An educational intervention focused on teaching Qualified Empathy to social work students in Finland

Introduction

In our historical and political era, social work education is carried out to help students develop their sense of connection to the people they serve as well as the skills to assess their needs without being swallowed up by complex problems and difficult ethical situations. Our modern age is challenging, both globally and locally, and we need to ponder how we could become, or remain, connected to one another, remain respectful of one another and still be able to have an opinion of our own which reflects our personal values. Although, social work is a high stress profession that involves working with people in distressing circumstances, as observed by, for example, Stanley and Mettilda (2015), it is too often overlooked that we need to support students in building their self-care skills through education (Newell and Nelson-Gardell, 2014). Empathy training should not be taken for granted during studies. This is one of the main reasons why the benefits of empathy need to be recognized and explored more thoroughly.

In general, it can be concluded that empathy includes many benefits. As a way of example, studies have shown (Gerdes and Segal, 2011; Howe, 2013; Sinclair et al., 2017) that clients who experience empathy while working with professionals manifested better results and higher levels of effectiveness. Empathy was found to provide protection against burnout and to improve the balance of professionals' roles (Wagman et al., 2014). Based on these findings, Wagman et al. consider that studying empathy is justified and should be a core part of social services studies. Furthermore, the lack of information and training resources focused on professional self-care (Newell and Nelson-Gardewell, 2014, p. 432) support our position that there needs to be more emphasis on the development of empathy in social work education. In order to develop professionalism within the social sector, educational policymakers need to assist students to develop better trust-based interactions, emotional skills and empathy. It is important for social work education to focus on empathy in students through supervision and guidance, in order to support their professional ability and develop more sustainable working environments in the social work context.

To sum up, there is a significant need for empathy skills in the world, especially in the social and health field. Currently, empathy is being taught in many ways, but because in the rapidly changing world we face new complicated global problems (such as immigration, climate change and recently, the COVID-19 pandemic), this is not enough.

The aim of this article is to describe the results of an educational intervention focused on teaching Qualified Empathy to social services students in higher education in Finland. We explore how Qualified Empathy is experienced and developed by students, as an optional framework for professional empathy, rather than a skill set as such. The recognition of the feeling of Qualified Empathy, and how to use it ethically and effectively to support the development of the relationship with the client and opportunities for supportive guidance between the worker and the client were some of the objectives of the educational intervention. In addition, we wanted to create a mental framework for professional practice.

What is Qualified Empathy, why do we need it, isn't empathy enough?

This article is based on the concept of Qualified Empathy. Introducing this concept previously (Raatikainen et al., 2017), we characterized a Qualified Empathy professional as a practitioner with the ability to frame any client interaction by using accurate or targeted empathy. Qualified Empathy requires compassion for empathic action and includes the ability for professional self-reflection, emotional skills and a healthy set of boundaries. It contains the ability to tell the difference between sympathy and empathy and the ability to use compassion for acting in an empathic way. Such empathy is not only for the clients but also for the professionals themselves and the environments surrounding the interactions. In other words, our understanding of the Qualified Empathy professional is someone who has empathic skills and compassion toward themselves, colleagues, clients and the environment. Qualified Empathy is more of a mindset or work orientation than a method that is rooted in ethical thinking. An empathic social worker is able to be a mirror to others and adjust his or her interactions without immersing themselves into the other's emotional world or context.

Qualified Empathy has its roots in the conventional understanding of the term empathy. According to Rogers (1975), being empathic involves understanding the inner world of the other. For the professional, this involves accuracy of understanding and control of personal emotional components while “feeling “as if” they were the client” during the interaction. If we lose the “as if” state, we would only determine through cognitive recognition but we would not achieve compassionate recognition (Rogers, 1975). Rogers (2007) pointed out the importance of empathic understanding in a counseling relationship. Gerdes and Segal (2009) refer to Decety and Moriguchi's outline of the four components of empathy: (1) affective sharing or the experience of similar emotions between the self and other; (2) self-awareness which recognizes that although there is temporary identification between the self and other, there is no confusion between the self and the other; (3) mental flexibility or the ability to cognitively imagine another's situation “from the inside”; and (4) emotion regulation, which utilizes regulatory processes to modulate the subjective feelings, associated with emotion. Without the possession self-awareness of others and the ability to mentalize (Fonagy et al., 2004), an individual will have difficulties to imagine oneself in, another's position (Iacoboni, 2008).

