{"paper_id":"b23ad642-6d9c-4257-84db-f9a8cbe5f1a3","body_text":"1 \n \n \nEmpathy as dynamic social meaning-making: Audience responses to patient-generated \nmaterials about endometriosis care  \n \nElisabeth El Refaie  \n \nAbstract \nThis article uses 25 Think Aloud interviews to investigate the ability of patient-generated \nmultimodal materials about endometriosis health care in the National Health Service Wales, \nUK, to evoke empathy in others. Critically evaluating relevant findings from several \ndisciplines, empathy is reconceptualized as a dynamic and context-dependent form of social \nmeaning-making. The combination of thematic analysis with a dynamic-systems approach to \ndiscourse analysis enabled the distinction between four interactive processes involved in \nempathy – “recognition”, “resonance”, “alignment”, and “affiliation” – as well as revealing \ncommon linguistic resources used to express or withhold empathy in the data. Specifically, \nthe study findings show that an individual’s socially situated identities, as well as their own \nexperiences of a particular healthcare system, may encourage or impede their empathic \nresponses to representations of other people’s suffering.  \n \nKeywords \nDynamic systems; empathy rules; health communication; National Health Service; reader \nresponses; Think Aloud \n  \n\n2 \n \n1 Introduction \n \nEmpathy – broadly defined as recognizing, sharing, and responding with compassion to \nanother’s emotional state – is a key concept in several academic disciplines and fields of \nprofessional practice, including healthcare (Cuff et al. 2016; Jami et al. 2023; Zhang et al. \n2024). Recently, there have been calls for a paradigm shift in how empathy is understood and \nstudied. Eichbaum et al. (2022) criticize prevailing conceptualizations for being too focused \non individuals, advocating instead for a “relational” understanding of empathy that is \n“dynamically attentive” to structural inequalities and social contexts (p. 644). Shapiro (2008) \nmakes a similar point, arguing that people’s ability and willingness to empathize with others \nis often shaped by cultural belief systems and ingrained institutional practices. While these \nauthors are primarily concerned with empathy in interpersonal healthcare interactions, I argue \nthat their criticism is equally applicable to research into audience responses to symbolic \nrepresentations of illness experiences (Campbell and Babrow 2004; Peng et al. 2020; Shen \n2019), as it, too, tends to concentrate on the message features that make an empathic response \nmore or less likely, while ignoring the socially situated nature of any such effects. This makes \nit hard to know how to campaign effectively for the healthcare needs of particular patient \ngroups to be recognized, for example.  \n \nThis article uses the qualitative framework of “Think Aloud” (TA) (Van Someren et al. 1994) \naudience responses to a patient-generated, multimodal booklet about endometriosis to \npropose a more dynamic conceptualization of empathy. Endometriosis is a chronic \ngynecological disease affecting around 10% of women of reproductive age that is caused by \nendometrial tissue growing outside the womb and that is often associated with severe pain \nand other debilitating symptoms (Pugsley and Ballard 2007). Many sufferers report a lack of \n\n3 \n \nempathy on the part of others, including health professionals, which compounds the psycho-\nsocial impact of endometriosis and may delay diagnosis and treatment (Endometriosis UK \n2024). These difficulties are reflected in the booklet used in the present study, which aimed to \nraise awareness of and increase empathy for women with this condition, with a focus on their \nexperience of feeling insufficiently heard and understood by doctors working in the National \nHealth Service (NHS) Wales.  \n \nThe NHS occupies a unique place in the cultural imagination of the British people. When it \nwas founded in 1948 by Clement Attlee’s Labour Government, it was the first healthcare \nsystem in a western country to offer medical care that was free at the point of use to the \nwhole population. Both working for the NHS and accessing its services are still seen by many \nthrough the lens of civic duty and patriotic sacrifice (Stewart 2023). However, rising costs \nassociated with an aging population and ever more complex treatments, together with periods \nof systematic underinvestment, particularly by successive conservative governments, have \nled to a state of crisis. Although public commitment to the ideal of the NHS remains \nremarkably resilient, satisfaction levels are at a historical low (Morris et al. 2023). For people \nliving in Britain, expressing a view about the NHS is thus inextricably bound up with their \nown values, social identities, and political affiliations. \n \nInvestigating empathy as a dynamic form of social meaning making requires a shift away \nfrom the survey-based quantitative research methods that currently dominate the field (see \nWieck et al. 2022), toward a more qualitative approach that is context-sensitive and able to \ndetect subtle changes and ambiguities in the way empathy is experienced and expressed. The \npresent study uses a novel combination of TA interviews, thematic analysis (Braun and \nClarke 2006), and a dynamic systems approach to discourse analysis (Cameron et al. 2009; \n\n4 \n \nCameron and Seu 2012), to examine both the content and the linguistic realizations of \nparticipants’ responses to patient-generated materials about endometriosis. \nThe article starts by critically reviewing conceptualizations of empathy from a range of \ndisciplines, arguing that crucial social and contextual factors are often neglected in empirical \nwork in this field. Section 3 describes the data, methodologies and analytical procedures used \nin a small-scale qualitative study designed to address this gap in empathy research. In Section \n4, representative data extracts are subjected to detailed thematic and linguistic analysis. The \nfinal chapter outlines the main findings and theoretical conclusions, as well as providing \nconcrete suggestions for using TA interviews to investigate dynamic, social aspects of \nempathy.      \n \n \n2 Literature review \nEmpathy has been studied extensively from a wide range of disciplinary and theoretical \nperspectives, which has led to multiple distinct definitions of the concept (Cuff et al. 2016). \nMost scholars would agree, however, that empathy has at least three key dimensions: an \ninstinctive emotional resonance with the other person’s feelings; the more conscious and \ndeliberate cognitive understanding and adoption of his or her perspective; and “empathic \nconcern”, involving “other‐oriented feelings of care and compassion” (Fourie et al. 2017: 47). \n \nA well-established finding in social psychology is that we are generally more likely to feel \nempathy for members of our own in-groups than for those we regard as ‘other’ (Fourie et al., \n2017). However, perceived similarity does not guarantee an empathic response, nor is it a \nnecessary precondition for empathy. In experiments that measured people’s empathy for a \nfictional stranger in need, Batson et al. (2005) discovered that the target’s appeal to \n\n5 \n \ninstinctive nurturant tendencies (e.g., when the fictional stranger was a child or a puppy) was \nmore highly correlated with empathy than perceived similarity (e.g., when the stranger was a \nfellow student). For another’s perceived need for care and protection to trigger empathy, \nhowever, “the potential empathizer must value the target’s welfare” (p. 24). In other words, if \nsomeone is considered unworthy of support, people may be less willing to respond \nempathically when confronted with their plight.  \n \nSociological approaches emphasize the key role of “empathy rules”, socially learned and \ninternalized expectations about who should rightfully empathize with whom, and in which \nsituations, in determining an individual’s responses. For example, birth doulas may consider \nbirthing women and their partners, but not hospital staff, to be unambiguously deserving of \nempathy (Ruiz‐Junco 2017: 423). Similarly, male nurses in the US have been found to \nrecognize and respond to opportunities for empathy less frequently than their female \ncounterparts, despite being capable of the same levels of empathy in principle (Strekalova et \nal. 2019). This suggests that both neurobiological and social factors may be involved in the \ndiscovery of significant sex and gender differences in empathic responses, which appear to \nwiden across the life span (Rochat 2023). \n \nWhile the majority of work in empathy research focuses on empathic attitudes and behavior \ntowards physically present others in everyday life and in the caring professions, there is also a \ngrowing body of research into empathy as an audience response to aesthetic or persuasive \nforms of communication, including feature films (Gallese et al. 2020), written narratives \n(Keen 2007), and public health messages (Campbell & Babrow 2004; Peng et al. 2020; Shen \n2019). Indeed, it is becoming increasingly clear that there may be little functional difference \nbetween empathy in face-to-face situations and empathy in response to representations of the \n\n6 \n \nexperience of physically absent or even fictional persons. Studies using brain imaging have \nled to the discovery of mirror neurons and embodied simulation processes that are activated \nin the brains of onlookers when they see, read about, or even just imagine, another’s actions, \nperceptions, or emotional reactions (De Greck et al. 2012; Gallese 2009).  \n \nA common focus of research into empathic audience responses is on identifying any features \nof content or style that foster imaginative engagement with other people’s experience, yet the \neffects of any such features are likely to be highly dependent on the medium and genre in \nwhich a message is conveyed. In audio-visual public health communication, for example, \nfeatures that have been found to promote an empathic response include “vividness, gaze, \nrealism, pain and suffering, social relationship, and emotion expression” (Shen 2019: 1335), \nas well as explicit realism or at least verisimilitude (Campbell & Babrow 2004). In the case \nof literature, by contrast, fictionality is considered by some to be more conducive to \nemotional responsiveness than factuality, because it releases readers from the felt need for \nskepticism regarding the author’s sincerity (Keen 2007: 220).  \n \nA critical review of the literature thus shows that empathy cannot be studied merely as the \ndecontextualized response of one individual towards another. Rather, it is always related to a \nperson’s own social identities, their relationship with and sense of responsibility towards the \ntarget individual(s) in question, as well as the immediate situation and the cultural context \nwithin which a (real or symbolic) encounter takes place (Jami et al. 2023). Moreover, \nidentities are not essential, stable properties, but contextually shaped constructions that are \nconstituted in discourse, narratives, and social practices, and that can change over time \n(Bamberg et al. 2007). Our sense of allegiance with other individuals or groups, and our \n\n7 \n \nresulting willingness to empathize with them, is therefore also likely to be fluid and ever \nshifting. \n \nIt is this dynamic aspect of the empathic response that is often neglected in the relevant \nliterature, where by far the most common research methods deployed to measure empathy are \nquantitative studies using post hoc self-report questionnaires (see Wieck et al., 2022). More \nqualitative approaches include the analysis of spoken interactions through particular coding \nsystems (Bylund and Makoul 2002; Macagno et al. 2022) or Conversation Analysis (Ford et \nal. 2019; Weatherall 2023), though here again the focus tends to be on empathy as manifested \nin specific exchanges, without much consideration for the broader contexts within which \nthese exchanges take place. A rare example of research that considers empathy as discursive \nmeaning making is Cameron and Seu’s (2012) analysis of focus group data to investigate \nempathy towards people affected by human rights abuses abroad. Their key finding is that \nwitnessing beggars in the streets and being exposed to media reports of distant suffering lead \nparticipants to construct a symbolic landscape of empathic concern, with the optimal distance \nfor empathy being one where the other is “near enough to be seen and understood but not \nentering the personal space” (p. 298). This demonstrates that individuals’ responses are \nalways embedded in wider socio-cultural discourses and power dynamics.  \n \nWhat is thus needed is an approach to the study of empathy that captures the context-\nsensitive nature of all human communication, especially where it pertains to something as \ncomplex as our willingness to engage imaginatively and emotionally with another’s \nexperience of a chronic health condition. Inevitably, this will be impacted by implicit cultural \nassumptions about the nature of illness, the perceived (gendered) roles and responsibilities of \n\n8 \n \npatients and medical professionals, and a person’s own experiences of accessing a particular \nhealthcare system.  \n \n3 Data and methodology  \n \nThe materials used as the basis for the present study were created during a DrawingOut (DO) \nworkshop with 14 women with a diagnosis of endometriosis, run by a research team from \nCardiff University led by Prof Jacky Boivin and including the author of this paper. DO \ninvites participants to visualize their illness experience by drawing pictures of concrete \ncreatures, objects, or places, and to share these with one another (Gameiro et al. 2018). An \nanonymized selection of the artwork and quotes from the women’s accompanying \ncommentary was used to produce a 15-page long booklet, “Experiences of Endometriosis in \nWales” (www.drawingout.uk/resources). Produced in partnership with the patient advocacy \ngroup “Fair Treatment for the Women of Wales”, it was designed to raise awareness among \naffected women’s friends, family members, and healthcare workers. Because of the present \narticle’s thematic focus on endometriosis health care, detailed analysis will be restricted to \nreader responses to page 6 of the booklet (Figure 1), which consists of two drawings and \nthree related verbal comments about the women’s sense of frustration over the poor standard \nof care they had experienced in the NHS Wales.  \n\n9 \n \n \nFigure 1: “Experiences of Endometriosis in Wales”, p. 6.  \n \n\n\n10 \n \nThe booklet subsequently formed the basis for 25 Think Aloud (TA) (Van Someren et al. \n1994) interviews, which were conducted between March 2020 and June 2021 by seven \nMaster of Arts students (six female, one male) as part of a credit-bearing “Research \nExperience” module at the School of English, Communication and Philosophy, Cardiff \nUniversity, whose ethics committee approved the project. The 14 female and 11 male \nparticipants, with a mean age of 27 (range 19-59, one unknown), were recruited by the \nstudents, using convenience sampling. The only exclusion criteria were insufficient English \nand any direct personal or professional experience of endometriosis. The participants gave \nwritten consent in advance. \n \nThe purpose of the study was described to the participants as investigating how people \nrespond to verbo-visual materials about endometriosis; the specific focus on empathy was not \ndisclosed until after the interviews, via the debrief form. Because of restrictions imposed by \nthe COVID-19 pandemic, some of the interviews were conducted online, while the others \ntook place face-to-face in a private setting. The students received clear instructions and \npracticed the TA method on each other. They followed the same interview protocol, keeping \ntheir own interventions to a minimum (e.g., to remind interviewees to keep talking if they fell \nsilent for too long, or to proffer reassurances that “there are no right or wrong answers”).  \n \nAfter asking some basic demographic questions (age, gender, and occupation) and \nconducting a warm-up exercise to familiarize the participants with the TA method, the \ninterviewers outlined the nature of endometriosis and gave the participants a copy of the \nbooklet. The participants were then invited to leaf through the booklet at their own pace, \nsaying what they were looking at and reading on each page, and continuously verbalizing all \ntheir thoughts and feelings. The interviews were audio recorded and transcribed, using a \n\n11 \n \ntranscription key based on approximate intonation units (adapted from Cameron and Seu, \n2012).1 The names and any other identifying details were removed. The participants are \ndistinguished by gender and numbered in the order they appear in the discussion below (F1, \nF2 etc. for females, and M1, M2 etc. for males), while the interviewers are indicated by the \nletter I.  \n \n3.1 Analytical procedure \nThe complete anonymized transcripts were imported into NVivo and subjected to thematic \nanalysis (Braun and Clarke 2006), starting with the three main aspects of empathy identified \nin previous research (emotional resonance; cognitive understanding; and empathic concern) \n(Cuff et al. 2016; Fourie et al. 2017; Jami et al. 2023). During the coding process, these \ncategories were refined and/or renamed, and a fourth category added in response to the data: \n“Recognition” refers to a person’s ability to identify the emotional experiences of another \nperson; “resonance” is defined as the spontaneous, vicarious sharing of another person’s \nemotional experience; “alignment” describes the more conscious and deliberate imaginative \nact of taking another’s perspective, and “affiliation” is the adoption of a supportive, \n \n1 The extracts from the audio recordings are transcribed line by line as intonation units, which \ndo not always coincide with syntactical clause boundaries: A comma denotes continuing \nintonation, a question mark rising intonation, a dash an incomplete intonation unit, a full stop \nfinal closing intonation, and an exclamation mark an animated/emphatic tone. Underlining \nindicates emphasis, a dot or numbers in brackets a micropause or pause measured in seconds, \nnon-verbal responses such as laughter are described in square brackets, three full stops in \nsquare brackets indicate the omission of a section of the transcript, and words in italic \nrepresent quoted text from the booklet. \n\n12 \n \ncompassionate stance towards them, based on a sense of shared identity, values, or \nexperiences. Thus, what other scholars have tended to subsume under the umbrella of \ncognitive understanding is split into the two separate processes, in order to distinguish more \nprecisely between the ability to grasp another’s experience at an intellectual level \n(“recognition”) and the more imaginative endeavour of actively adopting their perspective \n(“alignment”). Furthermore, I choose to use the term “affiliation” instead of “empathic \nconcern” (Fourie et al. 2017: 47), as the former has more explicit social connotations than the \nlatter.2  \nIn a second step, the subset of the data relating to the participants’ responses to page 6 of the \nbooklet was subjected to further detailed analysis, using a complexity/dynamic systems \napproach to discourse analysis (Cameron et al. 2009). This approach is sensitive to subtle \nshifts in people’s discursive meaning making, which, in turn, is seen as indicative of the \nhighly context-dependent and ever-changing nature of human cognition. Rather than \nregarding individual responses as being inherently empathetic or unempathetic, for example, \nthey are broken down further into intonation units, each of which can then be examined for \nevidence of empathy on different scales and at different levels, while always paying close \nattention to the discourse context and the precise linguistic resources being used. \n \n \n2 Some of these terms were inspired by film theorist Murray Smith’s (1994) influential work, \nalthough he used them to refer to rather different phenomena, arguing that spectators would \nonly fully identify with cinematic characters who are presented as unique individuals \n(“recognition”), who are visually aligned with the viewers through cinematic techniques like \nclose-ups or point-of-view shots (“alignment”), and who embody similar values to their own \n(“allegiance”).  \n\n13 \n \nEmpathic responses have been found by previous research to take a wide range of verbal and \nnon-verbal forms (Weatherall 2023). Cameron and Seu (2012) discover that the dialogic co-\nconstruction of empathy often involves metaphor and metonymy; personal stories, which are \n“usually told in the past tense” and tend to be signaled by discourse markers such as “once” \n(p. 287); and typifying scenarios, which involve imaginary characters, settings and \nconversations and which often use “you pronouns and present tense” (p. 287). Because of the \nfocus of the present study on empathy as an expression of social identity, I am particularly \ninterested in the use of personal pronouns, including the first-person plural “we” and \ngeneralized/impersonal “you”, to convey category membership (Pearson 2023; Stirling and \nManderson 2011).  \n \n4 Data analysis \n \nThe analysis of the 25 study participants’ responses to page 6 of the booklet revealed that all \nof them were able to identify the negative valence of the experiences represented in the \nbooklet, although they differed regarding how, exactly, they understood and evaluated these, \nand the extent to which they displayed empathy. All the excerpts discussed below are \nselected based on being representative of the whole data set. The following extracts (1-4) are \nexamples of responses that show clear signs not just of recognition but also resonance, \nalignment and/or affiliation with women with endometriosis.  \n \nExtract 1 \nF1:  erm and that quite it upsets me actually.  1 \nhaving dealt with medical professionals for my own issues, 2 \nand kind of experiencing (.) maybe a similar reactions, 3 \nnot having them believe me either way you want them to  4 \nand not taking you seriously?  5 \n\n14 \n \nI imagine that’s what (.) they would perhaps feel like,  6 \nmight feel similar to how I felt at that time.  7 \nso I can actually empathize in that aspect erm (.)  8 \nwith what they might be,  9 \nlike their frustrations about not being heard  10 \ntheir own pain,  11 \nbecause at the end of the day  12 \nyou know your body better than anyone else.  13 \nso it just seems silly just because they have a degree  14 \nor trained in certain professions  15 \nthat they think that they know you (.)  16 \nbetter than yourself.17 \n \n \nF1 starts by expressing spontaneous resonance with the represented emotions, declaring \nherself from the start to be “upset” by the drawings and verbal commentary. She goes on to \nsay that she has had similarly negative experiences with medical professionals, suggesting \nexplicitly that this shared experience is helping her to “empathize” with the women \nrepresented in the booklet. Finally, she shows an affiliative stance by describing health \nprofessionals’ belief in their inherent superiority as “silly” (line 14). These processes of \nresonance, alignment, and affiliation are reflected in her pronoun use. She starts by mixing \nfirst person singular (“upsets me”, “not having them believe me” lines 1 and 4) and \ngeneralized “you” (“way you want them to and not taking you seriously”, lines 4-5) to \nrepresent the wider validity of her own feelings and experiences, and then moves on to the \nuse of third person plural pronouns (“their frustrations”, “their own pain”, lines 10-11) to \nconsider what women with endometriosis might be going through. Concluding her thoughts, \nF1 reverts to generalized “you” to express what she clearly feels to be self-evident truths, and \nthird person plural pronouns to condemn uncaring medical professionals (“they think that \nthey know you (.) better than yourself”, lines 16-17).  \n \nAnother female respondent, F2, is prompted by page 6 of the booklet to tell the story of a \n\n15 \n \nprevious co-worker who often used to call in sick and ask her to cover her shift. Although F2 \nalways agreed to her colleague’s requests, they made her feel resentful. It later transpired that \nthis co-worker had endometriosis, but at the time no one else, including their manager, \nappreciated the seriousness of this condition. The respondent uses this “personal story” \n(Cameron and Seu 2012) to illustrate how poorly understood endometriosis is. The following \nextract (2) shows that her attitude towards endometriosis sufferers has since shifted.  \n \nExtract 2 \n \nF2:  the NHS is already sometimes difficult  1 \n to get to if things are poorly (.) misunderstood  2 \n or like poorly diagnosed  3 \n or there’s not enough teaching in it anyway,  4 \nbut yeah (.) and then it seems like it’s maybe  5 \n more effort than it’s worth to try and get  6 \n somebody who understands (.)  7 \n or has any kind of experience in dealing with it,  8 \n[…]  9 \nyeah that is kind of like highlighting  10 \n the fact that doctors don’t necessarily speak to you  11 \n on the level they speak to other medical professionals? 12 \nI:  yes 13 \nF2:  and that they kind of treat you as though I don’t know  14 \n you’re like a lesser person or whatever.  15 \nwhich is crazy because it’s not really  16 \n what we hope they are doing, 17 \nbut yeah maybe it’s just a (4) yeah that’s sad. (4) 18 \n yeah it just makes me feel  19 \n I guess sad is a pretty inadequate word but that erm (.)  20 \n and a little bit angry  21 \n that people just get kind of like brushed away. 22 \nand that’s probably why it’s not been,  23 \nit’s been something that people struggle with undiagnosed  24 \n for so long because it’s just not taken seriously enough  25 \n or because there’s no like easy answer,  26 \nit’s just like,  27 \noh that’s what it is!  28 \nhere’s some pain killers!29 \n \n \n\n16 \n \nF2 starts by acknowledging widespread problems with timely access to specialist care in the \nNHS. She shows resonance by talking about her own feelings of sadness and anger in \nresponse to the materials. Again, the generalized “you” is used to express a sense of solidarity \nwith the women (“the fact that doctors don’t necessarily speak to you on the level they speak \nto other medical professionals?”, lines 11-12, “they kind of treat you as though […] you’re \nlike a lesser person”, lines 14-15). Making an overt value judgement, F2 describes such \nattitudes as “crazy” and says that they are “not really what we hope they are doing” (lines 16-\n17). Here, the first-person plural “we” seems to include not just herself and the interviewer, \nbut potentially any patients in the unlucky position of being reliant on the inadequate care \n“they”, i.e., the medical professionals, are providing. She concludes by recounting what \nCameron and Seu (2012) would call a “typifying scenario”, involving a medical professional \nmaking a rash diagnosis and just prescribing pain killers for symptoms that deserve to be \ninvestigated properly (lines 27-29).  \n \nThree of the female study participants explicitly refer to gender roles when discussing their \nthoughts and feelings about page 6. F3, for example, mentions “other stories” she has heard \nof women struggling to access appropriate medical care due to harmful stereotypes (Extract \n3).   \n \nExtract 3 \nF3:  the first comment,  1 \nyou just constantly having to get through obstacles  2 \nto get to the right doctor.  3 \nerm it sort of amplifies you know other stories I’ve heard  4 \nof women not being taken seriously at the doctors. 5 \nI:  mmhmm 6 \nF3:   because apparently,  7 \nit’s the high threshold for pain and they always,  8 \nwe’ve been socialized to downplay it as well I feel.9 \n \n\n17 \n \n \nF3 expresses a low level of confidence in the veracity of the notion of women having a higher \npain threshold than men by qualifying it with the adverb “apparently” (line 7). She then \nswitches to the first-person plural pronoun to talk about the way “we’ve been socialized to \ndownplay it” (line 9), signaling affiliation with all women suffering from a patriarchal \nhealthcare system.  \n \nAlthough the extracts discussed so far reflect a more general pattern in the data, whereby \nfemale respondents are more likely than males to express empathy for endometriosis sufferers \non the basis of shared experiences, some men do also display obvious signs of resonance, \nalignment and/or affiliation with these patients. M1 (Extract 4) is a particularly clear \nexample. As a student nurse, he has evidently learnt about the importance of patient-centered \ncare, while also witnessing situations where this principle was not applied in practice. After \ntaking in the drawing at the bottom of page 6 and reading the associated verbal comments \nabout “blind and deaf doctors” out loud, he goes on to take a firm stance in support of the \npatients and in opposition to those doctors who do not deliver the quality of care he clearly \nbelieves patients deserve. \n \nExtract 4 \nM1:   which (.) to be fair  1 \nsounds quite like a doctor (.) to me. (1) [laughter] 2 \num (2) um I (.) but (.)  3 \nas a nurse that makes me feel quite (.) sad, 4 \nbecause (1) um (1) really  5 \nit should be centered around the patient, 6 \nbut I think (1) it should be centered around the patient  7 \nand um, (1) yeah (.) it m- makes me feel sad for them  8 \nbecause (.) if you imagine yourself not being able to be  9 \n(.) listened to or everyone ignoring you  10 \nthat wouldn’t be very nice (.)  