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Review: Mind Fixers by Anne Harrington

In spite of the many patients who have been helped to lead emotionally stable, more productive lives thanks to two generations of psychopharmacological medicines, psychiatry is facing an ongoing challenge of its foundation and legitimacy. That is the take-away in Anne Harrington’s Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness (W.W. Norton, 2019, 366 pp., $27.95).

 So what is the “trouble” with the “troubled search”? Thereby hangs the tale. The optimistic biological psychiatry of the 1980s and 1990s is beginning to unravel in the new millennium. Harrington’s is an equal opportunity debunking.

All the new drugs that eventually displaced the Freudians, whose pride in the 1950s through 1980s preceded their fall, were developed during that period of time. “All

The first antidepressant: Tuberculosis Patients dancing after being given iproniazid for their TB - turns out to have antidepressant properties

The first antidepressant: Tuberculosis Patients dancing after being given iproniazid for their TB – turns out to have antidepressant properties

the major categories of drugs still used today in psychiatry were discovered then [….] no minds were changed that did not want to be changed” (p. xvi).

Meanwhile, in 2013 some thirty years after the biological psychiatrists declared victory, Thomas Insel, Director of the National Institute of Mental Health (NIMH), reported with concern that all of psychiatry’s diagnostic categories were still based, not on biological markers of disease, but “on a consensus about clusters of clinical symptoms.” This was, according to Insel, “equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever” (p. xv).

With a characteristic dry wit, Insel concludes that biology never read the DSM. If this was supposed to be the biological underpinning of psychiatry, the firm foundation was more shifting sand than any might wish.

The really troubling thing that I learned from Harrington is not that drug companies have become less an “engine of innovation” than a “vast marketing machine.” That is already widely appreciated by anyone who has not been living in a cave – including most psychotherapists, psychiatrists, and front line medical doctors.

Harrington’s reasoned, documented, and compelling narrative contains the ultimate smack down: “many psychiatrists, having tethered so much of their identity to drugs and prescribing rights, sold their services to the drug companies” (p. xviii). This remains the blind spot of the profession, even among those who acknowledge the dilemma. If you make a deal with the devil, be sure to read the find print.

The blind spot becomes a black hole as the gravitational pull, in this case of revenue, prevents practitioners from escaping, even though they really want to talk with their patients at the length needed to figure out what is actually troubling them.

The breaking news? What is less well known is that Big Parma is now nearly flat out stopped in its quest. The quest to find the biological foundations of mental illness is on a slope of diminishing return; and Big Pharma seems to be abandoning the search. This does not mean that there will not be copycat drugs of medicines coming off patent or new variations on old themes. To my mind, this development needs to be better known and debated.  

Another former NIMH director, Steven Hyman, comments on the abandonment of the field by the pharmaceutical industry: “the underlying science remains immature and . . . therapeutic development in psychiatry is simply too difficult and too risky” (p. xv). 

In a separate email communication with Harrington, Hyman writes: “When [pharmaceutical] companies were told they had to compare new drugs not only to placebo but to an existing drug known to be efficacious, or have a predictive biomarker to gain approval in Europe – their response was ‘we don’t know how to do that.’ . . .  In essence the EMA [European Medicines Agency] called their bluff” (p. 266).

Full disclosure: in my own training as part of the Committee on Research and Special Topics (CORST) at Rush Medical University in the 2010-2012 time frame, all my teachers, the psychiatrists, without exception, made us memorize the generic name for the medications so as not unwittingly to give publicity to the brand name of the drug companies.

While acknowledging that the medicines often helped, the teachers sensed – indeed knew – something was off the rails. Thus, they expressed their disdain for the monopoly rents of Big Pharma (though not using these exact words). Yet, for so many reasons, they continued to turn the crank as rapidly as possible in prescribing the pharmacological interventions that were the prevailing paradigm. No alternative paradigm was visible.

How could this happen? The irony is that, at a high level, the biological psychiatrists made the same mistake as the Freudians. It is a “pride that goeth before the fall” moment, and notwithstanding selected voices of moderation, both sides came to embrace a position that no one else but us (really) knows anything about anything.

