed, will experience this as “calling out” that he is “psychotic” and resist such an approach.

But you may help him by informing him that there is a mechanism for emotion suppressing and somatization, that alexitimia exists and that as part of the treatment most of the psychotherapeutic schools work on correcting distorted beliefs and on developing emotional literacy at the same time, and in this way symptoms control, i.e. body reaction to emotions is achieved. During such treatments, triggers may often be identified, i.e., why the disorder occurred and what mental conflict is in the background.

Once this is clarified, a person can approach conflict resolution and learn how to resolve conflicts in the future rather than somatise it, after which the person has been cured.

How is hypochondria treated, how long does the treatment last, and can it be successfully or only partially cured?

  • There is no “spontaneous” healing – and/or, it is possible that a person himself stops to have fears, if he is aware of his distorted beliefs, the psychological conflict and the circumstances under which the disorder has occurred.

But in quite a number of cases, psychotherapy is needed, which will help the person to clarify this problem faster.

Sometimes medication is required – anxiolytics (benzodiazepines) and drugs that act in an anxiolytic manner and which are better in the long run – antidepressants, which have a good anxiolytic effect almost without exception.

What happens when hypochondria is not treated and what further problems can it result in?

  • If a person does not get into the nature of his or her own problems, it can greatly damage the quality of life, and in some cases, the person blames himself for, which can result in the secondary depression.

Are there persons who pretend to be hypochondriac, who are hiding behind this diagnosis and how should they be distinguished from those truly affected by hypochondria?

  • Persons who pretend to be hypochondriac are rare as hypochondria is not such a disorder that can be used to get a specific benefit out of it – as for example, if you successfully act out some serious disorders to get some material gain.

Someone would hardly accept to undergo all examinations that hypochondriacs undergo and who will repeatedly undergo unpleasant and unnecessary examinations week in, week out, to be calm for a certain period of time.

Can hypochondria be acted and why would someone do it?

  • Any disorder can be acted, but there is a clinical experience, as well as tests that can distinguish between true and “acted” disorders in most cases.

A person who acts the role of a hypochondriac would soon realize that the benefit is very short-lived – i.e. the concern of the persons he is close to will soon turn into preaching and/or ignoring, as this unfortunately also happens to people who really suffer from hypochondria because they are not only a burden for themselves but also for their environment, and people close to them often find it very difficult as they do not know how to behave with the patient – they have usually tried with having care, understanding, preaching, anger, ignoring, pleading, threatening etc., and the patient still has the same problems he has had before.

Do real hypochondriacs constantly visit doctors and seek help or not, and what does it depend on?

  • Real hypochondriacs constantly seek the help of a doctor, they constantly ask for referrals for new examinations, they are afraid that doctors have missed something, that they have not paid enough attention to some symptom or finding, they ask doctors to calm them down, but they also do not believe them.

They usually respond to a warm approach and understanding, but empathy is not enough to solve the problem.

Systematic problem solving is required, starting with work with symptoms, relating them with the body, emotions, thoughts and conflicts or trauma to solve the problem.

What percentage of the population can be classified as hypochondriacs and are there some subcategories of this condition, and how many of such people are there in our country (if any such information is available)?

  • There is no accurate data on how much this disorder is common in our country, it is estimated that this disorder is present in 1% to as much as 7% of the population. These higher percentages refer to the number of patients who seek advice in primary healthcare facilities, i.e., from general practitioners.

Less than half of these people gets to a psychiatrist, psychologist and psychotherapist, as some cases are treated in general practice, which is good if such treatment is successful.

The interview is available at the website of Večernje novosti.

[1] He/she may be used alternatively