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The Brain that Changes Itself: A Powerful Message of Hope – and Hard Work!

I have been catching up on my reading.

Norman Doidge’s book, The Brain that Changes Itself (Penguin, 427pp. ($18)), was published in 2007, now some twelve years ago. This publication occurred towards

Cover Art: The Brain That Changes Itself by Norman Doidge

Cover Art: The Brain That Changes Itself by Norman Doidge

the beginning of the era of neuro-hype that now has us choking on everything from neuroaesthetics to neurohistory, from neuromarketing to neurozoology. So pardon my initial skepticism.

However, this book is the real deal. To those suffering from a variety of neurological disorders or issues, extending from major strokes to learning disabilities or emotional disorders, Doidge’s narratives offer hope that hard work pays off. If more authors and editors would have read (and understood!) it, today’s neuro-hype would be a lot less hyped.

Let me explain. There is neural science aplenty in Doidge’s exposition and defense of the flexibility – key term: plasticity – of the brain. There are also plentiful high tech devices (prostheses) that make for near science fiction innovation, except that they are engineering interventions, not fictions.

 However, what distinguishes Norman Doidge’s contribution is that, in every case without exception, the neural science “breakthrough” on the part of the patient is preceded by substantial – in some cases a year or more – of hard work on the patient’s behalf to regain lost neural functionality.

 Yes, from the point of view of our everyday expectations of what can be attained in six weeks of twice a week rehabilitation, the results are “miraculous”; but upon closer inspection the “miracle” turns out to be 99% perspiration and 1% inspiration.

I hasten to add that the exact distribution of effort varies. But the point is that, while the “miraculous” is supposed to be uncaused, lots of hard work on the part of the patient, properly directed, is a key determining factor. This in no way detracts from the authentic innovations and corresponding effort on the part of the neural scientists and engineers engaging in the rehabilitation process.

The woman who lost her sense of balance tells of a woman (Cheryl) whose ability to orient herself in space is “taken out” by an allergic reaction to an antibiotic (gentamicin) administered to treat an unrelated condition. Balance is sometimes considered a sixth sense, for without it the person literally looses her balance and falls over. Thus, Cheryl became the woman perpetually falling.  She becomes a “Wobbler.”

While such a condition does not cause a person to die, unless the fall proves fatal, but it destroys the ability to engage in the activities of daily living. Enter  Paul Bach-y-Rita, MD, and Yuri Danilov (biophysicist) (p. 3), who design a helmet that transmits orientation data to Cheryl through an ingenious interface that she can hold on her tongue like a small tongue depressor. It transmits a tingling sensation towards the front of the stick if she is bending forward, towards the back of the stick if she is bending backwards, and so on. Who would have thought it? Turns out that the tongue is a powerful brain-machine interface.

After some basic training as Cheryl wore it, she was able to orient herself and not fall over. After awhile, she took the helmet off and found that the ability to orient herself lasted a few minutes. There was a residual effect. With more training, the persistence of the after effect was extended. Finally, after a year of work, she was able to dispense with the helmet. She had “magically” regained her sense of balance. The neural circuits that had been damaged were in effect by-passed and the functionality taken over by other neural areas in the brain based on the training. Cheryl was no longer a Wobbler.

This is the prelude to the narrative of the dramatic recovery of Bach-y-Rita’s own father, the Catalan poet Pedro Bach-y-Rita, who has a massive disabling stroke, leaving him paralyzed in half his body and unable to speak.

After four weeks of rehabilitation based on pessimistic theories that the brain could not benefit from extended treatment, the father, Pedro, was literally a basket case. Enter brother George – Pedro’s other son. Now George did not know that rehab was supposed to be impossible, and took the father home to the house in Mexico. They got knee pads and taught him to crawl – because it is useful to crawl before one walks, which Pedro eventually did again after a year of effort. Speech and writing also returned after much effort copying and practicing phonetics.

Pedro returned to teaching full time at City College in New York (p. 22) until he retires years later. After Pedro’s death, a routine autopsy of his brain in 1965, showed “that my father [Pedro] had had a huge lesion from his stroke and that it had never healed, even though he recovered all these functions” (p. 23).

The take-away? What modern neural science means when it asserts that nerve cells do not heal is accurate. But “plasticity” means that the brain is able to produce alternative means of performing the same messaging and functional activity. “The bridge is out,” so plasticity invents a detour around the damaged area. Pedro walks and talks again and returns to teaching.

Conventional rehab usually lasts for an hour and sessions are three times a week for (say) six weeks. Edward Taub has patients drill six hours a day, for ten to fifteen days straight. Patients do ten to twelve tasks a day, repeating each task ten times apiece. 80 percent of stroke patients who have lost arm functionality improve substantially (p. 147). Research indicates the same results may be available with only three hours a day of dedicated work.

 In short, thanks to plasticity, recovery from debilitating strokes is possible but – how shall I put it delicately? – it is not for the faint of heart. Turn off the TV! Get out your knee pads?

So when doctors or patients say that the damage is permanent or cannot be reversed, what they are really saying is that they lack the resources to support the substantial but doable effort to retrain the brain to relearn the function in question – and are unwilling to do the work. The question for the patients is: How hard are you willing to work?

The next case opens the diverse world of learning disabilities. Barbara Arrowsmith looms large, who as a child had a confusing set of learning disabilities in spatial relationships, speaking, writing, and symbolization. Still, she had a demonstrable talent for reading social clues. She was not autistic, but seemingly “retarded” – cognitively impaired. She had problems with symbolic relationships, including telling time.

With the accepting and tolerant environment provided by her parents, who seemed really not to “get” what was going on, Barbara set about to cure herself. She (and her parents) invented a series of exercises for herself that look a lot like what “old style” school used to be: A lot of repetitive exercises, rote memorization, copying, and structure. Flash cards to learn how to tell time. There is nothing wrong with the Montessori-inspired method of letting the inner child blossom at her or his own rapid rate of learning, except it does not work for some kids. Plasticity demonstrates that “one size fits all” definitely does notfit all.

The result? The Arrowsmith School was born, featuring a return to a “classical” approach:

“[…] [A] classical education often included rote memorization of long poems in foreign languages which strengthen the auditory memory […] and an almost fanatical attention to handwriting, which probably helped strengthen motor capacities […] add[ing] speed and fluency to reading and speaking” (pp. 41–42).

This also provides the opportunity to take a swipe at “the omnipresent PowerPoint presentation – the ultimate compensation for a weak premotor cortex.” Well said.

Without having anything wrong with their learning capabilities as such, some children have auditory cortex neurons that are firing too slowly. They could not distinguish between two similar sounds – e.g., “ba” and “da” – or which sound was first and which second if the sounds occurred close together (p. 69):

“Normally neurons, after they have processed a sound, are ready to fire again after about a 30-millesecond rest. Eighty percent of language-impaired children took at least three times that length, so that they lost large amounts of language information” (p. 69).