Harrington’s ultimate analysis of the unraveling of the optimistic biological psychiatry paradigm of the 1980s: “I argue that this happened, not just become the gap between hype and the state of scientific understanding was too great to bridge (though it was), but also because of a critical error that the original revolutionaries had made. Instead of reflecting on the extent to which the Freudians had lost credibility by insisting that they could be experts on everything, the new generation of biological revolutionaries repeated their mistake: they declared themselves thenewexperts on everything. No one suggested that it might be prudent to decide which forms of mental suffering were best served by a medical model, and which might be better served in some other way. Revolutionaries don’t cede ground” (p. xvii).

Harrington’s narrative is a page turner, even for those who already know the details and the usual suspects, extending from Charcot’s ground breaking work and monumental self-deception, Emil Kraeplin’s distinction between thought disorder and mood disorder, Karl Jasper’s “brain mythology,” the psychoanalysts domination of psychiatry, through the fever cure of Julius Wagner-Jauregg, John Cade’s lithium salt discoveries, the dancing tuberculosis patients responding to iproniazid (complete with a photo from Life Magazine, 1952), the human rights violations, “operation icepick” of Walter Freeman (and James Watts), Ugo Cerletti’s electroshock machine, the breakthrough to the chemical lobotomy of chlorpromazine, the emptying of the asylums, the broken promises, the litigation faced by Chestnut Lodge, the appalling case of Rose Kennedy, listening to Prozac, anti-psychiatry, the accidental judgments, the good intentions gone bad, and, in the upshot, purposes mistook and fallen on the inventors’ head. All this does Harrington truly deliver.

The narrative left me wondering whether we are not living through another period of brain mythology. Granted the account of neurotransmitters, of serotonin and/or dopamine imbalance, can be traced down to neural synapses, science is at the effect of a massive correlation versus causation fallacy. The voodoo correlations in fMRI research support the colonization of vast areas of the social sciences and humanities by neurophilosophy, neuromarketing, neurolaw, neurohistory, neuroaesthetics, and so on. But enough of my cynicism and resignation.

What are the possibilities going forward? Is an alternative paradigm coming into view? Though Harrington’s recommendations are combined in a section on Afterthoughts that left me wishing for more, what she does offer are powerful and on target. Still, after having spent so much time and effort telling the tortured tale of psychiatry’s rise and looming fall, will the profession be willing to listen to her call for “an act of great professional and ethical courage” (p. 273)?

Her recommendation is to cut scope. Given the lack of underlying science, this also implies expanded modesty about psychiatry’s entitlement to power, authority, and market boundaries. Positively expressed, renew the commitment to engaging with the most severe forms of mental illness and leave the routine care of the “worried well” and support for the mentally ill to other professionals. “

Harrington: “The new psychiatry I am envisioning could also aim to overcome its persistent reductionist habits and commit to an ongoing dialogue with the scholarly world of the social sciences and even the humanities [….] [E]ven as it [psychiatry] retains its focus on biological processes and disease, it seeks to understand ways that human being functioning, disordered or not, is sensitive to culture and context (as the recent crisis over the placebo effect in psychopharmacology […] has likely shown)” (pp. 275 – 276).

Harrington calls for interdisciplinary collaboration on a “pluralistic, powering-sharing approach” (p. 274). Make it a priority to overcome the position that “the knowledge and practices of all the nonmedically trained workers are by definition subordinate to those of the medically trained ones” (p. 274). This would help to close the credibility gap suffered by the psychiatric establishment as a result of the shameful ways of deinstitutionalization in the 1960s and ‘70s led to homelessness, incarceration, and premature death (pp. 274 – 275).

I can hear psychiatrists saying, off camera, we too were blindsided, we too did not know. That may indeed be the case, but professional psychiatry has been left holding the smoking chlorpromazine gun. A major tranquilizer and a highly useful one; but nothing like insulin that a diabetic would contemplate taking for lifetime due to a specific disease that leaves the patient deficient in insulin. Begin the process of rehabilitation by acknowledging the solid social science research that shows many people with serious mental disorders benefit far more from being given their own apartment and access to support communities than a script for new or stronger antipsychotic (p. 275).

