The Evidence: Empathy is Teachable, Trainable, Learnable
This essay is an excerpt from Chapter Four of the book Empathy Lessons. This essay is motivated by the need to debunk the position that the practice of empathy is vague and fuzzy and cannot be taught, that you either have it or you don’t. Bunk. I am addressing scientists, researchers, health care professionals who dismiss empathy as not scientific of evidence-based.
Substantial evidence is available that if you practice empathy, you get better at it. A bold statement of the obvious? Indeed. Yet the requirement to marshal the evidence is a significant one, even if it is often a function of resistance to practicing a rigorous and critical empathy. Key term: resistance to empathy. Overcome the resistance to empathy and the practice of empathy spontaneously and naturally comes forth. [See Empathy Lessons and other books by Lou Agosta on empathy: https://amzn.to/2S0ISPr.%5D
Even if one understands “evidence” in the most narrow and rigorous sense, substantial evidence is available from peer-reviewed research and publictions that empathy training is effective. The implications for evidence-based empathy training are direct. Empathy works. Some of this material may seem difficult or complex; but it is important to engage with it, because it undercuts the subtle resistances to empathy that dismiss empathy in the misguided belief that there are no evidence-based peer reviewed publications.
The first example is an empathy intervention so short that it passed the Institutional Review Board (IRB) criteria for the use of human subjects. The study was complete before people had a chance to drop out. An advertisement went out for people to receive a complimentary, free screening and short intervention for “problem drinking.” In fact, only problem drinkers responded.
The people were divided randomly into groups and given either an immediate check up with confrontational counseling that directed them to stop drinking; or the subjects were given a check up with motivational interviewing that used client-centered counseling and did not try counsel changing the client’s behavior, but in the manner of motivational interviewing explored the person’s motives with him or her. Motivational interviewing employs empathic methods of listening and questioning and, in this example, becomes a proxy for empathy.
Strictly speaking, the counselor facilitated a dicussion with the client of what might happen if the client either did or did not stop (reduce) drinking. A third group of clients was wait-listed, for control, without intervention. Motivational interviewing is a client-centered intervention that relies on empathic listening, questioning, and responding.
Both groups that received intervention resulted in a 57% reduction in drinking within six weeks, and the result was sustained at 1 year. However, there was one dramatic finding. The lead researcher and author (William Miller) reports: “Therapist styles did not differ in overal impact on drinking, but a single therapist behavior was predictive (r = .65) of 1-year outcome such that the more the therapist confronted, the more the client drank.”[i]
This bears repeating: the more confrontational the counselor, the more the client drank. If one starts with a confrontational approach rather than empathy, one is headed for trouble.
In another study, perspective taking was practiced in which the other person was imagined to be a neighbor or a member of one’s own community rather than a stranger.[ii] This examines empathic interpretation, though the study does not use that terminology. Practice perspective taking, it improves.
Other practitioners have developed exercises that focus on specific groups such as doctors of individuals with autism. This expands empathic understanding, though, once again, the terminology is different. Other experiments conduct explicit training in mentalizing, specifically, teaching participants in the training about associations between target facial expressions and emotions.[iii]
In a separate study, a large meta analysis by the Cochrane Library that reviewed fifty-nine peer-reviewed studies with 13,342 participants of a motivational interviewing intervention based on empathy for substance abuse over against other active interventions or no intervention and produced a similar result: motivational interviewing helped people cut down on drugs and alcohol.[iv]
Still, the debate goes on.
Is the empathic questioning, the back-and-forth conversation, in the motivational interview that causes something (attitude, hope, fear, and so on) in the client to shift? Or do people convince themselves? Or do they just get better informed? Or do they stop blaming themselves and feel better, and so they “self medicate” less with alcohol or street drugs?
Lots of questions. No easy answers. Yet when something is so effective across so many studies and researchers are still skeptical, then one has to say: “Okay, skepticism is proper and scientific. Yet nothing is wrong here; but there is something missing—empathy.”
Let’s do the numbers.
Evidence shows that those who train and practice being empathic succeed in expanding their empathy. Educational programs that target empathy have a demonstrably positive effect on empathy skills, according to peer reviewed studies.[v]
Another case in point: a meta analysis of 17 empathy nursing courses in an educational context indicated statistically significant improvement in empathy scores in 11 of the 17 studies (and non statistically significant improvements in the other 6). Similar positive outcomes were reported when medical students, training to be doctors, were included. When nurses and medical students work at practicing empathy; and they get better at it. How about that.[vi]
A disturbing factoid: The empathy of persons studying to become physicians peaks in the third year of medical school according to measures applied periodically (as reported by Dr. M. Hojat and his colleagues at Thomas Jefferson University).[vii] Empathy expands; but then it seems to contract. The suspicion is that the burnout occurs in the “college of hard knocks.”
Use it or lose it? The stereotype of the harried medical doctor, seeing twenty or thirty patients a day, is increasingly accurate. As the MD (or other health care professional) is pushed down into survival mode, empathy is not improved or expanded. Hear me say it, and not for the last time, the things that make us good at the corporate transformation of American medicine, improving productivity and efficiency, do not expand our empathy. This does not mean that empathy and efficiency are mutually exclusive. It means we have to get better at balancing quantity and quality in both business and empathy.
In another example, training sessions directed at aggressive adolescent girls in a residential treatment center showed the benefits of expanded affective empathy. Affective empathy is the automatic dimension of empathy (“empathic receptivity” in my definition) that is perhaps hardest to influence.[viii] Parental effectiveness training (PET) was demonstrated to move the participants from below facilitative on the Truax Accurate Empathy Scale up to or beyond the facilitative level. “Facilitative” means knowing how to get things done. That is, the outcome is that the parent’s empathic effectiveness was expanded.[ix]
The effectiveness of empathy training is not limited to the affective dimension. A team at the University of Toronto produced a meta analysis of twenty-nine articles, using seven different approaches to empathy training. All the studies except two (93%) had positive outcomes, improving the cognitive component of empathy (86%). These studies were distributed as follows: education (24%), nursing (14%), therapy (7%), medicine (21%), social work (3%), psychology (7%), human service (7%), couples (10%) and divorcees (3%). Regardless of the training method, individuals expand their empathy when they practice or engage in effortful training.[x]
In another study, some 42 couples involved in a romantic relationship completed a five week empathy training program. The change in empathy was assessed by measured analyses of variance. The assessment reproduced the positive results of earlier findings. The training produced reliably increased empathic interaction between the partners. Scores on three empathic measures improved over a follow up six month period.[xi]
Further evidence that empathy is trainable is available in “The Roots of Empathy” (ROE). This is a formal program developed by Mary Gordon and colleagues in Canada.