11 \nin any situation never mind in a hospital (1) um12 \n\n18 \n \n  \n \nM1 expresses his own emotional response twice using very similar wording (“that[it] makes \nme feel [quite] sad”, lines 4 and 8)) and shows alignment with patients by imagining how \n“you” might feel if you are not treated with respect, especially in a hospital setting (lines 9-\n10). The fact that he judges the criticism of doctors in the booklet to be “fair” and that he \nrepeats the same explicit value judgement twice (“it should be centered around the patient”, \nline 7) shows that he is also explicitly affiliating himself with the women. This, in turn, \nindicates that M1 is heavily invested in his evolving identity as a caring, empathic health \nprofessional (“as a nurse”, line 4), and that he has similarly high expectations of his medical \ncolleagues, particularly those in positions of power.  \n \nTwo of the older male study participants (in their late 50s and early 40s, respectively) seemed \nto be very unsure of their interpretations of the materials and reluctant to talk about any \nthoughts or feelings that these may have triggered. M2’s and M3’s responses to page 6 of the \nbooklet (Extracts 5 and 6) are given in full below. \n \nExtract 5  \nM2:  erm ok this is obviously the problems with (.)  1 \nthe drawings are less (.) explicit,  2 \n(2) erm there’s obviously problems with  3 \nhaving it diagnosed and dealt with? 4 \nnow looking at the doctor-patient drawings,  5 \nsee no patient hear no patient speak behind the patients,  6 \nso there’s real frustration here about (.)  7 \ndoctors not understanding what this is.8 \n \n \nExtract 6 \n\n19 \n \nM3:  so I guess obviously whoever wrote this  1 \nand drew this is feeling very erm let down,  2 \nby err by the NHS or the medical profession in general, 3 \ngiven that they’re feeling that their condition  4 \nis not being taken seriously and not being catered for.5 \n \n \nWhile recognizing the represented women’s sense of exasperation and despondence, M2 and \nM3 display an “epistemic stance” (Roseano et al. 2015) that vacillates between the expression \nof a high level of confidence through the repeated use of the adverbial “obviously”, and a \nlack of certainty through the description of the images as “less explicit” (M2, line 2) and the \nuse of terms such as “I guess” (M3, line 1), as well as rising intonation at the end of \nstatements. M3 talks about the women’s experiences in the third person (“they’re feeling that \ntheir condition is not being taken seriously”, lines 4-5), while M2 uses “this” and “there” as \n“dummy subjects” (Peters 2004) (“this is obviously the problems with”, line 1, “there’s \nobviously problems”, line 3, “there’s real frustration here”, line 7) to describe the emotions \nmanifested on this page, without referencing the persons whose experiences are being \nrepresented. Neither of these respondents describes their own reactions to what they are \nseeing, making it impossible to know whether they felt any empathy towards the women in \nthis situation.  \n \nF4 is the only study participant to interpret this page as showing the patients’ sense of \nembarrassment and inadequacy, rather than their frustration with the inadequate healthcare \nthey have received (Extract 7), which may be seen as a form of partial “misrecognition”.   \n \n \n \n  \n\n20 \n \nExtract 7 \n \nF4:  there’s a picture here of one tiny little person  1 \nand then you have a super huge person 2 \nwith a medical sign as well,  3 \nand they’re kind of blocked off by a fence,  4 \nand I guess that’s like the physical barriers  5 \nand mental barriers that you put up for yourself,  6 \nand you’re not going to understand it,  7 \nlike people might not actually want to as well  8 \nto go through and speak to their doctor.  9 \nthere can be sometimes I guess,  10 \npeople can feel embarrassed by it, 11 \nerm they might not want to discuss it, 12 \nerm they might not feel it’s normal,  13 \nthey might not know it actually happens to more people.  14 \nso I guess they just feel like it just happened to them, 15 \nand nobody else is gonna get it until they get over that, 16 \n[…] 17 \nbut on the other side that  18 \nthere are people there with open arms, 19 \nit kind of looks like I don’t know  20 \na medical figure being like,  21 \nyeah we’re here for you.22 \n \n \nWhen describing the drawing at the top, F4 focuses on what she perceives to be the doctor’s \nopen arms and winning smile, and the smallness of the woman on the other side of the fence, \nwhich she takes to be an expression of “the physical barriers and mental barriers that you put \nup for yourself” (lines 5-6). This respondent initially employs this generalized “you” to signal \na degree of alignment with the experience of being reluctant to seek medical help. \nSubsequently, F4 repeatedly uses the third person plural to refer to the patients’ failure to “get \nover” (line 16) their misplaced embarrassment and to realize that they are not alone in \nsuffering from the symptoms of endometriosis (or illness more generally, perhaps). \nExpanding on her reading of the drawing, F4 describes medical staff as welcoming patients \nwith open arms and offering their support (lines 18-22). Although this shows imaginative \n\n21 \n \nengagement with the represented experiences, F4 seems to be aligning herself with the \ndoctors rather than with their patients, which means that hers cannot be described as a truly \nempathic response to the plight of endometriosis sufferers.  \n \nIn other cases, the respondents’ failure to fully empathize with the women is due to \ndisaffiliation rather than misrecognition.  