Harrington makes a powerful case that general practitioners and psychiatrists are perpetuating a fiction that the drugs they are prescribing are correcting biochemical deficiencies caused by disease, much as (say) a prescription of insulin corrects a biochemical deficiency caused by diabetes (p. 273). Such rhetoric is badly oversold. Harrington does not say that the medicines do not help the person tolerate distress, regulate emotions, or self-sooth. Often they do. If one is going to step in front of a bus, far better to take the medicine. Live to fight another day.

Given the complexity of the scientific challenges, psychiatry need not feel embarrassed. However, neither should it be zealously promoting imminent breakthroughs and revolutions as if it were an adjunct to the popular press or a corporate press release.  

Harrington makes the case that the underlying science is not anywhere near the level the neurohype would have us believe. “You have a chemical imbalance” is a marketing position, not a scientifically established truth. “Schizophrenia is like diabetes and you have to take this antipsychotic drug for the rest of your life” is a rhetorical position, not a scientific fact. This is scientism, not science. This is psychiatry’s troubled search for the biological basis of mental illness.

(c) Lou Agosta, PhD and the Chicago Empathy Project



Review: Narrative Exposure Therapy – and empathy

Narrative Exposure Therapy (NET) was originally designed as a treatment for victims of war, persecution, and torture. Civil wars (e.g., Rwanda, Burundi, DR Congo, Iraq) often target civilians and include widespread atrocities and human

Narrative Exposure Therapy (NET) by Schauer, Neuner and Elbert

Narrative Exposure Therapy (NET) by Schauer, Neuner and Elbert

rights violations. For example, the widespread use of rape as a weapon of war and the recruitment of child soldiers in the civil wars of east Africa have left entire populations traumatized even after the cessation of hostilities.

Engaging with these survivors is not for the faint of heart. Therapists are at risk of compassion fatigue and burn out. Many survivors have had to run the gauntlet of multiple, complex traumas, requiring a raid on the inarticulate even to bring their suffering to language. NET is such a raid on the inarticulate.  

The colleagues at the Universities of Konstanz and Bielefeld have innovated in the matter of an intervention that aims at restoring the survivor’s humanity, does not leave the therapist overwhelmed, is scalable, is relatively brief, indirectly gathers data to pursue justice against the perpetrations, and is evidence-based in reducing the symptoms of post traumatic stress disorder (PTSD) even in populations with limited resources.

In a Grand Rounds session on NET at Rush Medical Center, Chicago, in March (2019), I raised the issue of empathy and the risk of burn out with Dani Meyer-Parlapanis Doctor of Psychology, University of Konstanz). Dr Dani is notone of the authors of the text under review here. However, she trains NET practitioners and is providing leadership in extending NET to other applications, including girls and women who embrace violence. I said to her: “If this is not empathy, I would not know it: Empathy LIVEs in NET and in the work you-all are doing. You are engaging with child soldiers and really tough cases. What about it?”

Dr Dani of course acknowledged that compassion fatigue (“burn out”) was a significant risk in engaging with large numbers of survivors of complex trauma, so the NET trainers, are, in effect, counseling the lay counselors notto go into unnecessary detail at first (or words to that effect). Just get the time-line and a label for what happened. But then acknowledging full well that the work was precisely to go into the details she said: “The idea is to be like an investigative reporter.” Though acknowledging the matter may be controversial, I took that to mean empathy in the sense of data gathering and sampling the survivor’s experience, not immersing oneself in it. The investigative reporter is not hard-hearted, but in tune with what the survivor is experiencing. That indeed is the heart of the investigation.

Thus, “empathy” is distinct from compassion. Empathy targets a form of data gathering about what the other person experienced, a sampling of the other’s experience. Such empathy is in tune with the boundaries between self and other and leaves each individual whole and complete in a context of acceptance and toleration. I believe the definition of empathy of Heinz Kohut (1959) as vicarious introspection aligns remarkably well with that employed in NET.

 In the face of compassion fatigue, dial empathy up or down by simulating the role of an investigative reporter. If one can say exactly what happens, the trauma begins to shift, lose power, and shrink, typically by being reintegrated in the context of everyday life and experience. In this case, the investigative reporter also uses vicarious introspection. Easier said than done; but necessarily both said and done.  

The reader in Chicago may say that’s fine, but what has it got to do with the situation here in the USA? We do not have child soldiers or wide spread traumatized populations.