The solution? Exploit brain plasticity to promote the proliferation of aural dendrites that distinguish relevant sounds and sounds, in effect speeding up processing by making the most efficient use of available resources.

 Actually, the “solution” looks like a computer game with flying cows and brown bears making phonetically relevant noises. Seems to work. Paula Tallal, Bill Jenkins, and Michael Merzenich get honorable mentions, and their remarkable results were published in the journal Science(January 1996). Impressive.

Though not developed to treat autism spectrum disorders, such exercises have given a boost to children whose sensory processing left them over-stimulated – and over-whelmed, resulting in withdrawal and isolation. Improved results with school work – the major “job” of most children – leads, at least indirectly, to improved socialization, recognition by peers and family, and integration into the community (p.75). Once again, it seems to work.

As a psychoanalytically trained medical doctor, one of Doidge’s interests is in addiction in its diverse forms, including alcohol and Internet pornography. For example, Doidge approvingly quotes Eric Nestler, University of Texas, for showing “how addictions cause permanent changes in the brains of animals” (p. 107). This comes right after quoting Alcoholics Anonymous that there are “no former addicts” (p. 106). Of course, the latter might just be rhetoric – “don’t let your guard down!” Since this is not a softball review, I note that “permanent changes in the dopamine system” are definitely notplasticity. A counter-example to Doidge’s?

Doidge gets high marks for inspirational examples and solid, innovative neural science reporting. But consistency?

A conversation for possibility – that is, talk therapy – which evokes the issues most salient to being human – relationships, work, tastes, and loves – activate BNGF [brain-derived neural growth factor], leading to a proliferation or pruning back of neural connections. This is perhaps the point to quote another interesting factoid: “Rats given Prozac [the famous antidepressant fluoxatine] for three weeks had a 70 percent increase in the number of cells in their hippocampus” [the brain area hypothesized to be responsible for memory translation in humans] (p. 241). This is all good news, especially for the rats (who unfortunately did not survive the experiment), but the devil, as usual, is in the details.

On a positive note, Freud was a trained neurologist, though he always craved recognition from the psychiatric establishment [heavens knows why – perhaps to build his practice]. In a separate chapter including a psychoanalytic case (“On Turning Our Ghosts into Ancestors,” an unacknowledged sound byte from Hans Loewald, psychoanalyst), Doidge’s points out in a footnote that having a conversation with a therapist changes one’s neurons too. The evidence is provided by fMRI studies before and after therapy (p. 379). This is the real possibility for – get ready, welcome to  – neuropsychoanalysis.

Like most addictions – alcohol, street drugs, gambling, cutting – Internet porn is a semi-self-defeating way of regulating one’s [dis-regulated] emotions. The disregulated individual may usefully learn expanded ways of regulating his emotions, including how to use empathy with other people to do so. Meanwhile, the plasticity of addictive behavior turns out to be more sticky and less flexible than the optimistic neuro-plasticians (if I may coin a term) might have hoped. 

Doidge has an unconventional, but plausible, hypothesis that “we have two separate pleasure systems in our brains, one that has to do with exciting pleasure and one with satisfying pleasure” (p. 108). Dopamine versus endorphins? Quite possibly. Yet one doesn’t need neuropsychoanalysis to appreciate this. 

Plato’s dialogue Gorgias makes the same point quite well (my point, not Doidge’s). Satisfying one’s appetites puts one in the hamster’s wheel of endless spinning whereas attaining an emotional-cognitive balance through human relations, contemplation, meditation, or similar stress reducing activities provide enduring satisfaction. The tyrant may be able to steal your stuff – your property, freedom, and even your life – but the tyrant is the most miserable of men. The cycle of scratching the itch, stimulating the need further to scratch the itch, is a trap – and a form of suffering. Suffering is sticky, and Freud’s economic problem of masochisms looms large and still has not been solved.

Doidge interweaves an account of a breakthrough psychoanalysis with a 50 plus year old gentleman with a narrative of Eric Kandel’s Nobel Prize winning research. Kandel and his team published on protein synthesis and the growth of neural connections needed to transform short- into long-term memory. While it is true that humans are vastly more complicated than the mollusks in Kandel’s study, the protein synthesis is not.

Thus, another neural mechanism is identified by which Talk Therapy changes your brain. Mark Solms – founding neuropsychoanalyst – and Oliver Turnbull translate Freud’s celebrated statement “where id was ego shall be” into neural science: “The aim of the talking cure […] from the neurobiological point of view [is] to extend the functional sphere of the influence of the prefrontal loves” (p. 233).

Even if we are skirting close to the edges of neuro-hype here, it is an indisputable factoid that Freud, the neurologist, draws a picture of a neuronal synapse in 1895 (p. 233). At the time, such a diagram was a completely imaginative and speculative hypothesis. Impressive. Freud also credibly anticipates Hebb’s law (“neurons that fire together wire together”), but then again, in this case, so did David Hume (in 1731) with his principle of association.

Meanwhile, back to the psychoanalysis with the 50-something gentleman who has suffered from a smoldering, low order depression for much of his life. Due to age, this is not considered a promising case. But that was prior to the emerging understanding of plasticity.

This provides Doidge with the opportunity to do some riffing, if not free associating, of his own about trauma, Spitz’s hospitalism, and psychopharmacology. “Trauma in infancy appears to lead to a supersensitization – a plastic alteration – of the brain neurons that regulate glucocorticoids” (p. 241). “Depression, high stress, and childhood trauma all release glucocorticoids and kill cells in the hippocampus, leading to memory loss” (p. 241). The result? The depressed person cannot give a coherent account of his life.

The ground breadking work of Rene Spitz on hospitalism – of children confined to minimum care hospitals (anticipating the tragic results in the Rumanian orphanages after the fall of the USSR) – is invoked as evidence of the damage that can occur. When the early environment is sufficient to keep the baby alive biologically but lacks the human (empathic) responsiveness  required to promote the emotional well-being of the whole person, the result is similar to acquired autism – an overwhelmed, emotionally stunted person, struggling to survive in what seems to the individual to be a strange and unfriendly milieu.

I summarize the lengthy course of hard work required to produce the result of Doidge’s successful psychoanalysis. The uncovering of older, neural pathway gets activated and reorganized in the process of sustained free association, dream work, and the conversation for possibility in the psychoanalytic “talking cure”. Through an elaborate and lengthy process of working through, the patient regains his humanity, his lifelong depression lifts, and he is able to enjoy his retirement.

So far neural plasticity has been a positive phenomenon and a much needed source of hope and inspiration to action. However, plasticity also has a dark side. For example, if one loses a limb due to an amputation, the brain takes over what amounts to the now available neuronal space on the neural map. One’s physical anatomy has changed, but the brain seems plastically committed to reusing the neural map of the body for other purposes.