In our exploration of the literature, empathy as a socio-emotional (social affective) phenomenon is often based on interaction and relationship (Cunico et al., 2012). Empathy is an essential part of a functioning human relationship and manifests itself as an ability to recognize when the other person needs support (Thompson and Woods, 2000, p. 160). Rogers (1961) (in Thompson and Woods, 2000) said, “Empathy requires the emotional capability to commit to understanding another person's world, but it does not mean that we should “take all the other's emotions as our own’”. Empathy recognizes a sense of equality (Thompson and Woods, 2000). When we look into it from a neurobiological, “micro” perspective, research on mirror neurons has shown that our bodies respond to another person's emotions or actions, “as if” we would feel a degree of that emotion ourselves (Decety and Jackson, 2004). We have a drive to imitate others from birth and it never decreases (Iacoboni, 2008) but continues to develop as we gain linguistic abilities (Eckerman and Didow 1996 in Gerdes and Segal, 2009). According to Arnold (2014), in accordance with our view, empathic intelligence is a complex concept beyond the neurophysical, including both intersubjective (interactions between subjects) and intra-subjective (experiencing within subjects) aspects.

Professional empathy is often believed to occur by itself, unconsciously and intuitively. Unfortunately, that is not often a realistic way to see it. According to Grant et al. (2014) we take students' empathy skills for granted, and expect that they are able to demonstrate an awareness of their own emotional resilience and the impact of their actions when working with clients. We expect them to be able to use their own experiences in interactions while managing their own safety and wellbeing. As work within the social services sector is largely interactive in terms of creating relationships and trust-based interventions these skills are paramount for the workers to support both the client's and their own wellbeing. For example, according to Lloyd et al. (2011), however, social workers are identified as being at risk for experiencing stress and burnout, because social work is strongly client-based and often involves complex social situations and conflicts.

Too often, we as educators assume that social work students have a “natural skill” for empathy and altruism. Still, many ways to teach empathy exist. For example, studying outside of the classroom, such as Service Learning projects (Engaged Scholarship) (Trad, 2013) or by movie viewing and based on reflection (Briggs et al., 2012). Further methods include literature circuit (Shapiro et al., 2004), learning of better communication skills (Winefield and Chur-Hansen, 2000) or self-assessments, i.e. different types of measures of empathy in self-evaluation (e.g. The Empathy Scale for Social Workers, ESSW) (King and Holosko, 2011). In addition, creative methods have been explored and used while teaching empathy to students.

In a changing and unpredictable world, we need a more systematic, professional, approach to empathy. A people-to-people perspective is insufficient, we need a wider perspective in order to create a more sustainable future for all. Qualified Empathy offers a wider perspective; it includes social pedagogical and eco-social approaches for empathy in professional contexts. In order to establish a truly sustainable definition and application of Qualified Empathy, we need to look at the larger context of wellbeing as part of the living environment.

Methodology and implementation of study

Typically, case studies involve multiple methods of data collection (Robson, 2012). Additionally, in case studies, the “case” can be an individual, group, situation or even an organization. According to Yin (2009) “case studies are a strategy for doing research which involves an empirical investigation of a particular contemporary phenomenon within its real life context using multiple sources of evidence”. In our study, the case was a student group at Metropolia University of Applied of Sciences in the Social Services Degree Programme in Helsinki. Like Hakim (2000) states, in case study research the focus can be on “studies of organizations and institutions and examples of processes of change”. Our research question was: How do students construct Qualified Empathy as a dimension of their own professional expertise?

We collected data by using open questionnaires, learning diaries and written documentation related to the final internship (see Figure 1). The intervention had four student activity phases. As the first data collection point (1), the pre-assignment comprised an open questionnaire prior to the Individual and Community Counseling course. The questionnaire included six thematic areas:

1. Meaning of empathy in social work,

2. Abilities of an empathic person,

3. Most important characteristics of an empathic person,

4. Students' assessment of their own qualities (in relation to previous areas),

5. Students' assessment of missing skills,

6. Example of an empathic moment in social work.

The second data collection point (2) was an individual report after the theory lectures at the beginning of the intervention. The third data collection point (3) was the final work practice individual report based on the students' work practice at the end of the intervention. The final data collection point (4) took place at the end of the semester using an open online questionnaire. The same questions were used as at the beginning of the Individual and Community Counseling course, with the exception of the last question on self-reflection “How aware of your internalization of “Qualified Empathic skills' were you, in the case example?”