First started in 1996 and introduced into U.S. schools in 2007, the ROE program has been featured on the Public Broadcasting System (PBS) in the USA. ROE aims to build more peaceful and caring communities by expanding empathy in children.[xii]
The program targets elementary school classes, and consists of weekly visits to the class room by a new born baby and the baby’s mother for an entire school year. The group sits in a circle and the mom and baby interact, accompanied by a conversation about the life of the baby, biologically, psychologically, and socially.
The empathy lessons are elementary—unless you do not happen to have ever been exposed to a baby or the empathic care of one. Babies cry when they are hungry or wet or cold; they coo and gurgle and giggle when they are content and happy.
Some lessons are elementary; some, sophisticated, engaging with human development, of which the baby is Exhibit A, as the baby grows throughout the school year.
The roots of empathy are present in front of the class: the baby. The powerful presence of the baby calls forth the emotional resonance, natural curiosity, and wonder of the children. The baby provides the empathy lessons, in effect being the teacher. The baby provides the opening for conversations with the children about human development, socialization, and building a community. The vast majority of human beings are naturally inspired to care for a baby. Whether people know how to deliver such care effectively is a separate issue, requiring separate training. A complex species, these humans: human beings are naturally empathic just as they are also naturally aggressive.
At the heart of this kindergarten through 8th grade program is the goal of dialing down aggressive behavior patterns in children at an early age, in particular, curbing bullying (about which more in an entire chapter below). For example, roughly 160,000 children miss school every day “due to fear of an attack or intimidation by other students,” according to the National Education Association.
The program also documents an 11% improvement in standardized achievement tests for the class that is exposed to the Roots of Empathy intervention.[xiii] This is definitely not a predictable result. It should put us in touch with the humbling sense that there are many things that we do not even know we do not know.
When kids get the empathy to which they are entitled, they study harder and work smarter. When bullying is reduced, kids are less fearful, are less distracted, have more fun, and are able to study. When they study harder and smarter, they get improved scores.
The results of the program are “over the top” positive; and since this is the age of evidence-based everything, the program also spend a lot of cycles gathering key metrics on the results of the roots of empathy. A randomized control trial was conducted.
Findings indicated that children who had participated in the program compared to children who had not, were more advanced in their social and emotional understanding on all dimensions assessed. These included emotional understanding, perspective-taking, peer acceptance, classroom supportiveness, pro-social behavior and characteristics. Concomitant reductions in aggressive behaviors and increases in pro-social behaviors (e.g., helping, sharing, cooperating) were noted.
In particular, teachers rated three child (student) behavior outcomes (physical aggression, indirect aggression, and pro-social behavior). The Roots of Empathy program had statistically significant and replicated beneficial effects on all three child behavior outcomes.[xiv]
Peer reviewed research is compelling, but equally compelling are market dynamics: organizations are voting with their dollars that empathy is trainable.
People with chronic life style diseases such as hypertension (high blood pressure), type 2 diabetes, congestive heart failure, asthma, and so on, enjoy statistically favorable outcomes when their physicians show empathy—a fancy way of saying people “get better.”
Relying on such evidence, a company called “Empathetics” has been founded to train medical doctors in expanding their empathy.
Using intellectual property developed at Massachusetts General Hospital, affiliated with Harvard University, Empathetics, Inc. trains physicians in expanding their empathy through the use of biofeedback.
The CEO, Helen Riess, MD, delivered a Ted Talk about the value of empathy in health care.[xv] Dr. Riess and her colleagues at Mass General performed a meta analysis of the effects of empathy on all kinds of diseases.
Dr. Riess (and her colleagues) report on randomized controlled trials (RCTs) in adult patients, in which the patient-clinician relationship was systematically monitored and healthcare outcomes were either objective (e.g., blood pressure) or validated subjective measures (e.g., pain scores). Those doctors (and related professionals) that scored higher on the empathy screening tests had demonstrably better patient outcomes than those with lower empathy scores.
Three trials included patients with diabetes, two included patients with osteoarthritis. Other disorders included fibromyalgia, oncology, lower respiratory infection, osteoarthritis, hypertension, smoking, somatic complaints, and asthma. The median patient sample size was 279 (range: 85 to 7,557). That’s a lot of people.
In summary, empathic doctoring produces favorable results. Patients get better compared with those whose doctors who do not score as well on the applied empathy scale. A word of caution. Correlation points to a significant path to improved outcome through empathic relatedness, but, at least in the context of this study, correlation is not causation.
Using the language of evidence-based medicine is trending. The “effect size” of empathy is so large that it overwhelms any confounding variables that might be hiding beneath the surface of experience. Thus, empathy fits right in with the trend. The results are compelling. Applying empathy in interacting with the vast majority of people is like using penicillin to treat the vast majority of significant bacterial infections. Applying empathy in interacting with people is like using a parachute when jumping out of an airplane. If you don’t do it, you are headed for trouble.
Common factor, empathy, in social healing practices
Psychotherapy is regarded as an example of a social healing practice. Psychotherapy is a conversation for possibility between two persons, one of whom is dealing with difficult personal issues and emotions and another person who is committed to making a difference through empathy.
Experience shows that physical disorders, injuries, and lesions get elaborated psychosocially. This is not just hypochondria or imaginary disorders that are “in someone’s head.” This is lower back pain, migraines, life style disorders such as type 2 diabetes, asthma, and irritable bowel that are aggravated by job, family, and relationship issues (conflicts, stresses, upsets) in a person’s life. Nutrition and exercise are behavioral practices that positively affect health, but can be difficult to influence.
People have different ways of expressing their pain and suffering. When an investigation of the person’s life indicates that non-biological factors are contributing to the person’s decline or distress, then it is useful to engage an alternative point of view on pain and suffering. It is useful to undertake an inquiry without making too many assumptions that one knows what is actually going on. It is useful to have a conversation for possibility.
The first person to undertake such an inquiry of whom we have any record was named “Socrates.” His student, Plato, wrote down what Socrates had to say, the most famous statement of which was that he knew only one thing: “I know that I do not know.” Socratic’s approach was so powerful that he was able to undertake fundamental inquiries that challenged his own inauthenticities and those of the persons with whom he engaged in dialogue. His questioning led to insights about basic values of truth, right and wrong, pleasure and enjoyment, and the organization of the community. The example of Socrates inspired talk therapists of all kinds—not to mention religious leaders, politicians of integrity, and educators in diverse disciplines.
The word “empathy” does not occur in Plato’s dialogues with Socrates, who instead spoke of being a “midwife” of ideas. When a friend of mine read this account of Socrates as a midwife, he shared with me an anecdote from when he was a medical student. He was walking through the hospital maternity department one evening after class. As he passed an open door, one of the patient’s called out to him. She was in labor and she asked his help. As he told me candidly, at that time in his medical training, he knew nothing about childbirth. Thus, as far as he was concerned, the qualification of Socratic ignorance was satisfied.