The limb is no longer there, but it hurts, cramps, burns, itches, because the neural map has not been amputated. However, the patient suffers – sometimes substantially – because one cannot massage or scratch a limb that does not exist. Yet the pain LIVEs in the neural system – and that makes it real.

Pain is the dark side of plasticity. Pain is highly useful and important for survival. It protects living creatures from dangers to life and limb such as fire or noxious substances. We have a painful experience and learn to avoid that which caused the pain.

Yet pain can take on a life of its own. Anticipating pain can itself be painful. Once pain is learned it is almost literally burned into the neurons and it takes considerable work (and ingenuity) to unlearn – to extinguish – the pain.  

“Our pain maps get damaged and fire incessant false alarms” (p. 180). V. S. Ramachandran has performed remarkable work with understanding that most recalcitrant of phenomena, phantom limb pain. Ramachandran’s is deservedly famous for many reasons. But his simple innovation of the mirror box really requires an illustration. It is literally done with a mirror.

Illustrating mirror box therapy with an intact limb being reflected so as to create the appearance that the amputated limb is present: the individual experiences the presence of his missing limb

Illustrating mirror box therapy with an intact limb being reflected so as to create the appearance that the amputated limb is present: the individual experiences the presence of his missing limb

The subject with the missing hand is presented with a reflected image of the good, intact hand, which in reflection looks just like the missing hand. The subject experiences the limb as being a part of his body. (That in itself is a remarkable effect – the neural “socket” is still there.) In effect, the individual gets the hand back as something he owns. He is able to experience closing his missing hand by closing the good hand. This relieves cramps and stiffness.

In other experiments, the lights are turned off and various areas of the body are touched. The area that was once the [now missing] hand is used to map sensations on another area of the body, for example, one’s face. Scratching an itch on the phantom limb by scratching just the right spot on one’s face becomes possible because the neural map of the missing limb has been taken over and is now being used to map a different part of the anatomy

Doidge ends with a flourish:

“V. S. Ramachandra, the neurological illusionist, had become the first physician to perform a seemingly impossible operation: the successful amputation of a phantom limb” (p. 187). He did this by changing the brain – in effect deconditioning (deleting) the representation of the phantom limb from the brain. Thus, the promise and paradox of plasticity.

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

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Book Review: Susan Lanzoni’s Empathy: A History connects the dots between the many meanings of empathy

Short review: two thumbs up. Superb. Definitive. Well written and engaging. Innovative and even ground-breaking. Connects the dots between the different aspects and dimensions of empathy. Sets a new standard in empathy studies. The longer – much longer – review follows. Note also that since this is not a softball review, several criticisms, incompletenesses, and limitations are called out.

Susan Lanzoni’s comprehensive history of the concept of empathy – the concept, not the mere word – breaks new ground in our understanding of the distinction.  She

Cover art: Empathy: A History by Susan Lanzoni - showing the full spectrum of aspects of empathy from projection to receptivity in interpersonal relations

Cover art: Empathy: A History by Susan Lanzoni – showing the full spectrum of aspects of empathy from projection to receptivity in interpersonal relations

explores empathy’s significance for diverse aspects of our humanity, extending from art and advertising to race relations and talk therapy: Empathy: A History. New Haven: Yale University Press, 392 pp., $30 (US).

Just to be clear: Lanzoni’s is not a “how to” or self-help book; which does not mean that one cannot expand one’s empathy by engaging with empathy’s deep structure in this multi-dimensional, historical encounter. One can. However, the reader will not find explicit tips and techniques in applying empathy.

Lanzoni engages with empathy and: (1) natural beauty and art (2) the 19th century psychological laboratories of Wilhelm Wundt (1832–1920), Edward Bradford Titchener (1867–1927), and their rivals (3) theatre and modern dance (4) mental illness such as psychosis and schizophrenia (5) social work and psychotherapy (6) measurement using psychometric questionnaires (7) popular culture including advertising and the media (8) race relations (9) neuroscience.

Lanzoni begins by quoting the work of Ted Cohen (1939–2014) on metaphor in Thinking of Others: On the Talent for Metaphor(2009). Formulating a metaphor and imagining oneself in another person’s position point to a common twofold root, an art [Kunst] hidden in the depths of the human soul, whose true operations we can divine from nature and lay unveiled before our eyes only with difficulty, but whose depths we are unlikely to be able ever adequately to plumb. Lanzoni’s implies the art in question is precisely empathy and the translation it makes possible. Thus, we always honor the late Ted Cohen, whose predictably cutting, caustic and cynical wit, however, masked a deep and abiding empathy.

The narrative proper begins with Violet Paget (Vernon Lee (1856–1935)), who, with her partner and muse Clementina (Kit) Anstruther-Thomson, engaged in introspective personal journaling to detect and report the physiological effects of art and beauty on the human organism. Paget’s research crosses paths with that of Munich psychologist Theodor Lipps (1851–1914). Lanzoni reports that Lee and Lipps may have met in person in Rome at the Fifth International Congress of Psychology in 1905 (where both were on the program).

At the risk of over-simplification, Paget, Lipps, and Karl Groos (1861–1946) form a triumvirate of empathy innovators, who turn to motor mimicry, inner imitation, sympathetic muscular memory, and aspects of physiological resonance to account for the stimulating effects of artistic and natural beauty on human experience. Their analysis is the flip side of the implicit panpsychism, personification, anthropomorphism by which beautiful nature is animated with human expressions of the emotional life – for example, angrystorms in the ocean, melancholymists in the valley, a joyfulsunrise, a fearfuldarkness.

This remarkable feature of human experience: that we attribute emotions (and even intentions) to natural objects – angry storms, cheerful sunsets, and melancholy clouds. Magical, primitive thinking? An adaptive reflex? This review does not require that anyone, including Lanzoni, have solved this problem. However, some contemporary thinkers have speculated that it is a cognitive design defect of human nature to attribute intentionality (including emotional propositional contents) to otherness – whether human or physical – as an adaptive mechanism arising in the context of biological evolution.

 Theodor Lipps is the one who puts Einfühlung on the map between 1883 and 1914 (his death), and those who are contemporaries must explain how they differ from his position.

 Lipps’ position on empathy was already multidimensional, extending Einfühlung from the projection of feelings into objects to the perception of other people’s expressions of animate life. Lanzoni’s reading of Lipps is much more charitable than mine, and I find Lipps at loose ends and philosophically naïve as he tries to account for the first person’s access to the experiences of the second person by “an original innate association between the visual image and the kinesthetic image (1903: 116). Lipps thinks he has demolished the philosopher’s problem of other minds but unwittingly recreates it in his own terms (e.g., Agosta 2014: 62 – 63).