Think again. Gangs are recruiting children of tender age not only as messengers but also as triggermen, because they know youngsters will face a different criminal justice system and process, generally more lenient, than adults.

 After two wars, stretching back to the consequences of the 2001 terrorists attacks, the population is peppered with wounded warriors, both men and women, with a diversity of untreated symptoms from subclinical substance abuse to PTSD, thought disorders, and depression. Violence against (and abuse of) women is no longer an issue in the inner city, but is acknowledged to be a challenge from Hollywood to corporations and the US Supreme Court. 

So, while NET has not received much application in the USA (or the first world), the unmet need is great and it deserves consideration. Hence, the value of this overview.

In some four to fourteen sessions of 90–120 minutes each, the therapist and client create an autobiographical time-line that names the events that have stimulated the most affective arousal in the person’s life. These include traumatic events such as aggression, sexual boundary violations, deaths of loved ones, becoming a refugee, and so on. Positive events are also included on the time-line such as births, marriages, graduations, and life successes. Fast forwarding through the process, the client is handed a copy documenting the narrative at the end of the sessions and a copy is retained just in case the client wishes/agrees to submit the report to the authorities for judicial, prosecutorial follow up.

One of the innovations and most challenging aspects of the narrative in working with former child soldiers (who have grown up in the interim) is to create a context of acceptance and tolerations. Naturally the therapist must employ empathy, but he or she does so as an investigative reporter gathering data about what happened. To become a child solider the survivor is generally required to commit an atrocity such as kill a member of his or her family. Issues of shame and guilt along with the deadening loss of one’s own humanity are powerfully present and evoked.

The first session begins. Diagnosis and psycho-education occur up front. The client may not even know what is PTSD. The client may be living a basically resigned and hopeless existence, and she or he must be enrolled in the possibility of recovery. The education includes information on symptoms, what is involved in the therapy, as well as a statement about the universality of human rights.

An initial pass through the client’s autobiography occurs. A time-line, the life span history, is completed during the second session. The task is to name or label the event in the course of one 90–120 minute session without calling forth the details and hot emotional impact of the traumatic incident. A rope line is used with a variety of stones for traumas, flowers for positive events, and sticks for when the client perpetrated a dignity violation against another. The subsequent work of sessions three through fourteen is to engage sequentially with the events. The work at hand is to find words to express what has previously been unexpressible.

The narrative work consists of going through the events of the time-line. When? Where? And what? The five senses are invoked. Hot memory, sensation, cognition, and emotion are called forth.  What did the background look like? What were the people wearing. Small, cold details call forth powerful hot emotions.

The idea is to put into words and capture verbally the hot affect and experience. The session is not over until the client (often with the support of the therapist) is able to describe what happened in words – that is the narrative.

Now “what a person made it mean” also starts to emerge at this time, and those meanings will naturally be compared with reasonable (or unreasonable) assessments of what to expect of children or people literally with a gun or machete to their necks.

Talking about what happened in the course of the traumatic events calls forth the hot experiences. Talking about what happened following the traumatic events put the hot events back into the context of cold experience. Talking about what happened following the trauma enables the client to reintegrate the trauma into the all-encompassing, greater life narrative. The client is reoriented in time and space to the present, the trauma is contextually situated as to emotional meaning. Before the session ends, the therapist verifies and validates that the client’s arousal has subsided to standard levels and is oriented to the present.

Cognitive restructuring occurs automatically in the days after the story telling. The client may return to the next session with new insights, meanings, and understanding of her or his own behavior in the trauma. Formerly inaccessible details (memories) may emerge and should be included in the narrative. 

For example, one child soldier reported that he killed his sister by cutting her neck with a machete as part of the initiation, for which he bore a great emotional and moral burden; but he subsequently remembered that one of the paramilitaries hit his sister in the head with his rifle butt, a fatal blow, prior to his own action. Therefore, though he did in fact cut his sister, he did not kill her. Small comfort; and not a choice anyone should have to make; yet a significant step in recovering this individual’s dignity and humanity.

In the final session, the client is given a document of her or his narrative lifeline with the details filled in. Where appropriate, the client is asked if he wants to forward the data to the authorities for prosecution of the high level authorities and perpetrators who organized the war crimes. Follow up occurs at six months and a year, often documenting further improvement in symptom reduction, acquisition of life skills, and accomplishments.