My friend asked the woman how he could help. She asked to hold his hand. He thought to himself, “Now this I know how to do!” He held her hand for awhile. She pushed and pushed. The result was a healthy baby boy. How or why the woman was left alone, and what further help arrived was not specified.
My friend cited this as an example of empathic understanding that just shows up spontaneously. In his recollection this was an example of empathy at a moment of crisis to which no words were adequate. I would say the woman was training him in being empathic, and the empathy lesson worked just fine.
Socrates did not claim to produce original knowledge himself. But he acted as a midwife for others, who were trying to give birth to sustainable, viable knowledge. In terms of empathic understanding, Socrates exemplified the commitment to new possibilities as opposed to conformity. Socrates made the case for dwelling in the comfort-zone stretching, discomfort of open-ended inquiry in the face of “being right.” He helped his dialogue partners give birth to ideas of their own and distinguish those ideas that are viable from those that are still-born.
Socrates enjoyed a special relationship with his students and colleagues. He had a special rapport that was a combination ofidealization and affection that set him apart from many of the other teachers of his time, called “Sophists.” The latter were masters of argumentation and rhetoric for hire.
The sophists were perhaps the original purveyors of “alternative facts” and “fake news.” Socrates’ relationship with the sophists in the community was not positive. He spoke truth to power in such a way that those in power were deeply threatened. Some of those in authority came to fear and hate him.
Eventually Socrates was indicted and convicted, in a trial of questionable merit, of a crime against the state, corrupting the youth. For reasons that are still controversial today, Socrates decided to drink the hemlock instead of fleeing into exile, becoming a martyr to prejudice and political intrigue.
Nevertheless, the principles that Socrates espoused have become the basis for talk therapy—and overcoming resistance to empathy. To engage in therapy with human beings in their struggle with emotional pain and suffering requires: providing a gracious and generous listening and an authentic human response; inquiry into possibility and open-ended questioning; an alliance between the therapist and client against the disorder and suffering against which the client is struggling; and an understanding of cultural context and community.
Amid an alphabet soup of therapeutic approaches today, the Socratic method of inquiry stands out as a common factor. It is challenging to try to find something in common between cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), eye movement desensitization routine (EMDR), rational emotive behavioral therapy (REBT), acceptance and commitment therapy (ACT), psychodynamic therapy, psychoanalysis, existential and humanistic psychotherapy, and so on.
“Common factor” is an idea given credibility by Jerome and Julia Frank in their book on Persuasion and Healing.[xvi] The Franks debunk not only psychoanalysis, but also many of the alternative therapeutic approaches. The Franks’ position is that the beneficial results of therapy are a function of persuasion and suggestion. The therapist is applying his or her own empathic and emotionally generous personality in the context of the trusted relationship, committed to healing, to persuade the client to alter his habitual life practices in the direction of behaviors that are adaptive, accommodating, and empowering. The hypnotists called it “the rapport”; modern practitioners, “the therapeutic alliance.”
However, the point here is not to back into an advertisement for empathy. Rather the point is to look at what actually happens in stage one of therapy whether it is CBT, DBT, or one of the diverse talk therapies. Each of these interventions, after establishing a framework around schedule and fee, takes steps to deepen and expand the client’s “in touchness with” his or her own experiences. In DBT this is called “mindfulness”; in psychoanalysis, “free association”; in CBT and REBT, identifying and “interrupting the pathogenic thought”; in existential-humanistic therapy and ACT, “radical acceptance” of what’s so.
This “getting in touch with” is also the first step in becoming more empathic, and so highly relevant to empathy training. One has to be in touch with one’s own experiences in order to appreciate how the other person shows up in one’s vicarious experiences of that other person. In short, empathy is a common factor shared by virtually all approaches to talk therapy.
The problem is that grouping empathy with “common factors” has become a way of dismissing empathy. All the interventions share empathy. It occurs on all sides of the multi-dimensional equation, and so empathy itself cancels out. Empathy falls out of the equation—and out of the discussion.
I suggest an alternative point of view.
What if empathy were the very process that was creating the benefit—and the very equation itself—for each of these supposedly distinct interventions? What if empathy were the very thing that was creating the clearing for EMDR, ACT, and so on, to be effective in the person’s shifting out of stuckness, attachment to suffering, emotional disregulation, self-defeating behavior, or repetitive enactment?
What if empathy was not the idle wheel, falling out of the equation, but the drive shaft? What if the techniques of CBT, DBT, ACT, EMDR, and so on, were themselves so much formal scaffolding, providing a ritual framework for the dynamics of the empathic relatedness to have its effect?
Following the baton or dancing light in EMDR would be something to keep the client distracted while he was verbally expressing his experience of the trauma into the gracious listening of the therapist.
Filling out the paperwork, the surveys, and the homework of CBT would be so much busy work designed to keep the client’s mind off of his anxiety and depression for long enough for the therapist’s empathic responses to the client’s issues to have an impact.
The breathing in and out of mindfulness, literally a metaphor for empathy as oxygen for the soul, would be a useful holding pattern enabling the client to get in touch with his experience so he can communicate it to the therapist and be “gotten” for who he is as the possibility of radical acceptance in empathic understanding.
The “tough love” of DBT and the group skills back-and-forth would be a useful distraction for the client’s intolerable emotions until the therapist was either able to get it right with his empathic interpretation or the client exhausted the payer’s twelve approved sessions. Then, in every case, the empathic exchange as it occurs in the conversation between therapist and the client would be what is making the difference.
More work is definitely needed on this hypothesis. Nor is it likely to be an “either/or” matter. CBT’s “trigger log,” “dysfunctional thinking report,” and “daily thought record,” are useful exercises. Highly useful. It is just that, absent empathy, the CBT process is indistinguishable from dental work—and then the client does not even do the “homework.” What would an evidence-based comparison between empathic and alternative interventions even look like?
The client comes in, and the therapist greets him with a standard human response, using all her abilities to understand and grasp that with which the other person is struggling. Is one supposed to compare being empathic with being rude? With being hard-hearted? With being confrontational? With misunderstanding the other person? With being stone-faced and unemotional? All of these are possibilities. The stone-faced option has actually been tried, but not with adults presenting for therapy. Presumably because it would be a short session. The adults would not stand for it, and most (possibly excepting the masochistic) would get up and walk out.
However, it has been tried with infants in the context of attachment studies. When infants are briefly presented with a “still face,” a blank face from which emotion has been removed on the part of care-takers, who are usually warm and welcoming, the infants become noticeably upset. Some start to fuss; others, to cry. So do most people, whether in personal or experimental situations such as being on “candid camera.” Babies and children of tender age are people, too, and I suggest that their response is an example of a standard human one, albeit without any grammatical use of language, and typical of what one might expect from adults.