 Lanzoni engagingly (but briefly) references the critique of Lipps’ theory of projective empathy by the phenomenologists Edith Stein (1891–1942), Max Scheler (1874–1928), Edmund Husserl (1859–1938), Maurice Merleu-Ponty (1908–1961), and Martin Buber (1878–1965) (p. 37).

 Lanzoni notes Sigmund Freud’s (1856–1939) debt to Lipps based on transference as a kind of projection. For Lipps, psychological processes were performed, with few exceptions, beneath the threshold of consciousness, which is another factor that made Lipps’ positions attractive to Freud.

 Any thinker or author who used the term “Einfühlung” would inevitably also conjure up the image of Theodor Lipps, which limited the thinkers ability to use it without extensive argument or the risk of being mistaken as a follower of Lipps. This point is key: in his own time Lipps had in itself branded himself as the “go to guy” for all matters empathic. More on the significance of this dilemma below.)

 By the way, Lanzoni does not italicize the word “Einfühlung” unless it is used in a specifically German context. “Einfühlung” is now an English word!

 Johann Herder (1744–1803) also gets honorable mention at this point (p. 32) as a philosopher in the Romantic tradition. Herder is noteworthy as a proponent of empathy as a verb – sichhereinfühlen– to feel one’s way into. Herder was a fellow traveler of Goethe and actually “on staff” as the chief Lutheran prelate at Weimar, innovating in the historical development of language in a proto-evolutionary (and metaphysical) context. This points to an entire undeveloped paradigm of empathy not developed by Lanzoni. For example, for Herder empathy was required to feel one’s way into the world of Homer in order to produce an accurate translation of Homer’s Iliad.

 This paradigm of empathy as translation is arguably at the same level of generality as empathy as projection, but remained undeveloped until the rise of hermeneutics along a separate trajectory. And since Lanzoni seemingly unquestioningly accepts Rudolf Makkreel’s dismissal of the relevance of Einfühlung for Wilhelm Dilthey (granted he has little use for the word), this approach is not further explored.

 Yet the modern innovators of interpersonal empathy such as Carl Rogers (1902–1987) might be read as leap-frogging back to the original sense of entering the other’s world in order to translate it into the first person, subject’s own terms. Such Herderlike usages also fits well with what Gordon Allport (1897–1967) and Kenneth Clark (1903–1983) were doing in arraying empathy against racism and prejudice in expanding the boundaries of community by empathically translating between them (see Chapter Nine).

 An entire possible alternate history of empathy, as yet unwritten, opens up at this point – empathy as translation between subjects. (Granted that Rogers probably never heard of Herder, at least not in the context of empathy, so this is a conceptual nuance; but Rogers probably never heard of Lipps either.)

 As is by now well known, in part thanks to Lanzoni’s work, the word “empathy” itself comes into English thanks to Edward Bradford Titchener, the founder of a Wundtian style psychology lab at Cornell University (and translator of Wundt). However, what is less well known is the back-and-forth about the meaning of Einfühlung as explored in detail by Lanzoni.

I was impressed by the work of James Mark Baldwin (1861–1934), who contribution to empathy as semblance was interrupted and obscured as he had to leave town in a hurry – apparently for Paris – after being arrested in a raid on a Baltimore house of prostitution. Baldwin was innovating with empathy in terms of semblance – the “as if” of child’s play and the play of the artist.

 Lanzoni quotes in detail the devaluing remarks about “empathy” made by James and Alix Strachey, the translators of Freud, who call it a “vile word” (p. 67). Though Freud used variations of “Einfühlung” some 22 times in 24 volumes, the word is often paraphrased or mistranslated by the Stracheys, using synonyms such as “sympathetic understanding.”

 It is amazing how much empathy or lack thereof turns on a mistranslation. My take on it? Basically Freud did not use the word Einfühlung more often because he was not someone who could abide being a footnote to Lipps (who, as noted, virtually owned the distinction Einfühlungin German). There are other technical reasons Freud chose not to comment more extensively on empathy, including his dismissal of the philosophical uses of introspection as a function of the conscience (superego), whereas introspection and empathy are “joined at the hip” in a therapeutic context (see also Agosta 2014: 66 – 82).

 I hasten to add that Freud did say in his “Recommendations for Physicians Beginning Psychoanalytic Treatment” (1913) that if the would-be analysts start in any other way than with empathy, they are headed for trouble. But once again the reader has no idea of Freud’s true position, because “empathy” is mistranslated as “sympathetic understanding.” However, these observations are less critical to Lanzoni’s point, which is otherwise unexceptionally on target.

 Meanwhile, Titchener has numerous ideas (that we would today consider highly unconventional) about how images accompany word meanings, but his translation of “Einfühlung” as “empathy” sticks. In an otherwise comprehensive engagement (Lanzoni really does seem to have read everything!), she does not mention how empathy subsequently becomes embroiled in the disappearance of introspection controversy (behaviorists regard it as illusory) and ultimately is “taken down” by the behaviorists in their attack on all things relating to subjective consciousness and inwardness. However, all this lies ahead in the B.F. Skinnerian 1950s through 1980s, and the Chapter ends with Einfühlung being an intertwining of projection, aesthetic appreciation, and Baldwin’s “semblance.”

 But how does one get from a empathy that projects human emotions and mindedness onto objects in art and nature and an empathy as human understanding of another, second person who contains an emotional life and mind of his or her own distinct from that of the first person?

 Lanzoni skillfully navigates the challenge of engaging how the projective aesthetic empathy of Lipps et al get transformed, translated, and reconciled, with the interpersonal receptive empathy of talk therapy and personal counseling.

 One missing link comes in modern dance. The missing link is identified as to “live in the mind of the artist who designed it [the object]” (p. 97). At this moment in the text, the intentionality of the artist looms large. In effect, the regression (my word, not Lanzoni’s word) is back from the intentionality built into the artistic artifact or performance towards human subjectivity. Now intentionality is available to build a bridge between a projective empathy of the object and a receptive intersubjective empathy of the human subject.

 Both projective empathy and receptive empathy are ways (admittedly divergent) of dealing with and transforming otherness– the otherness of the object and the otherness of the human subject. This is why aesthetic empathy and interpersonal empathy belong to the same concept and are not merely the same homonymous word for different underlying concepts.

 Another missing link occurs in “Personality as Art.” Lanzoni gathers together the contributions of Herbert Langfeld (1879–1958), Wilhelm Worringer (1881–1965), Carl Gustav Jung (1875–1961), who expand the boundaries of aesthetic, projective empathy in the direction of the understanding of human beings. The study of the artistic self-expressions of psychotics incarcerated in mental asylums also deserves mention here as opening up the exchange between aesthetic projective empathy and interpersonal receptive empathy.