NET is trauma focused but unlike many trauma focused therapies that require the survivor to identify thetrauma or select the worst trauma (“good luck with that”), NET acknowledges that survivors of war, torture, and persecution have encountered a sequence of traumas. This is call a “life span” approach.

Granted NET evokes a grim calculus, the number of traumatic event types – beating, rape, killing, torture, branding, amputation, witnessing these, destruction of home by paramilitaries, domestic violence and/or substance abuse by family member, perpetrating or participating in these, and so on – predicts the symptoms of PTSD over and above the actual number of traumatic events.

The results? Studies showing the effectiveness of NET have been independently conducted (Hijazi et al 2014, Zang et al 2013). Centrum 45 in the Netherlands and the Center for Victims of Torture in Minnesota use NET in treating survivors and refugees. NET manuals are now available in English, Dutch, French, Italian, Slovakian, Korean, and Japanese and are also available from the authors in Spanish and Farsi.

Further detailed evidence of the effectiveness of NET is at hand. Reorganizing traumatic memories seems to be inherently stress reducing. Chronic stress causes a weakening of the body’s resilience and defenses against disease and emotional disorder. Reducing stress improves one’s health and well-being. “Morath, Gola et al. (2014) showed that symptom improvements caused by NET were mirrored in an increase in the originally reduced proportion of regulatory T cells in the NET group at a one-year follow-up.” “These cells are critical for maintaining balance in the immune system and regulating the immune response to infection without autoimmune problems. This finding fits with the observation that NET reduces the frequencies of cough, diarrhea, and fever for refugees living in a refugee settlement (Neuner et al. 2008, Neuner et al 2018).”

NET works. NET produces positive results for those suffering from PTSD. This brings us to the question: Why does it work? Thereby hangs a tale – and a theory.

NET conceptualizes PTSD and related disorders as disorders of memory.

For example, hot memories include the sounds of people screaming for help, the sight of dead or wounded persons, the smell of the perpetrator pressing his body against the victim, the taste of one’s own vomit, the experience of being unable to move and helplessness, and so on. These are “hot memories.” These occur or occurred in a context of coldmemories of place, time, and standard activities.

For example: “We were working in the garden behind the house when the paramilitaries drove up in a truck.”  In the case of an individual trauma or series of traumas of the same type, as a defensive measure to preserve the integrity of one’s personal experience, the individual may take himself out of the situation in thought automatically, watching and experiencing the situation as if he was an observing third party. How this occurs is not well understood, but it seems to support survival of the organism in extreme situations.

This disconnects the “hot” and “cold” contexts. In the case of an individual surviving multiple trauma types, beating, rape, loss of home, the cumulative traumatic load causes the traumas to be grouped into a network disconnected from the standard, cold context of everyday life. Fear generalizes forming a fear network. Emotional, sensory, cognitive and physiological representations interconnection with the excitatory force of hot memories. Ordinary, random events become triggers of this network.

The trauma LIVEs. It takes on a life of its own as the fear network. PTSD survivors learn to avoid triggers that act as activators of hot memories. The client isolates. He or she has difficulties with the cold context of autobiographical memory. A negative cascade of experiences is mobilized as symptoms suck the life out of the individual, leaving him or her as an emotional zombie. “Shut down” replaces intrusive thoughts and hyper-arousal with passive avoidance and disassociation.

The effectiveness of NET consists in reestablishing the connections between hot and cold memories, the hot traumatic events and the cold, everyday occurrences that situate them in place and time. In a context of acceptance and toleration (i.e., non-judgment and empathy), the client is supported in reliving the details of what happened by putting them into words without losing the connection to the here and now. If one can say what happened, the emotion is called forth and reintegrated into the context of the person’s life. The trauma starts to shrink.

The imagined exposure to the traumatic event is maintained long enough for the affect, especially the fear, to be called forth and allowed to begin to fade in intensity. The narrative is essential. Absent words, retraumatization – invoking the trauma in an uncontrolled way – is the risk to the client. Even if time is running short, the session must not end until the client (with the help of the therapist (as appropriate)) has found some words to describe what happened. (If the trauma involves organized or domestic violence, the testimony may be recorded or documented for forensic purposes.) 