What is clear is that an overwhelming number and diversity of psychotherapy approaches engage in the use of empathy. This is so even when these interventions allow empathy subsequently to fall out of the equation as a “common factor.”
Even if the approach in question devalues empathy as a narrow psychological mechanism, it has to endorse its use, because when empathy is absent, generally, positive outcomes are also absent. Those few interventions that devalue empathy—electro shock therapy (ECT), shaming, jail, capital punishment, collective shunning—begin by paying it rhetorical lip service. The result? The amount of aggregated experience that indicates that empathy is an effective intervention is vast and arguably sufficient to overcome any hidden, confounding variables.
Judgments based on clinical practice, tacit knowledge, and deep life experience will continue to have a essential role; however, these need to be qualified by the best available evidence. As noted, the issue is that there are some interventions such as penicillin and using a parachute when jumping out of an airplane that seem to limit or even defy the gold standard. It would be unethical not to give someone penicillin if they were infected with an infection serious enough to require such treatment, since it is a matter of historical accident that penicillin was invented prior to the “evidence based” paradigm shift. And, as regards using a parachute, that case is the reduction to absurdity of not using common sense as a criteria in deciding what counts as evidence. What is going on here? The answer bears repeating for emphasis: The effect size is so large that it outweights and overwhelms any hidden confounding factors and so rises to the level of evidence (without quotation marks). [xvii]
The “effect size” is a function of the facts—the evidence—that there are so many examples and so much experience that penicillin works—that parachutes work—that the risk of one’s over-looking some other confounding variable is vanishingly small. It really was the penicillin, not (say) the effects of the alignmnet of the planets hidden behind the penicillin.
Likewise, with empathy. The use of empathy in human relations is demonstrably so effective in the medical and behavioral health world in question that not to apply empathy would be like not prescribing antibiotics against a bacterial infection. Empathy has been effective in shifting the suffering and transforming the psychic pain throughout history. The criticism of empathy has usually been that it results in burnout and compassion fatigue. But penicillin, too, has to be properly dosed, and people allergic to it excluded, or the results will be unpredictable.
In conclusion, the critical path lies through empathy training: empathy is not an on-off switch but a dial/tuner that requires training to get it just right. Examples of peer-reviewed publications exist in which empathy was shown to be effective (in comparison with less empathy) in correlating with favorable outcomes in diabetes, cholesterol, and the common cold (?!) and are cited in the bibliography (and will be further engaged in Chapter Six of Empathy Lessons).[xviii] Expect this work to expand and gain traction in other areas such as psychiatry and cognitive behavioral therapy.
In short, not to begin with empathy would be like jumping out of the airplane without a parachute or not providing penicillin when the infection was bacterial. If you are jumping out of an airplane, use a parachute; if engaging with struggling, suffering humans, use empathy.
[i] W.R. Miller, R.G. Benefield, J.S. Tonigen. (1993). Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles, Journal of Consultative Clinical Psychology, June; 61 (3): 455-61: 455.
[ii] Jay S. Coke, Gregory Batson, Katherine McDavis. (1978). Empathic mediation of helping: A two-stage model, Journal of Personality and Social Psychology 36(7):752–766. DOI: 10.1037/0022-3522.214.171.1242; Mark H. Davis, Laura Conklin, Amy Smith, Carol Luce. (1996). Effect of perspective taking on the cognitive representation of persons: A merging of self and other, Journal of Personality and Social Psychology, Vol 70(4), Apr 1996: 713–726.
[iii] Ofer Golan and Simon Baron-Cohen. (2006). Systemizing empathy: Teaching adults with Asperger syndrome or high-functioning autism to recognize complex emotions using interactive multimedia, Development and Psychopathology 18, 2006: 591–617. DOI: 10.10170S0954579406060305; J. Hadwin, S. Baron-Cohen, P. Howlin, and K. Hill. (1997). Does teaching theory of mind have an effect on the ability to develop conversation in children with autism? Journal of Autism and Developmental Disorders, 27: 519–537. DOI:10.1023/A:102582600 9731.
[iv] Geir Smedslund, Rigmor C. Berg, Karianne T. Hammerstrom, Asbjorn Steiro, Kari A Leiknes, Helene M Dahl, Kjetil Karlsen. (2011). Motivation interviewing for substance abuse, Cochrane Database of Systematic Reviews, May 11, 2011, Issue 5: CD 008063. DOI: 10.1002/12651858.CD008063.pub2.
[v] C.T. Ozcan, F. Oflaz, B. Bakir. (2012). The effect of a structured empathy course on the students of a medical and a nursing school, International Nursing Review, Vol. 59, Issue 4, December 2012: 532–538. DOI: 10.1111/j.1466-7657.2012.01019.x.
[vi] Scott Brunero, Scott Lamont, Melissa Coates. (2010). A Review of empathy education in nursing, Nursing Inquiry: Vol. 17, Issue 1, March 2010: 65–74.
[vii] M. Hojat, M. J. Vergate, K. Maxwell, G. Brainard, S. K. Herrine, G.A. Isenberg. (2009). The devil is in the third year: A Longitudinal study of erosion of empathy in medical school, Academic Medicine, Vol. 84 (9): 1182–1191.
[viii] E.V. Pecukonis. (1990). A cognitive/affective empathy training program as a function of ego development in aggressive adolescent females, Adolescence, Vol. 25: 59–76.
[ix] Mark E. Therrien. (1979). Evaluating empathy skill training for parents, Social Work, Vol. 24, no. 5 (Sep 1979): 417–19.
[x] Tony Chiu, Ming Lam, Klodiana Kolomitro, Flanny C. Alamparambil. (2011). Empathy training: Methods, evaluation practices, and validity, Journal of MultiDisciplinary Evaluation, Vol. 7, No. 16: 162–200.
[xi] J..J. Angera and E. Long. (2006). Qualitative and quantitative evaluations of an empathy training program for couples in marriage and romantic relationship, Journal of Couple & Relationship Therapy, Vol. 5(1): 1–26.
[xii] PBS staff reporter. (2013). Using babies to decrease aggression and prevent bullying. PBS News Hour: http://www.pbs.org/newshour/rundown/using-babies-to-decrease-aggression-prevent-bullying/
[xiii] PBS staff reporter 2013.
[xiv] Mary Gordon. (2005). The Roots of Empathy: Changing the World Child by Child. New York/Toronto: The Experiment (Thomas Allen Publishers): 250–256.
[xv] Helen Riess. (2013). The power of empathy, TEDxMiddlebury: https://www.youtube.com/ watch?v=baHrcC8B4WM [checked on March 23, 2017]. See also: John M. Kelley, Gordon Kraft-Todd, Lidia Schapira, Joe Kossowsky, Helen Riess. (2014). The influence of the patient-clinician relationship on healthcare outcomes: A systematic review and meta-analysis of randomized controlled trials, PLOS, Vol. 9, No. 4 | e94207: 1–7 Helen Riess, John M. Kelley, Robert W. Bailey, Emily J. Dunn, and Margot Phillips. (2012). Empathy training for resident physicians: A randomized controlled trial of a neuroscience-informed curriculum, Journal General Internal Medicine. 2012 Oct; Vol. 27(10): 1280–1286. DOI: 10.1007/s11606-012-2063-z.