 Nowhere does any one (including Lanzoni) say, “Relate to the human being with the respect and interpretive finesse with which one relates to a work of art,” but that is the basic subtext here. In our own time, the late Richard Wollheim, a notorious free spirit, sometimes took such a position about art and its objects.

 The engagement with empathy as human understanding picks up speed. Whenever a breakdown occurs the possibility of a breakthrough also arises. Such is the case with schizophrenia. In apparently separate but overlapping and near simultaneous innovations, E. E. Southard (1876–1920), Roy G. Hoskins , Louis Stack Sullivan (1892–1949), Karl Jaspers (1883–1969), and C. G. Jung identified schizophrenia as a challenge to or a disorder of empathy. In short, it is hard to empathize – Jaspers maintained it was impossible – with people who were disordered in such a way that they displayed the cluster of symptoms we now group as schizophrenia including perceptual distortions, incoherent speech patterns, disordered thinking, lack of reality testing, bizarre ideas, emotional flatness, intermittent acute anxiety or paranoia, lack of motivation, lack of responsiveness, burn out, and (occasionally) lack of personal hygiene.

 Southard designed an “empathic index” (p. 101) guiding the psychiatrist through a series of questions such as: How far can you read or feel yourself into the patient? Thus the first, admittedly over-simplified, version of the schizophrenia test: Can you imagine experiencing what the patient reports he or she is experiencing? If not, then that counts as evidence they are on the equivalent of what we would today call the “schizophrenic spectrum.”

 We finally arrive at our present day folk definition of empathy: the ability to step into and walk in another person’s shoes and then to step back into one’s own shoes again, and, in so doing, to “feel along with, to understand, and to insinuate one’s self into the feelings of another person” (p. 124).  

 Lanzoni asserts: “[T]he psycho-therapeutic rendering of empathy traded self-projection for its opposite: one now had to bracket the self’s findings and judgments in order to more fully occupy the position of another” (p. 125). Thus, a coincidence of opposites in which the two extremes are perhaps counter-intuitively closer to one another than either point is to the middle.

 With Chapter Five on “Empathy in Social Work and Psychotherapy,” Lanzoni makes yet another decisive contribution to empathy scholarship.

 Carl Rogers famously puts empathy on the map in the 1950s, 60s, and beyond, as the foundation for psychotherapeutic action. Though it is an oversimplification, in client-centered Rogerian therapy, one gives the client a good listening – one gives the client empathy – and the client gets better.

 Lanzoni connects the empathy dots. They lead back into the empathy archives. They lead back from Carl Rogers to D. Elizabeth Davis, a student of Jessie Taft (1892 – 1960), a nurse and social worker, who, in turn, was strongly influenced in her conception of relational therapy by G. H. Mead’s (1863–1931) social behaviorism and Otto Rank (1884–1939). Rank belonged to Freud’s inner circle along with Ernest Jones (1879–1958), Karl Abraham (1877–1925), and Sándor Ferenczi (1873–1933).

 Not a medical man or even a scientist, Otto Rank met Freud in 1905 when he presented Freud with his innovative work on the artist as inspired by Freud’s theories. Something clicked between them. In 1905 Freud was less isolated, but still hungry for recognition and fellow travelers. Think: father son transference.

 Rank eventually completed a PhD dissertation at the University of Vienna on literature (the Lohingrin Saga), in part thanks to the financial generosity of Freud. Freud paid him to be the recording secretary of the Psychoanalytic Association. The literary dimension is of the essence, and, in our own time, we have a renewed appreciation that studying literary fiction expands one’s empathy.  This too  strengthens the case for the overlap of the aesthetic and interpersonal dimensions of empathy.

 As was often the case with Freud and his “sons” – Jung, Ferenczi, Adler – the seemingly inevitable “falling out” between Rank and the Freudian establishment was especially bitter. Ultimately Louis Stack Sullivan made the parliamentary motion to expel Rank from the American Psychoanalytic Association. With friends like these … Rank formed his own separate Association and continued to innovate and earn Greenbacks.

 Carl Rogers learns of Rank’s work through one of his colleagues, who is being analyzed by Rank, now residing in the States. Rogers invites Rank to speak at a three-day seminar (circa 1936), lecturing to forty-five social workers and educators. Rogers later notes that it was in this context “that I first got the notion of responding almost entirely to the feeling being expressed” (p. 144). Voila! Mark the historical moment: Client-centered therapy is conceived.

 Mine is a bare bones outline of how Lanzoni connects the dots. The dynamics and the personalities, which Lanzoni richly narrates, make for fascinating story telling in themselves. Fast forward to the 1930s as Jessie Taft, a nurse and social worker separately innovating in empathic relatedness, is translating Rank’s Will Therapyfrom the German. There is still research to be done to follow the threads into Rank’s work, whose literary skills in mining myth and fiction are used in elaborating an approach to the emotions that transgresses the relatively narrow definition of Freudian libido (desire).

 Though Lanzoni does not get so far, I do not believe that Rank had the specific distinction of Einfühlung, but worked with the communication and understanding of the emotions in such a way as to produce psychological transformation. Rank uses the word “love” in the way of an empathy-like “unconditional positive regard.”

 By the time Rogers is fully engaged with Einfühlung, “empathy” does notmean agreement with the other or mere mirroring. The therapy client may usefully be self-expressed about the emotions with which he or she is struggling. These emotions, in turn, are thereby brought to the surface, acknowledged, worked through, and able to be transformed. The therapist helps the client to metabolize the emotional congestion and gives back to the client the client’s own experience in a form that the client recognizes, hypothetically opening up a reorganization of psychic structure.

 Lanzoni also gives a “shout out” to Heinz Kohut, MD (1913–1981), but just barely. Kohut was the innovator who puts empathy on the map in psychoanalysis (then the dominant paradigm in psychiatry) starting in 1959 with his celebrated article “Introspection, empathy, and Psychoanalysis.”

 Kohut was very circumspect about his sources relating to empathy and regarding those who inspired him in his work on empathy. Chronically under-appreciated (and sometimes even under attack) by the prevailing orthodoxy of Freudian ego psychology, Kohut’s footnotes about empathy as such are few and far between. Surely knowing the fate of Adler, Jung, Ferenczi, and Rank, not even to mention Jeffrey Masson, Kohut pushed back against the unfriendly accusation that Kohut’s emerging Self Psychology was distinct from Freudian psychoanalysis, even as Self Psychology seemed increasingly to be so.

 It is likely Kohut was influenced by Sándor Ferenczi and Michael Balint (Lunbeck 2011). Speaking personally, I have never seen a shred of evidence that Kohut read Rank, who was by that time devalued as yet another notorious “bad boy” and psychoanalytic heretic. Of course, that does not mean that Kohut did not do so – and it is also possible that I just need to get out more. Kohut and Rogers seemed to have inhabited parallel but wholly distinct universes.