Students were informed of the research during the initial theory course; both oral and verbal permissions were received from the participants when they filled in the questionnaire. We followed the Finnish National Board on Research Integrity and our organization's guidelines for good practice. https://tenk.fi/en/advice-and-materials/guidelines-ethical-review-human-sciences. In our questionnaire, we included information on how and where the data would be used.

Good scientific practices and research's ethical principles were followed in the acquisition and analysis of the research material (Walby and Luscombe, 2017). In our study, student participation was voluntary, their consent was confirmed and they remained informed as we provided sufficient information about the study throughout its duration. The research material was anonymized and oral permission for the study was obtained from the institution's area manager.

The acquisition of the research material was carried out by researcher triangulation (Robson, 2012). In our study, it meant that all three authors participated in gathering relevant literature and data analysis. Initially, (1) each author analyzed the data independently, followed by (2) synthesis and (3) the results. The reliability and trustworthiness of the research and its results were ensured by the research team's numerous discussions about the results. Preliminary results were also presented in several seminars in order to obtain feedback and foster interaction with a wider audience.

Participants and analysis

The participants were 20 first-year undergraduate social work students, between 18 and 30 years of age, taking part in the Individual and Community Counseling and Supporting Everyday Lives courses. We followed the student groups' development of their empathy skills during the spring of 2018. As detailed above, data were collected in those two courses, four times during the education intervention, lasting one semester. The data consisted of (1) open electronic questionnaire before the course, (2) individual final report, (3) individual final reflection on work placement learning and lastly (4) an open electronic questionnaire at the end of the semester (during the Supporting Daily Lives course, after the work placement).

The data analysis was based on students' writings, online questionnaires and internship reports, using an abduct approach and theory-based content analysis. For analysis we adopted categories of self-reflection, emotional aspects and action. These elements are connected to the students themselves, colleagues, clients and the environment. Data were read repeatedly in order to categorize the data into smaller parts. After categorizing the data into main and sub-categories, the results were generated. Table 1 shows examples of data gathered.

The analysis was performed in two stages:

1. The first stage was a thematic reading of the data. Our category themes followed the research question and keywords as well as Theory-related material (Ryan and Bernard 2003; Robson, 2012). The analysis keywords and perspectives were based on our previous review article (Raatikainen et al., 2017).

2. The second stage was content analysis. In this stage, we gave the students “space” to hear something new, coming from outside the Qualified Empathy definition.

Due to the relatively small data sample, we concentrated on the content of the data and not only compared pre- and post-intervention results, but transformations as well. We also studied all data as a whole, from the theoretical point of view in addition to content analysis.

Results

According to our results, there were three “progress elements” as outcomes of the learning process, where we recognized how empathic skills could be improved during the intervention targeting the development of Qualified Empathic skills. After the two readings and analysis stages, students' internalization process leading to Qualified Empathy from empathy was thus categorized into three areas of progress: (1) from an emotional reaction toward an empathic emotional response, (2) from understanding to empathic acting and (3) from a client perspective to a more systematic approach, including the workers themselves, co-workers and a global dimension, see Table 2:

Summary of results

Students saw the framework of Qualified Empathy as a helpful professional and theoretical tool, helping them to relate their learning experiences to their development, and their way of working professionally and empathically in practice. Many pointed out that using the theoretical framework was beneficial and the concept of accurate or Qualified Empathy was easier to internalize as a tool for action. It helped them to create some distance from the “personal part of the empathy”.

The aim of the intervention was to help students internalize the deeper skills of empathy or Qualified Empathy; we believe we achieved this. Qualified Empathy is a professional approach, to reduce professionals' risk for burnout and to increase awareness of the risk of inappropriately intense empathy in client relationships.