[xvi] Jerome D. Frank and Julia B. Frank. (1981). Persuasion and Healing: A Comparative Study of Psychotherapy. 3rd ed. Baltimore: Johns Hopkins University Press; 1991. I express appreciation to Danny Levine, MD, for calling my attention to this outstanding contribution from the Franks. Also see my A Rumor of Empathy: Resistance, Narrative, and Recovery (2015) for a critique of the psychopharmacological (psychiatric) approach in chapter three “Plato, Not Prozac!” (a title that I borrow from Lou Marinoff (2000), who I hereby acknowledge for his contribution).
[xvii] Howick 2011: 5, 11.
[xviii] Howick 2011; M. Hojat et al, 2011; John M. Kelley, Helen Riess et al 2014); David P. Rakel, Theresa J. Hoeft, Bruce P. Barrett, Betty A. Chewning, Benjamin M. Craig, and Min Niu. (2009). Practitioner empathy and the Duration of the common cold, Family Medicine 41(7): 494–501.
(c) Lou Agosta, PhD and the Chicago Empathy Project
Empathy is good for your health and well-being (The evidence)
Empathy is good for your health and well-being: Empathy is on a short list of stress reduction practices including meditation (mindfulness), Tai Chi, and Yoga. Receiving empathy in the form of a gracious and generous listening is like getting a spa treatment for the soul. But do not settle for metaphors.
For evidence-based research on empathy, empathy and stress reduction, and empathy training you may start by googling: Antoni et al. 2011; Ciaramicoli 2016; Del Canale et al 2012; Farrow et al. 2007; Irwin et al. 2012; Maes 1995, 1999; Pollack et al. 2002; Rakel et al. 2009; Segerstrom and Miller 2004; Slavich et al. 2013 [this list is not complete].
You do not have to buy the book, Empathy Lessons, to get the research, but if you would like more detail see especially Chapters Four and Six in Empathy Lessons (click here to get book from Amazon).
[Also included are chapters on the Top 30 Tips and Techniques for Expanding Empathy, Overcoming Resistance to Empathy, Empathy Breakdowns, Empathy as the New Love, Empathy versus Bullying, and more.]
The healing powers of stress reduction are formidable. Expanding empathy reduces stress; and reducing stress expands empathy. A positive feedback loop is enacted. Expanding empathy expands well-being. Here empathy is both the end and the means.
A substantial body of evidence-based science indicates that empathy is good for a person’s health. This is not “breaking news” and was not just published yesterday. We don’t need more data, we need to start applying it: we need expanded empathy.
Evidence-based research demonstrates the correlation between health care providers who deliver empathy to their patients and favorable healthcare
outcomes. What is especially interesting is that some of these evidence-based studies specifically exclude psychiatric disorders and include mainline medical outcomes such as reduced cholesterol, improved type 2 diabetes, and improvement in related “life style” disorders.
Generalizing on this research, a small set of practices such as receiving empathy, meditation (mindfulness), yogic meditation, and Tai Chi, promote well-being by reducing inflammation. These practices are not reducible to empathy (or vice versa), but they all share a common factor: reduced inflammation. These anti-inflammatory interventions have been shown to make a difference in controlled experiments, evidence-based research, and peer-reviewed publications.
Using empathy in relating to people is a lot like using a parachute if you jump out of an airplane or getting a shot of penicillin if one has a bacterial infection. The evidence is overwhelming that such a practice is appropriate and useful in the vast majority of cases. The accumulated mass of decades of experience also counts as evidence in a strict sense. Any so-called hidden or confounding variables will be “washed out” by the massive amount of evidence that parachutes and penicillin produce the desired main effect.
Indeed it would be unethical to perform a double blind test of penicillin at this time, since if a person needed the drug and it were available it would be unethical not to give it to him. Yes, there are a few exceptions – some people are allergic to penicillin. But by far and in large, if you do not begin with empathy in relating to other people, you are headed for trouble.
Empathy is at the top of my list of stress reduction methods, but is not the only item on it. Empathy alongwith mindfulness (a form of meditation), Yoga, Tai Chi, spending time in a sensory deprivation tank (not otherwise discussed here), and certain naturally occurring steroids, need to be better known as interventions that reduce inflammation and restore homeostatic equilibrium to the body according to evidence based research.
Biology has got us humans in a bind, since the biology did not evolve at the same rate as our human social structures. When bacteria attack the human body, the body’s immune system mounts an inflammatory defense that sends macrophages to the site of the attack and causes “sickness behavior” in the person. The infected person takes to bed, sleeps either too much or too little, has no appetite (or too much appetite), experiences low energy, possibly has a fever, including the “blahs,” body aches, and flu-like symptoms. This response has evolved over millions of years, and is basically healthy as the body conserves its energy and fights off the infection using its natural immune response.
Now fast forward to modern times. This natural response did not envision the stresses of modern life back when we were short stature, proto-humanoids inhabiting the Serengeti Plain and defending ourselves against large predators. Basically, the body responds in the same way to the chronic stressors of modern life—the boss at work is a bully, the mortgage is over-due, the children are acting out, the spouse is having a midlife crisis—and the result is “sickness behavior”—many of the symptoms of which resemble clinical depression—but there is no infection, just inflammation.
The inflammation becomes chronic and the body loses its sensitivity to naturally occurring anti-inflammatory hormones, which would ordinarily kick in to “down regulate” the inflammation after a few days. Peer reviewed papers demonstrate that interventions such as empathy reduce biological markers of inflammation and restore equilibrium. This is also a metaphor. When an angry—“inflamed”—person is listened to empathically—is given a “good listening” as I like to say—the person frequently calms down and regains his equilibrium.
Empathy migrates onto the short list of inflammation reducing interventions. The compelling conclusion is that empathy is good for your well-being.
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(c) Lou Agosta, PhD and the Chicago Empathy Project
The case of Dr Know-it-all: Empathy gives us our humanity
You do not need a philosopher to tell you what empathy is. What then do you need? How about a folktale, a fairy tale, a narrative, a Märchen?
Rather than start with a definition of empathy, my proposal is to start by telling a couple of stories, in which empathy (and its breakdown) plays a crucial role. Both stories are anonymous folktales from the collection edited by the Brothers Jacob and Wilhelm Grimm. The distilled wisdom of the ages accumulated in traditional anonymous narratives will do nicely. Both stories include a significant amount of humor, underscoring that humor and empathy are closely related (on humor and creating a community see also Ted Cohen’s book Jokes (1999)).