 My take? And not necessarily Lanzoni’s: Kohut was sui generis– and wherever he first got the word “empathy” itself (Kohut, though a Austrian, German-speaking refugee, was by 1959 writing in English), his definition of empathy as “vicarious introspection” is a wholly original contribution.

 One problem is that as soon as one engages Kohut’s The Analysis of the Self(1971), arguably a work of incomparable genius, discovering as it does new forms of transference, relations to the other, and possibilities for humanization, the reader is hit by a tidal wave of terms such as “cathexis,” “archaic object,” and “repressed infantile libidinal urges.” These make the reading a hard slog for most civilians.

 The force of historical empathy is strong with Lanzoni as she engages “Popular Empathy.” She describes how in the post World War II world “empathy” breaks out of its narrow academic context into the American cultural milieu at large.

For example, the then-popular radio (and eventually TV) personality Arthur Godfrey was featured on the February 1950 cover of Time magazine, asserting “He has empathy” (p. 208). The notorious quiz show scandals of the late 1950s were apparently a function of mis-guided empathy, giving contestants answers to build audience empathy for the contestants. Advertisers “got it”: help the audience empathize with the brand and the person using the brand – give the customer empathy, they buy the product. Even if it was never quite so simple, the Boston Globe(July 3, 1964) quotes the Harvard Business Review:  Empathy is “the ability feel as the other fellow feels – without becoming sympathetic” (p. 210).

 Meanwhile, Carl Rogers has an existential encounter with Martin Buber (celebrated author of I and Thou) at the University of Michigan (1956). Rogers is profiled in Timemagazine in 1957 as practicing a psychotherapy that uses empathy in contrast with the then-prevailing paradigm of psychoanalysis, which uses – what? Insert the caricature of an authoritarian analysis of the Oedipus complex.

 In an eye-opening Chapter on “Empathy, Race, and Politics,” Lanzoni documents the role of empathy in the movement for civil rights in the 1950s and 1960s in America. Both Kenneth B. Clark and Gordon Allport provided examples of (social) psychologists who were committed to social justice. They were committed to overcoming the one dimensional, trivial and convenient issues of academic research (still ongoing) instead engaging with urgent social realities such as prejudice, racism, poverty, and inequality.

 According to Lanzoni, Allport drew on the tradition of Einfühlung to describe empathy as a means of grasping the human personality holistically, thus breaking down the barrier between aesthetic and interpersonal empathy. Clark used empathy as the basis for arguing for equality under the law: “to see in one man all men; and in all men the self” (p. 217). Sounds like empathy to me.

 In 1944 Allport taught an eight-hour course to Boston police officers to tune down racial tensions. Allport encountered and faced what he called an “abusive torrent of released hostility.” In response Allport deployed the technique of nondirective or “unemotional listening,” learned from Carl Rogers. Once again, sounds like empathy. By the end of the session, the officers reportedly became bored by their own complaints. One who had “at first railed against the Jews tried in later remarks to make amends.” But empathy remained a two-edged sword, capable of eliciting searing anger when others thought they had not been given the dignity they deserved as well as dialing down narcissistic rage once it had been called forth (pp. 220 – 221).

Clark was so impressed by psychoanalyst Alfred Adler’s (1870–1937) power dynamics in the context of society that he shifted his major from neurophysiology to psychology. In 1946, Clark and his wife, Mamie Clark (PhD, Columbia) established the Northside treatment Center in Harlem to expand education, counseling, and psychological service for youth in Harlem.

 In July 1953 Clark wrote to Allport, asking help in preparing a document for the upcoming Supreme Court deliberations on desegregation in the Brown v. Board of Education case. Allport responded quickly. The rest, as they say, is history.

 Gunnar Myrdal (author of the celebrated American Dilemma, demonstrating that the history of the US isthe history of race relations (1944)) said of Clark’s work, especially Dark Ghetto(1965): a demand for “human empathy and even compassion of the part of as many as possible of those who can read, think, and feel in free prosperous white America” (p. 241). Just so.

 Instead of becoming ever more cynical and resigned in the face of prejudice that seemed baked into the neo-liberal, market-oriented vision of American society, Clark calls forth empathy. Clark’s calls for empathy became more insistent. What happens when Clark and empathy speak truth to power? Empathic reason? Rational empathy? One can only wish that Clark had lived to see the people of this great country elect Barak Obama as President of these United States. We do not know if this was an anomalous moment, a beacon in the current fog of fake everything, or a kind of liberal purgatory – one step forward, one step backward – to call forth further struggle. From the perspective of Q2 2019 as I write this review, such events seem like a dream. Breakdowns are hard but inevitably point the way to the next breakthrough.

 Lanzoni demonstrates that society’s interest in empathy had continuously been at the level of at least a steady simmer in the popular and social justice communities in the 1950s through 1970s even as professional psychology was lost and wandering through the wasteland of Skinnerian behaviorism.

 That which really brings the conversation about empathy to a rolling boil in the final chapter is the discovery of mirror neurons in the macaque monkeys by the group of brain scientists in Parma, Italy including V. Gallese,, L. Gadiga, L. Gogassi, and G. Rizzolatti.

 Mirror neurons are neurons are activated both when a subject takes an action and similarly when the subject watches another subject doing the same thing. For example, the set  of neurons in the premotor cortex of the monkey is activated when it drinks from a cup. Okay, fine. The astonishing finding is that these same neurons are activated when the monkey watches another monkey (or any one) drink from the cup. Could this be the underlying basis of the motor mimicry, inner imitation, felt resonance, with which thinkers such as Violet Paget, Theodor Lipps, and Karl Groos remarked? Could this be the neural infrastructure for Kohut’s vicarious engaged, or Roger’s felt sense of participating in the other’s experience? The infrastructure for Mark Davis or Alvin Goldman on perspective taking and simulation?

  The battle is joined.

 Lanzoni covers the explosion of theories, studies, and amazing results that have occurred since the identification of alleged mirror neurons. Bottom up, affective empathy is combined with top down, cognitive empathy to complete the picture of empathic relatedness.

 The author of Emotional Intelligence, Daniel Goleman, weighs in with a follow up on Social Intelligence– that is, empathy.  Victorio Gallese’s shared manifold hypothesis makes the case for a multi-person virtual manifold of experience that can be vicariously sensed by each partner in empathic resonance. Jean Decety’s seminal architectural definition of empathy paves the way for social neuroscience and functional magnetic imaging research (fMRI) that visualizes other people’s pain. Marco Iacoboni Mirroring Peopleargues that we have no need to use inference to understand other people. We use mirror neurons. Disorders of empathy are identified: Simon Baron-Cohen’s breakthrough work on Mindblindness(1995) identifies possible interventions for autism spectrum disorders.