At the beginning of the process, students described empathy as “understanding” and “getting into the other's shoes”, but after the intervention, there was a significant qualitative difference in the students' way of describing and giving meaning to empathy in the social work context. It became more professional, with a more reflective approach. During the first progress step, from understanding to acting, it seemed to be very important for the students to act empathically. As educators, we need to be more responsive in supporting future professionals in their work to assist clients in navigating their demanding life situations. Empathy needs action as well as boundaries.

According to the study, students became more aware of emotions; of their own, their clients' and coworkers'. Professional empathy is a significant component of the Qualified Empathy skills. During the intervention, the benefit of developing accurate Qualified Empathy was seen as one way to avoid over-empathizing and personal distress. As summarized in Figure 2, in the Qualified Empathy framework, the progression of Qualified Empathy is categorized thematically as (1) from emotional reaction to emotional response, (2) from understanding to empathic acting and (3) from client perspective to a more systematic approach (including the workers themselves, co-workers and eco-social/global perspective). Developing Qualified Empathy is about fine-tuning the skills for achieving change and influence from a wider perspective – the systemic approach – in an empathic way. Although students reflected on their learning in a more profound way, we underscored that maintaining the skill is a lifelong process; continuing reflection is needed.

Discussion

In this study, as in all studies, some limitations need to be taken into account. One limitation of this study is the size and “nature of data”. Secondly, challenges with the concept of Qualified Empathy need to be addressed and more research is needed to define it more concretely. Even so, as it is a new concept, we need more discussion on the differences in the definition of empathy and Qualified Empathy. However, this study offers one new perspective for discussion which is the need for empathy training, in social work education practices and in the field.

An important ethical aspect of research emphasizes that its implementation must not be to the detriment of the people being researched (Juuti and Puusa 2020, pp. 168). In all the various stages of our study, we paid attention to diligence and accuracy, transparency and respect for the work of others. In particular, we have considered our relationship as researchers and teachers, in the development and application of a new concept or approach. We have asked ourselves what is Qualified Empathy and what is empathy? Why do we need Qualified Empathy, isn't empathy enough? No, not in the professional context. We do not believe so as action is not directly needed to empathize.

We are aware of our intermittent subjectivity toward the subject under discussion. The chosen research methods, concepts and methodological solutions required serious discussion. The article was written in many different stages, and in some cases relatively slowly, as we needed in-depth discussions, e.g., on the ethical and conceptual side of the work. As stated earlier, the students gave their consent to the research both orally and by answering the e-questionnaire, which provided information about the research and its utilization. We also informed students about the preservation and handling of the material. The material was collected as part of the courses on the institution's e-form, where it is also stored. Internship reports are retained as a part of teachers' documentation requirements.

Conclusion

Our findings demonstrate that educational interventions can improve students' empathy skills to more qualified skills. We emphasized that maintaining the skill demands continuous reflection as a lifelong process. This article provides an overview of an educational intervention to improve students' Qualified Empathy skills and suggests a definition for educators to frame the teaching of professional empathy or empathy in a professional context – especially in the social work context. Furthermore, with this educational intervention in social work, we offer a way to support the students to – not only – have a more professional approach to empathy, but also to find a way to establish a more emotionally sustainable environment for professionals in social services. It is essential for social work education to focus on the growth of Qualified Empathy in students through supervision and guidance which supports their professional competence. By doing so, we contribute to the development of more sustainable working environments in the social work context. Further research should determine whether this measure could be translated into actual changes in student behavior – this might be one-step closer to it.

Moreover, for the students' professional growth, cultivation of empathic intelligence for future professionals, we must first help them as students to experience, understand and improve empathy as a skill. There are many ways to accomplish these goals, for example, art and art education can be seen as methods to support identity review and social awareness. In an era of eco-social crises, contemporary art education can also play an important role as a stimulus for environmental awareness (e.g. Foster et al., 2018). We welcome more research on Qualified Empathy in this broader context. Although the focus is on professional empathy in the social and health fields, the research results can be used more widely in many disciplines as part of professional activities. Professional empathy is seen as an important factor in building a socially sustainable society from the perspectives of employees, clients and patients. We noticed that it is important to allow time and space for the learners to internalize the concept of Qualified Empathy. When we allow for this, students begin to recognize and assign more value to it and, as we suggest, they become more adept in their interactions and work with clients.