Two of the strengths of NET are the low drop out rate and the scalability due to building a network of lay therapists. Lay therapists?

The World Health Organization endorses this approach for those communities with limited resources (Jordans, Tol 2012). Given the limited resources of third world countries or even many communities in the USA due to the monopoly-like rents being collected by healthcare insurance providers, NET embraces “task shifting.” “Task shifting” consists in training lay therapists to perform the intervention.

Regarding the training and use of lay therapists to deliver NET, it is scalable, affordable, and workable. It is also controversial. In the State of Illinois (USA) one needs a license to cut hair. However, so far as I know, one does not need a license to have a structured conversation for possibility with another human being about what they had to survive. No doubt the graduates of PsyD programs may have an opinion about that; but personally having taught in two PsyD programs, I know the dedication, commitment, and hard work of the students and teachers; and I also know that one cannot take a course entitled (or with the content of) “empathy lessons” or with “empathy training” in any of these programs. I know because I proposed to do so, but it simply did not get approval due to other priorities. 

NET offers significant potential not only to treat PTSD survivors of violence and trauma. Anxiety and panic disorders, depression, eating and substance abuse disorders, borderline personality disorder (BPD), all report intrusive memories filled with upsetting content but lacking cold memory context.

One final thought. Those suffering from PTSD are suffering from reminiscences –  disorganized, toxic memories. The astute reader may recall this is what Freud said, in slogan-like sound byte, about hysteria (Breuer, Freud 1893). Each memory has to be transformed into words, into a narrative. Each memory has to be expressed in speech so that the body no longer has to function as the corporeal narrator in flashbacks, startle response, panic attacks, intrusive ideas, emotional numbing and overstimulation. Narrative exposure therapy gives new meaning to the phrase “the talking cure,” and it is one. How shall I put it delicately? My “French” fails me: The more things change, the more they stay the same.


Breuer, Josef and Freud, Sigmund. (1893). Studies on Hysteria. Translated from the German and edited by James Strachey. (The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. II.) Hogarth Press, London 1955.

Hijazi, A. M., Lumley, M. A., Ziadni, M. S., Haddad, L., Rapport, L. J., & Arnetz, B. B. (2014).Brief narrative exposure therapy for posttraumatic stress in Iraqi refugees: A preliminary randomized clinical trial. Journal of Traumatic Stress, 27(3), 314–322. https://doi.org/10.1002/jts.21922

Jordans, M. J., & Tol, W. A. (2012). Mental health in humanitarian settings: Shifting focus to care systems. International Health, 5(1), 9–10.

Kohut, Heinz. (1959). Introspection, empathy, and psychoanalysis. Journal of the American Psychoanalytic Association7. (July 1959): 459–407.

Morath, J., Gola, H., Sommershof, A., Hamuni, G., Kolassa, S., Catani, C., … Elbert, T. (2014).

The effect of trauma-focused therapy on the altered T cell distribution in individuals with PTSD: Evidence from a randomized controlled trial. Journal of Psychiatric Research, 54, 1–10. https://doi.org/10.1016/j.jpsychires.2014.03.016

Neuner, F., Onyut, P. L., Ertl, V., Odenwald, M., Schauer, E., & Elbert, T. (2008). Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 76(4), 686–694. https://doi.org/10.1037/0022-006X.76.4.686

Neuner, Frank, Elbert, Thomas, Schauer, Maggie. (2011).Narrative Exposure Therapy: A Short-Term Treatment for Traumatic Stress Disorders, 2ndEdition, Göttingen, Germany: Hofgrefe Verlag.

Neuner, Frank, Elbert, Thomas, Schauer, Maggie. (2018).Narrative Exposure Therapy (NET) as a Treatment for Traumatized Refugees and Post-conflict Populations: Theory, Research and Clinical Practice. 10.1007/978-3-319-97046-2_9.

Zang, Y., Hunt, N., & Cox, T. (2013). A randomised controlled pilot study: The effectiveness of narrative exposure therapy with adult survivors of the Sichuan earthquake. BMC Psychiatry13(1), 41. https://doi.org/10.1186/1471-244X-13-41

 (c) Lou Agosta, PhD and the Chicago Empathy Project