 On a less positive note, the colonization by neural science of the humanities and social sciences has proceeded apace with neuroaesthetics, neurolaw, neurohistory, neurophilosophy, neuropsychoanalysis, neurozoology,and so on,  drawing provocative but, in many cases, highly questionable conclusions from what areas of people’s brains “light up” as they lay back in the fMRI apparatus and are shown diverse pictures or videos of people’s fingers being painfully impacted by blunt force.

 Lanzoni reports on the neuro-hype that accompanies the discovery of mirror neurons in monkeys: “Cells That Read Minds.” Hmmm. The backlash is predictable if not inevitable. Greg Hickok’s The Myth of Mirror Neuronsraises disturbing questions about voodoo correlations in fMRI research. Other than a single report from 2010 of human mirror neurons allegedly identified in epileptic patients undergoing surgery, there is no evidence of the existence of human mirror neurons.

 Lanzoni is an equal opportunity debunker: The fMRI research, while engaging and provocative, provides evidence of diverse brain functions that include thousands of neurons, not individual ones, whose blood oxygenation level data (BOLD) is captured by the fMRI. Correlation is not causation. The brain lights up! Believe me, if I doesn’t you are in trouble.

 Still, the neuro-everything trend has traction (and its merits). Even if human mirror neurons do not exist, it is highly probable that some neurological system is available that enables us humans – and perhaps us mammals – to resonate together at the level of the animate expressions of life.

 If there is a myth, it is that we are unrelated. On the contrary, we humans are all related – biologically, socially, personally. You know that coworker or boss you can’t stand? You are related. You know that politician you regard with contempt? You are related. You know that in-law or neighbor who gets your goat? You are related – intimately related, because we all share the same cognitive, affective, and neural mechanisms – and defects – designed in from when we were that band of hominids fighting off large predators and hostile neighbors in the environment of evolutionary origin.

 Since this is not a softball review, as noted, I call out the limitations and incompletenesses of Lanzoni’s impressive contribution. One of the challenges is that the history of the concept empathy is not limited to the word “empathy” or Einfühlung. Indeed prior to Lanzoni’s work, some entirely reasonable individuals had concluded that Lipps projective empathy and Roger’s interpersonal empathy were entirely distinct concepts. We now know that they belong together in a kind of coincidences of opposites because empathic animation of the work of art or beautiful nature and empathic receptivity to other human beings are related, but diverse, ways of engaging with otherness. 

 First incompleteness: Prior to Titchener’s invention of the word “empathy” as a translation of the German “Einfühlung” the main word in English was “sympathy.” Now it is a common place today to say that “sympathy” means a reactive emotion such as pity in contrast with “empathy” that captures a vicarious experience of the other’s experience or takes a sample or trace affect of the other’s experience. And that remains true today. David Hume (1711–1776) and Adam Smith (1723–1790) get barely a shout out.

 However, if one goes back as recently as David Hume’s Treatise of Human Nature(1731) one can find at least four different senses of sympathy – emotional contagion, the power of suggestion, a vicarious experience such as one has in the theatre, the conjoining of an idea and impression of another’s expression of emotion with the idea of the other [which starts sounding like our notion of interpersonal empathy].

 In addition, if one looks at Hume’s aesthetic writings, one finds the distinction of a delicacy of sympathy and of taste. If your delicacy of sympathy and taste is more refined than mine, then you may experience a fine-grained impression that is more granular than mine. For example, you perceive sadness behind a person’s outburst of temper whereas I only perceive the obvious anger. Your delicacy of sympathy and taste is superior to mine. In our own modern language, you empathy is more discriminating.

 A second incompleteness is in the treatment of the phenomenologist’s – Edith Stein (1891–1942), Max Scheler (1874–1928), Edmund Husserl (1859–1938), Maurice Merleu-Ponty (1908–1961), who receive honorable mention in a cursory nod to their diverse engagements with Einfühlung. For example, in a footnote, Scheler’s eight distinctions of sympathy and empathy are called out in a footnote (p. 360n40): Miteinanderfühlung[reciprocal feeling], Gefühlsansteckung[infectious feeling], Einsfühlung[feeling at one], Nachfühlung[vicarious feeling], Mitgefühl[compassion], Menschenliebe[love of mankind], akosmischtishe Person- und Gottesliebe[acosmic love of persons and God], und Einfühlung[empathy]. Well and good.

 Leaving aside purely practical considerations of editorial constraints on word count and that the phenomenological material may have been covered elsewhere [e.g., see Agosta 2014, especially Chapters 4 – 6]: the reason that the additional phenomenological chapter was not provided is a breakdown in an otherwise astute historical empathy. 

 In particular, today hardly anyone has heard of Theodor Lipps (granted that Lanzoni’s work is changing that). However, in his own day Lipps was famous – celebrated as the proponent of a theory of Einfühlungthat provided the substructure for aesthetics and grasping the expressions of animate life of other people. It was as if Lipps was an Antonio Salieri to would-be Mozarts such as Freud or Husserl (once again, except for the play (and movie) Amadeus). Using modern terms, it was as if in his own day Lipps was branded in the marketing sense as “the empathy guy.”

 Between roughly 1886 and 1914 (the date of Lipps’ death) no philosopher, psychologist, or psychoanalyst could use the word “Einfühlung” without being regarded as a follower – or at least a fellow traveller – of Lipps.

 In the case of the phenomenologist, the result is a sustained attack on Lipps. Edith Stein quotes Max Scheler against Lipps’ theory of “projective empathy.” Her contribution becomes a candidate deep structure of Husserl’s 5thCartesian Meditation. Husserl attempts to overcome the accusation of solipsism [there is nothing in the universe except my own consciousness] without using empathy as a mere psychological mechanism. Yet Husserl dismisses empathy, using a Kantian idiom, and “kicks it upstairs”: “The theory of experiencing someone else, the theory of so-called ‘empathy,’ belongs in the first story above our ‘transcendental aesthetics’ ” (1929/31: 146[173]). “Transcendental aesthetics” is a form of receptivity – such as receptivity to another subject. But then Husserl has to reinvent empathy in other terms calling it “pairing” and “analogical apperception.”

 One thing is certain: in Husserl’s Nachlass(posthumous writings) he makes extensive use of Einfühlungin building an account of intersubjectivity. Empathy is the window into the sphere of ownness of the other individual subject. Empathy is what gives us access to the Other, with a capital “O.” Empathy enacts a “communalization” with the other. Key term: communalization (Vergemeinschaftung).

 In his published writings Husserl was exceedingly circumspect in his use of the term “Einfühlung,” virtually abandoning it between Ideas(1913) and the Cartesian Meditations(1929/31).  But in Husserl’s work behind the scenes empathy was moving from the periphery to the center of his account of intersubjectivity. The Nachlassvolumes corresponding the Cartesian Meditations contain hundreds of references to Einfühlung, in which it is doing the work of forming a community of subjects. The anxiety of influence? The influence of Lipps? Quite likely.