How so? In both humor and empathy one crosses the boundary between self and other while preserving that boundary. In both humor and empathy one builds a community, even if only of two people, by transiently, temporarily weakening the boundary between self and other, then reestablishing it. In the case of humor, the boundary crossing is loaded with an element of aggression, violation of community standards, or sexuality—the source of the tension that is released in laughter—whereas with empathy proper the boundary is traversed with a respectful acknowledgement and communication of mutual humanity, whether as high spirits, suffering, or community expanding affinity and affection.
I hasten to add that while the philosopher does not necessarily have a better mastery of empathy than any parent, teacher, doctor, nurse, first responder, therapist, flight attendant, business person with customers, professional with clients, and so on, the philosopher is useful—and at times indispensable—in clarifying distinctions, analyzing concepts, and disentangling misunderstandings about empathy.
Thus, the fairy tale (Märchen) of Doctor Know-it-all is a perfect place to start a philosophical inquiry into
empathy. An uneducated, illiterate, hungry peasant named “Herr Crabb” delivers a load of wood to a doctor. Crabb observes the doctor eating a sumptuous lunch; and Crabb asks him how he (Crabb) might improve his station by becoming a doctor. The doctor tells him to sell his ox and cart and buy an ABC book, buy a fine suit of clothes, and put a sign in front of his hovel that says “Dr Know-it-All.” (Note that the English “Know-it-all” is a translation of the German “allwissend,” which is also the standard translation of the divine attribute “omniscient.”)
Scene two: thieves steal the treasure from the rich noble lord of the manor on the hill. Dr Know-it-all is called in to consult on the case, solve the crime, and recover the treasure.
Now getting a good meal is a recurring theme in this story, and Crabb insists on beginning the consulting engagement by coming to dinner. The nobleman, Crabb, and Crabb’s wife, sit down to a fine three-course meal served by the nobleman’s servants. The first servant brings in the first covered dish, and Crabb says, “That is the first.” Likewise with the other two courses: “That is the second” and “That is the third.”
Now the servants are starting to get worried, because, as is sometimes the case with such crimes, the theft was an inside job, and the servants were ones who did it. “This Crabb guy seems to be onto us,” say the servants to one another between courses. Meanwhile, the nobleman challenges Crabb to say what is under the third covered dish, testing Crabb’s credential as Dr Know-it-all. Of course, Crabb has no idea, and in frustration, he gestures as if to slap himself in the head and says his own name “Oh, Crabb!” Right! The meal is of crab cakes.
Now the servants are really worried—this guy really does know-it-all. The servants create a pretext to take Crabb aside and confess their theft to him, telling him that they will tell him where the treasure is hidden and even give him an extra fee in addition if only he does not identify them as the culprits. An agreement is reached. Crabb shows the lord where his treasure is hidden, collects ample fees from all sides, does not betray the servants, who, after all, are fellow suffers of social injustice like Crabb himself, resulting in the latter’s becoming rich and famous. By the end of the story, living into a self-fulfilling prophecy, as his performance catches up with his reputation, Crabb does indeed become Dr Know-it-all.
This is the perfect narrative with which to begin an engagement with a group of philosophers and thinkers who propose answers about the core issues in the study of empathy. One could let one’s scholarly egoism result in a narcissistic injury; but a better response would be self-depreciating humor. The occupational hazard of over-intellectualization looms large whenever philosophers sharpen the cutting edge of their analytic tools. And there is nothing wrong with that as such, but the approach does have its risks and constraints.
Philosophically speaking, the peasant Herr Crabb, Dr Know-it-all, is the personification of our Socratic ignorance. Socrates’ fame was assured when the Oracle at Delphi—a kind of latter day Wikileaks—proclaimed him as the wisest person in the world, because he acknowledged (i.e., knew) that he did not know.
Socrates was a commitment to pure inquiry; and that has remained a valid approach to philosophizing in such thinkers as Wittgenstein, Nietzsche, Hume in his skeptical phase, and the Kant of the transcendental dialectic. Nevertheless, the commitment of this review is to provide both questions and answers about empathy, in a Socratic spirit, even if those answers then become the basis for further debate, argument, and inquiry.
Meanwhile, the story of Dr Know-it-all is meant to be told with a totally strait face. Notwithstanding the relatively primitive state of medicine in 1804, one still had to go to the university, even if only the better to understand how the planets influenced disease as in influenza. Nevertheless, it is a depreciating and mocking guidance that the doctor gives in the opening scene to the peasant to sell his ox and get a sign that says “Dr Know-it-all.” The peasant follows the advice.
This is the first empathic encounter in the story. Crabb brings the mind of a beginner to the relationship. In a “once upon a time” moment, this is Crabb’s Socratic ignorance, though of course the story does not use such language. Crabb often seems to be thinking about his next meal, and, in that limited sense, he has a desire—to be well fed like the ruling class. However, in a deeper sense, Crabb is without desire and without memory. That is empathy lesson number one in this story: bring the innocence of a beginner’s mind to one’s relationships. That is the readiness assessment for empathy: be open to possibility, no matter how unlikely or counter-intuitive.
Next, in a series of seeming coincidences, Crabb makes simple, ambiguous statements such as: “That is the first one,” “That is the second one,” and so on. These statements become ambiguous Gestalt figures like the famous duck-rabbit, which spontaneously reverses between one figure and another, depending on one’s perspective. Is it a duck or is it a rabbit? (For an image of the duck-rabbit see Wittgenstein 1951: 194 (or Google it).) Likewise, in the folktale, does the statement refer to the dish of food being served or to the answer to the discussion question, who is the thief? Yes.
This is top-down cognitive empathy; take a walk in the other person’s shoes. The servants employ top down empathy—imagining that they are the consultant(s) brought in to solve the mystery of the missing treasure, taking Crabb’s perspective, putting themselves in his shoes. But their empathy misfires. It doesn’t work. Instead of taking a walk with the other person’s personality—Crabb is after all a poor peasant like the servants (but they do not necessarily know that)—they project their own issue onto Crabb.
Their issue? The servants know who are the thieves and they have one thought too many about it. They have guilty consciences. Though they are hungry peasants in their own way, they identify with the values of the dominant class. When authentic human relatedness misfires, then one gets the psychological mechanism of projection. The thieves guiltily project their knowledge onto Crabb. They imagine that Crabb knows their secret. Here the servants’ empathy is in breakdown. The readers learn about empathy by means of its misfiring, breaking down, going astray, and failing.
Taking a step back, the fundamental empathic moment is so simple as to be hidden in plain view. Crabb’s empathy tells him what the servants are experiencing. Fear. They are afraid. If Crabb identifies them as the thieves, they will be hanged. The servants actually say that to Crabb in the story.