Throughout their interviews, two young, male \nrespondents keep coming back to the idea that healthcare staff are doing their best and that it \nis wrong for patients with endometriosis to blame doctors for the poor treatment they have \nreceived. In the case of M4 (Extract 8), his defense of doctors is based on the limited \nresources available in the NHS. \n \nExtract 8 \nM4:  I mean the fact I’d never heard of this before  1 \nobviously shows that it’s still sort of such a quiet,  2 \nor sort of (.) under regarded issue, 3 \nit needs more um  4 \nit probably needs more um (.) recognition perhaps, 5 \nbut problem is so do so many things don’t they, 6 \nthere are so many issues out there that need recognition,  7 \ncan’t can’t recognize all of them (.) no!  8 \nlike there’s not enough money to go round,  9 \n(.) not taking away from obviously these people,  10 \nbut –11 \n  \n \nM4 starts by showing strong commitment to the proposition that endometriosis is \n“obviously” an “under regarded issue” (lines 2-3), but then qualifies this by hedging it \nthrough the modal adverbs “probably” and “perhaps” (“it probably needs more um (.) \nrecognition perhaps”, line 5) and going on to emphasize the many competing demands on \nresources. Although his final utterance appears to reiterate his compassion for the women \n\n22 \n \nwhose experiences are represented in the booklet (“not taking away from obviously these \npeople”), the fact that it ends in the conjunction “but”, which typically introduces a \ncontrasting idea, suggests that his empathic concern is, in fact, rather limited (lines 10-11).  \n \nA more explicit instance of disaffiliation can be seen in the following extract from the \ninterview with another male respondent (Extract 9).  \nExtract 9 \nM5:  I can (2) agree.  1 \nI like the drawing on the right.  2 \nunderstand feeling small and like people don’t understand,  3 \n(2) not that I understand fully.  4 \nobviously reading this I'm getting more understanding of.  5 \num (3) hard to get to the right doctor,  6 \nsame with every illness.  7 \neveryone has their specialism  8 \nand it’s just getting to the right place, 9 \n(2) not going to lie with the NHS and things like that,  10 \n(2) although it is brilliant  11 \nit is very ineffective sometimes with certain conditions.  12 \n(5) not sure about the blind and deaf docs bit.  13 \nI’m not sure about attacking the doctors!  14 \nbecause at the end of the day if doctors know  15 \nhow to treat an illness that’s vaguely medical  16 \nthey’ll try to fix and help things.  17 \nthe idea of the doctors ignoring them.  18 \nI can understand that feeling  19 \nif there’s nothing they can actually treat,  20 \n(.) but at the same time, 21 \nthey are trying to treat the symptoms,  22 \nit’s a bit bad to (1) fire at the doctors like that  23 \nbecause they definitely are (.) most doctors at least are,  24 \nor that they do give a shit and are trying to help,  25 \nso not sure attacking them is going to help anyone.26 \n \n \nLike M4, study participant M5 starts by expressing qualified support for women with \nendometriosis, especially in relation to the universal experience of feeling small and \n\n23 \n \nmisunderstood. However, he quickly switches to a more skeptical stance, emphasizing the \ndifficulties all patients face when accessing NHS treatment. He accuses the women who \ncreated the materials in the booklet of unfairly maligning the doctors, using battle metaphors \n(“attacking the doctors”, line 14, “fire at the doctors”, line 23) to decry what he perceives to \nbe the strident, exaggerated nature of their criticisms. When he says that doctors will always \ntry to treat any illness “that’s vaguely medical” (line 16), M4 appears to be insinuating that \nendometriosis is at least partially psychosomatic, thus echoing some of the same attitudes that \nthe booklet is trying to challenge.  \n \n5 Discussion and conclusion  \nEmpathy is a highly context-dependent process that is intricately bound up with people’s \nsocial identities, values, and behavioral norms, as well as the broader social, cultural, \neconomic, and political frameworks within which an encounter – whether interpersonal or \nmediated – takes place. The present study has provided empirical support for this argument. \nUsing thematic analysis and a dynamic systems approach to the analysis of Think Aloud  \ninterview data, I have demonstrated that empathic responses often do not unfold in a linear, \npredictable fashion, and that they interact with both the individual’s own values and \nexperiences, and with prevailing attitudes towards healthcare in Britain.  \n \nDistinguishing between four distinct but closely related, dynamic processes involved in \nempathy has enabled the identification of specific factors that might encourage or impede an \nempathic response. For many female respondents, feelings of solidarity based on shared \ngender or having had similarly poor experiences of NHS care encouraged their alignment and \naffiliation with endometriosis patients (Extracts 1-3), whereas, for a male student nurse, his \nprofessional values clearly influenced his responses (Extract 4). The widespread admiration \n\n24 \n \nfor the NHS, but also concerns about its current state of crisis, were reflected in the way that \nsome participants rejected any criticism of doctors and disaffiliated themselves from \nendometriosis patients, implicitly accusing them of overstating their suffering (Extracts 8 and \n9).  \n \nThese findings suggest that empathy in health communication has an important socio-\neconomic dimension, in the sense that it is harder to achieve empathy in a context where staff \nare struggling with low morale and service users may feel the need to compete with others for \nscarce resources. For a publicly funded healthcare system like the NHS to be sustained over \ntime, it is important to find ways of encouraging both its staff and the general public to \nempathize with patient groups who may require prolonged and potentially resource-intensive \nmedical care.  \n \nThe patient-generated materials used in this study are intended to provide a relatively \nstraightforward and cost-effective means of achieving this objective. Although the booklet \ndoes not tell a coherent story and lacks clearly identifiable, named characters, almost all \nrespondents nevertheless displayed signs of at least some degree of empathy towards the \nrepresented women with endometriosis in response to it. This challenges the idea – prevalent \nacross narrative and communication research – that audiences need to be able to engage with \nindividual narrative characters for deep emotional engagement to be possible (e.g., Peng et al. \n2020; Smith 1994).  \n \nThe key role of what I have called “recognition” in the empathic process is often neglected in \nthe literature, perhaps because it is less obvious in face-to-face situations than when people \nare responding to symbolic representations of some else’s experience. As demonstrated in \n\n25 \n \nthis study, reacting emotionally to another’s suffering cannot be described as truly empathetic \nif the original experience is mis-recognized (Extract 7). The simple drawing style and \nmetaphorical nature of the multimodal materials used in the booklet may have led to \nuncertainty and misunderstandings, thereby potentially hindering empathy. Conversely, these \nsame properties may have increased the booklet’s ability to enhance empathy, by being open \nto a range of different interpretations and thereby tapping into readers’ own unique \nexperiences. The question of whether the metaphorical nature and the specific multimodal \nstylistic features of the trigger materials may have shaped empathic audience responses goes \nbeyond the scope of the present study, although it clearly deserves further investigation. \n \nThe linguistic analysis of the interview data confirms Cameron and Seu’s (2012) finding that \nexperiencing – or, in some cases, withholding – empathy is often expressed through personal \nstories, typifying scenarios, and metaphors. Additionally, I have discovered the central role \nplayed by personal pronoun use in conveying subtle shifts in the interviewees’ attitudes. \nRespondents F1 and F2, for example, switched seamlessly from discussing the represented \nexperiences in the third person plural, to using a generalized “you” to introduce facts or \ncircumstances they held to be incontrovertibly true, to talking about their own emotions or \nthose they shared with the women in the first-person singular or plural, respectively. \nEpistemic stance, hedges, and contrast conjunctions also appear to play an important role in \nempathy discourses, particularly as a way for people to express ambivalent or uncaring \nresponses to another’s experience.  \n \nTA protocols have been used previously to investigate how people interpret metaphors (Šorm \n& Steen 2013), and in a small-scale study of students’ empathic responses to a graphic novel \n(Chisholm et al. 2017), for example. To the best of my knowledge, however, the present \n\n26 \n \nstudy is the first to use TA interviews to research empathy as an audience response in health \ncommunication. One of the advantages of this method is that study participants do not need to \nbe made aware of the research objectives, nor do any potentially leading questions need to be \nasked. On the other hand, as Van Someren et al. (1994: 35) acknowledge, there are \nsubstantial differences regarding the ease with which people verbalize their thought \nprocesses. Some of the study participants expressed their thoughts and feelings about the \ncontent of the booklet freely and at great length, whereas others chose to comment on only a \nsmall subset of the material, often giving minimal responses (e.g., Extracts 5 and 6). The \nlatter may well have had empathic thoughts and feelings that were just never voiced.  \n \nTA studies, like other interview or focus group studies, are also vulnerable to social \ndesirability bias, i.e., “the tendency to give answers that make the respondent look good” \n(Paulhus 1991: 17). Participants may not want to flout implicit “empathy rules” and come \nacross as uncaring, particularly if they know the interviewer personally. In our study, only \ntwo of the interviews were conducted by a male student; in all other cases, the interviewer \nwas female, which may have discouraged the male participants from expressing overtly sexist \nviews, for example. Indeed, there were several instances in the data where the respondents \nseemed to be addressing the interviewers directly and seeking their confirmation or approval. \nThis can be seen, for example, in the questioning intonation used by the participant in Extract \n2, which was followed by the interviewer’s minimal response (“yes”), a pattern that is more \ncharacteristic of a conversation (Fellegy 1995) than of a classic TA interview. While this may \nhave been partly due to the interviewers’ lack of experience with the method, it is important \nto recognize that TA can never guarantee access to the interviewees’ unfiltered thoughts; \ninevitably, they will be aware of the interviewer’s presence and at least somewhat attuned to \ntheir reactions.  \n\n27 \n \n \nResearchers wishing to use TA to study empathy may thus wish to consider ways to put \nrespondents at ease and reduce the potential impact of self-censorship, for example, by \nallowing more time for a practice run and ensuring that interviewers reduce their own \nresponses to an absolute minimum. It may also be advisable to avoid pairing up interviewers \nwith interviewees based on pre-existing relationships. Whether online TA interviews are \nmore or less likely to introduce biases than face-to-face interviews is another important \nquestion that calls for further research. Finally, video recording the interviews would provide \naccess to any non-verbal responses that might signal empathy, including in the absence of \nexplicit verbal references to participants’ feelings (see, for example, Weatherall 2023).  \n \n \nAcknowledgements \nI wish to thank Sofia Gameiro, who supported the original design of the study and provided \ninvaluable feedback on an early draft of this article, and the three perceptive anonymous \nreviewers for this journal, although any errors that remain are, of course, my sole \nresponsibility. 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