Note this is a world circa 1804 in Central Europe, in which there is a different set of rules for judging servants and noblemen. When a nobleman steals, it is called rent, taxation, or user fees. When the servants steal, it is a hanging offense. Theft remains a transgression, so the treasure must be returned. But when the hungry steal to eat, it is arguably a much less serious offense if not an actual entitlement. “Cast not the first stone: go—and sin no more.”
So the story also belongs to a type in which the servant outwits the master, a type of which The Marriage of Figaro is perhaps the most famous example. (See also the narrative approach of Jerzy Kosiński’s Being There, a major motion picture that features Peter Sellers as a naive gardener educated only by watching TV.) In our narrative, integrity is restored at multiple levels. The treasure is returned, the peasant Crabb and his wife acquire the means to eat well going forward, and the servants escape an unfair punishment.
This highly subversive message must be wrappered in humor, so as not to so threaten the prevailing social hierarchy or social injustice of rigid class distinctions with violent revolution. Getting the message out overrides transforming the social order, a perhaps unrealistic expectation in the listening of the folk audience. Crabb’s empathy tells him what the servants are experiencing; his compassion tells him what to do about it—not identify the servants as the perpetrators. I do so like a happy ending, rare though those be.
The case of the young man lacking empathy
The second fairy tale is a kind of thought experiment, a condition contrary to fact. What would be the case if someone completely lacked the capacity for empathy—and how would one acquire such a capacity?
“The story of the youth who set forth to learn fear” is about a young man who is such a simpleton that he does not even experience fear. It is a long and intricate story. I simplify. The folktale is a ghost story. In the story, as people are telling ghost stories, they say “it made me shudder”—a visceral sensation of “goose bumps” in German the onomatopoeic “grüseln.” This simpleton says: “I wish I knew what that was—shuddering. It sounds interesting, maybe I could make a career out of it.” His poor father is now in despair, thinking, “What am I going to do with this one?” Being charitable, we might say nothing is wrong with this young man, the protagonist in the story, but there is definitely something missing.
The father is agreeable. He apprentices the youth out to the local sexton to teach him fear. The sexton tries to scare him by dressing up in a sheet as a ghost at midnight, but the sexton breaks his leg when the youth is not scared and fights back. Thus, the youth is exiled, going on an educational journey into the world to learn visceral fear—shuddering. Having no idea what fear is, he volunteers to spend three nights in the haunted castle, from which no visitor has ever, ever returned alive.
The youth is a simpleton, but one might say, no fool. He takes with him, a knife, a turning lathe with vice grip, and a fire, the three things one is likely to need in case of an emergency. The first night he is confronted by dogs and cats with red-hot chains—the beasts of hell. He uses the knife to dispatch them. The second night he is confronted by fragmentation and dismemberment. Disconnected arms, legs, and heads fall down the chimney, and the zombie-like, quasi-men propose a game of bowling. But the heads, being elliptical, do not roll well. Fearless as usual, he uses the turning lathe to make well-rounded bowling balls, and all enjoy the game.
All the while, the youth is obsessively complaining: “I wish I knew what was shuddering. I wish I could shudder.” On the third night, pallbearers bring in a coffin with the dead body of his cousin. In a scene that authentically arouses the reader’s shuddering, the youth gets into bed with the corpse to warm it up. He succeeds. The corpse comes alive, and, not behaving in a friendly way, threatens to strangle him. But the youth is as strong as he is simple. He overpowers it. Then the old spirit appears, the old man in a long, white beard appears. They struggle. Though consistently depicted as a simpleton, the youth has a breakthrough in his intelligence. Instead of using the physical strength that has served him up until now, the youth cleverly catches the old one’s beard in the vice grip; and he thrashes him until the latter surrenders. The youth wins, and the old spirit shows the youth the treasure hard-to-attain, one third of which goes to the king, one third to the poor, and he gets to keep one third. He also gets the hand of the princess in marriage.
However, the youth has still not learned to shudder. Fear not! On the morning after his wedding night, the chambermaid hears of his persisting complaint from his wife. The chambermaid asserts that the problem is easily fixed. She takes the decorative bowl of gold fish in cold water and throws it on him, as he lies in bed still asleep. The little fish flop around. He awakes. He gets it: Goose bumps. “At last I understand shuddering!”
Fear is perhaps the most primordial and basic emotion. The flight/fight response is a function of the basic biological response of the organism to situations that threaten the integrity of our creaturely existence. The amygdala is activated, adrenalin (norepinephrine) pours into the blood stream, a visceral state of arousal of the body is mobilized that includes increased heart beat, rapid pulse, enhanced startle response, hair standing on end, and a withdrawal of blood from the surface of the skin that results in “goose bumps.” It is a thought experiment similar to riding on a beam of light, going light speed, to imagine a person who does not experience fear in the face of the fearful. Such a thought experiment might not require as much equipment as riding on a beam of light, but, in any case, it is just as rare.
However, no sooner did I pen these words, then I came across a case, in which an individual was identified who did not experience what we would conventionally call “fear.”
As usual, the real world is more complex than one’s thought experiments. It turns out that the individual in question (SM-046) does experience fear in certain situations, but much less so than most “normal” people, so-called “neurotypicals.” The subjective experience of suffocation upon inhaling carbon dioxide in a controlled setting did indeed arouse panic (fear) in her. Panic, fear—close enough?
A further analysis is required to determine what parts of the interpersonal world—personal space, trust of other people, social skills—are impacted (and by how much) by damage to the amygdala. In no sense is SM “less human”; but there is something missing from her empathic repertoire. This missing capacity for fear seems to diminish her social skills and ability to relate. She does not experience vulnerability in situations that are dangerous or risky when most other people would do so, which could be problematic in avoiding injury due to everyday hazards. In that sense, she may actually resemble the simpleton-hero in the folktale, who is so impervious to what others would experience as fearsome or scary that he naively acts courageously and triumphs in the face of long odds against success.
SM does not spend three nights in a haunted castle, so her experiences cannot be compared to those of the protagonist in the folktale. Yet, in any case, physiological fear becomes a symbol of empathic, struggling humanity and its quest for self-knowledge.
The hero-simpleton tries so hard to experience fear that he is effectively defended against his own emotional life. It is ironic that the simpleton is guilty of over-intellectualizing, usually an occupational hazard of philosophers. The youth imagines that someone can tell him in a form of words what is fear as shuddering, visceral goose bumps.
This lack of feeling points to an underlying deficiency in the capability to empathize. Today we might say that this youth is “on the spectrum”—the autistic spectrum—in that he is emotionally isolated and struggles with the reciprocal communication of affect. In short, the youth has an empathy deficit.
As in all classic folktales, the youth has to go forth on a journey of exploration of both the world and of himself. He becomes a traveller on the road of life, which is the narrative of his emotional misadventures to recover his empathy—and his affective life—and become a complete human being.
This must be emphasized. The recovery of feelings is the recovery of his humanity. The youth’s journey into the world can be described in many way; but I urge that it is a journey to recover his humanity in the form of experiencing the full range of human emotions in himself and others, the basic paradigm of which is fear and the basic capacity for which is empathy.
The youth’s recovery of his ability to shudder, his emotions, and his empathy unfold as a running joke. After each increasingly creepy encounter with something most people describe as fearful, he complains, “I wish I could shudder.” This is repeated a dozen times just to make sure the audience gets the point.
As noted, the folktale, the Märchen, is a ghost story, to be told on dark October nights around Halloween. The empathy of the audience is aroused by increasingly gruesome images of dismembered bodies. The audience definitely shudders, getting the creeps, but not the protagonist. Meanwhile, the audience is taken through the three stages of overcoming over-intellectualization, overcoming resistance to empathy, and recovering his full humanity in a rich emotional life.
We retell the story, emphasizing the empathic and emotional aspects.
In the first stage of recovering one’s empathy, one must descend into the hell of one’s own lack of integrity and inauthenticities to regain access to and expand one’s humanity. The dogs and cats with red-hot collars and chains are images from hell. The assignment? One has to descend into the hell of one’s empathy breakdowns, misfirings, inauthenticities, blind spots, self-deceptions, and failures, in order to break through the refiner’s fire of self-inquiry with renewed commitment to empathy, relatedness, and community. One must clean up one’s own act, restoring integrity where it is missing in one’s own actions before carrying empathy forward to others; otherwise the attempt to recover and expand empathy is like putting butter cream frosting on a mud pie. It doesn’t work.
However, even if one cleans up one’s act, acknowledges one’s blind spots and inauthenticities, and commits to empathic relatedness, the risks of failure are significant. That one is committed to relating empathically can leave one vulnerable to the risks of burn out, compassion fatigue, or emotional fragmentation.
The second night in the castle is filled with images of dismemberment. The youth’s self is vulnerable to fragmentation.
None of the dismembered body parts matter to the youth in the way they would matter to an affectively, emotionally whole person. Ghouls and living corpses surround him, but, ontologically speaking, he is the one who is an emotional zombie. Without empathy, the individual is unrelated and isolated—emotionally dead.
The guidance of the folktale is to be persistent. Set limits with courage and humor. The youth rounds the egg-shaped heads in his turning lathe, the better to play at bowling with the now-rounded heads and the dismembered legs as pins. It works. The youth’s good sense of humor and fellow feeling serve him well in relating empathically to what would otherwise be a harrowing encounter with emotional fragmentation. The integrity of the self is sustained and expanded. Everyone has fun, and the ghouls depart with the body parts at the end of the game.
On the third night, in a scene that is really quite creepy (and in which the audience, if not the youth, learns shuddering), the coffin of his dead cousin is delivered. The youth gets into bed with the cold corpse of his cousin, charitable lad that he is, in order to warm it up—and, even more uncanny, succeeds in awaking it!
The emotions are not pleasant that have long lain dormant and “dead” and are brought back to life. The person is at risk of choking on them due to their intensity. Anger and narcissistic rage are the order of the day. The awakened corpse tries to strangle the youth, but the youth overpowers it using physical strength.
The old spirit, the old man with the long, white beard, shows up for the final struggle. The simpleton youth has a breakthrough in his intelligence. He cleverly catches the old man’s beard in his vice grip and starts wailing on him.
As noted, the old spirit yields, and, delivers the treasure-hard-to-attain—the hidden gold and the hand of the princess in marriage. But, though the missing empathy ought to have been recovered by now, for rhetorical reasons, the story continues in describing the youth as still complaining about not yet having learned how to shudder. The climax is complete; the dénouement is at hand.
The individual cannot recover his empathy—or his humanity—on his own. The other is required. A relationship with the other is indispensable. The youth has raised the curse from the haunted castle and won the hand of the fair princess, and he stops trying to shudder. That is key: he finally stops trying. He stops thinking about it—over-intellectualizing. He has a passive overcoming, letting matters be. Then the other teaches him shuddering at the first available opportunity.
The wife’s chambermaid teaches him shuddering in a pun that cleverly masks the physical and sexual innuendo, throwing the cold water and flopping gold fish, causing goose bumps, a visceral experience hard to put into words.
Now the youth is finally a whole, complete human being. The absence of the ability to shudder becomes a symbol for the absence of empathy, the ability to communicate affectively. This youth had no feelings—not even fear. Thus, in this story, in contrast to Dr Know-it-all, we are dealing with bottom up, affective empathy. The absence of the emotion of fear is an extreme paradigm, a negative ideal case, of an absence of the underlying, bottom up capacity for empathy.
Taking the interpretation up a level, the youth is ontologically cut off from the community, who share emotions empathically. Life is disclosed and matters to members of the community based on their affects and emotions.
In the narrative, empathy becomes conspicuous by its absence. This absence of empathy is equivalent to the absence of the individual’s humanity. It is only after the youth undertakes a kind of training program in recovering his empathy—and his humanity—by descending into the hell of his own blind spots and inauthenticities that he is able to experience the full range of human emotions—and, ending with a laugh, shuddering.
With the assimilation of these two pre-ontological documents, we turn to the less humorous but equally significant task of defining different methods and approaches to understanding and applying empathy. The philosophy of empathy engages with diverse philosophical methods that provide access to it.
 Anonymous. (1804). Dr Know-it-all, The Complete Grimm’s Fairy Tales, Jacob Grimm, Wilhelm Grimm, eds., trs. Margaret Hunt and James Stern. New York: Pantheon Books, 1972/1994: 456–457; translation modified.
 Anonymous. (1804). “The story of the youth who set forth to learn fear,” The Complete Grimm’s Fairy Tales, Jacob Grimm, Wilhelm Grimm, eds., trs. Margaret Hunt and James Stern. New York: Pantheon Books, 1972/1994: 29–38; translation modified. This is a complete reworking of Lou Agosta. (1980). The recovery of feelings in a folktale, Journal of Religion and Health, Vol. 19, No. 4, Winter 1980: 287–297.
 See: R. Adolphs, D. Tranel, H. Damasio, A. Damasio. (1994). Impaired recognition of emotion in facial expressions following bilateral damage to the human amygdala, Nature. 372 (6507): 669–72. DOI: 10.1038/372669a0.
Image credit: Dr Know-it-all: Creative Commons: An old man in a top hat sitting in a wooden cart with wheels Wellcome V0020405.jpg
Image Credit: Otto Ubbelohde (artist) – Images of fragmentation: Märchen von einem, der auszog das Fürchten zu lernen (Public Domain)
(c) Lou Agosta, PhD and the Chicago Empathy Project