 I would not blame anyone – including Lanzoni – for not wanting to try to disentangle this complex of distinctions and influences of empathy in the context of phenomenology. It is not for the faint of heart.

 As of this date (Q2 2019), Lipps is not translated from the German so far as I know. There is a reason for that – Lipps falls through the crack between Immanuel Kant and Wilhelm Wundt. If ever there were someone of historical interest, it is Lipps.

 Lipps provides an elaborate rewrite of rational psychology using a quasi-Kantian idiom without any of the empirical aspects of Wundt. Still, Lipps enjoyed considerable celebrity in his own time. So far as I know, no one has commented on the fact that Lipps in effect substitutes the term “Einfühlung” for “taste” in his aesthetics. Those wishing to engage further may usefully see Agosta 2014: “From a Rumor of Empathy to a Scandal of Empathy in Lipps in A Rumor of Empathy: Rewriting Empathy in the Context of Philosophy: pp. 53 – 65: DOI: 10.1057/978113746534.0007.)

 A third incompleteness is the role of empathy in psychoanalysis proper, which was perhaps a wilderness too desolate to reward proper scholarly engagement. Lanzoni notes: “There were also handful of psychoanalysts, trained, not surprisingly, in Vienna, who ventured to explain empathy to a popular audience. Analyst and writer Theodor Reik published Listening with the Third Ear in 1948 [….] Empathy worked like wireless telegraphy to allow one to tune in to the inchoate messages of another’s unconscious” (p. 208). Empathy as receptivity andbroadcast of messages. However, Reik was not a medical doctor, and the American Psychoanalytic Association declined to validate his credentials, leaving him as yet another voice crying in the wilderness.

 Lanzoni gives Kohut another “shout out,” noting that empathy was an observational act that led the analyst to a scientific appraisal of the other person rather than one of the “sentimentalizing perversions of psychotherapy” (p. 207). Of course, Kohut moved steadily in the direction of asserting that empathy itself could be curative, though, in contrast to Rogers, mainly in a process of optimal breakdown, being ruptured and restored. Empathy breaks down, the attuned therapist acknowledges and cleans up the misunderstanding, empathy is restored, psychic (personality) structure is shifted and strengthened – thenthe patient gets better.

 A fourth incompleteness is the missing paradigm of empathy as translation between different individuals and the worlds in which the individuals inhabit. Once again, this is not a criticism of Lanzoni, but simply to note that, substantial though Lanzoni’s contribution is, there is more work still to be done.

 Herder was working on a complex interpretive problem of empathy, creating an entire world in all its contingencies and details in order adequately to translate a text from attic Greek into German or understand a work of art in its ancient context. Herder’s project envisions no trivial translation, and, if anything, is an application of empathy broader and bolder than what is being proposed here or in any reconstruction of Kant. According to Herder, in order to deliver an adequate translation, the translator must think and feel himself into – empathize into [sichhineinfühlen] – the world of the author or historical figure. The translator is transformed into a Hebrew, e.g., Moses, among Hebrews, a poet among bards, in order to “feel with” and “feel around” the world of the text (e.g., Herder as cited in Sauder 2009: 319):

 Feeling is the first, the most profound, and almost the only sense of mankind; the source of most of our concepts and sensations; the true, and the first, organ of the soul for gathering representations from outside it . . . . The soul feels itself into the world [sichhineinfühlen] (1768/69: VIII: 104 (Studien und Entwürfe zur Plastik)) (cited in Morton 2006: 147-148).

 Thinking from the point of view of everyone else is not to be confused with empathy in the Romantic idea of empathy where empathy is a truncated caricature of itself and summarily dismissed as merger, projection, or mystical pan-psychism. Nor is it clear that Herder, always the sophisticated student of hermeneutics, ever envisioned such a caricature of empathy. In any case, empathy is not restricted to the limitations of a Romantic misunderstanding of empathy as merger. Empathy as creating a context within which a translation – an empathic response – can occur stands on its own as an undeveloped paradigm (see also Agosta 2014: 36–37 (from which this text is quoted)).

 Among the many strengths of Lanzoni’s book is her engagement with the many women researchers and scholars who contributed to the history of empathy: Violet Paget (Vernon Lee), who was there are the beginning with the physiological, mirroring effect of empathy in inner imitation; Edith Stein, research assistant (along with Martin Heidegger) to Edmund Husserl and her dissertation The Problem of Empathy(1917), which was influenced by and, in turn, informed Husserl’s ambivalence about making Einfühlungthe foundation of intersubjectivity (community); Jessie Taft, who developed an entire model of psychotherapy, relational therapy, combining element of G. H. Mead’s social behaviorism and Otto Rank’s psychoanalytically informed approach to the emotions, which, in turn, decisively influenced Carl Rogers. All this and more does Lanzoni truly deliver.

 References and Further Reading

 Jean Decety (ed.). (2012).  Empathy From Bench to Bedside(2012). Cambridge, MA: MIT Press.

 Jean Decety and P.L. Jackson. (2004). “The functional architecture of human empathy,” Behavioral and Cognitive Neuroscience Reviews, Vol 3, No. 2, June 2004: 71-100.

Sigmund Freud. (1913). “Further recommendations: On beginning the treatment.” Standard Edition, Volume 12: 121-144.

Victorio Gallese. (2001). “The shared manifold hypothesis: embodied simulation and its role in empathy and social cognition.” In Empathy and Mental Illness, T. Farrow and P. Woodruff (eds.), Cambridge, UK: Cambridge University Press, 2007: 448-472.

Edmund Husserl. (1905/20). Zur Phänomenologie der Intersubjectivität: Texte aus dem Nachlass: Erster Teil: 1905-1920,I. Kern (ed.). HusserlianaXIII. The Hague: Martinus Nijhoff, 1973.

 ______________. (1913). Ideas: General Introduction to Pure Phenomenology, tr. W. R. Boyce Gibson. New York: Collier Books, 1972.

 _____________. (1918). Ideas Pertaining to a Pure Phenomenological Philosophy: Second Book, tr. R. Rojcewicz and A. Schuwer. Dordrecht: Kluwer Academic Publishers, 1989.

 ______________. (1921/28).  Zur Phänomenologie der Intersubjectivität: Texte aus dem Nachlass: Zweiter Teil: 1921-1928I. Kern (ed.). HusserlianaXIV. The Hague: Martinus Nijhoff, 1973.

 ______________. (1929/31). Cartesian Meditations, tr. D. Cairns. Hague: Nijhoff, 1970.

 _____________. (1929/35).Zur Phänomenologie der Intersubjectivität: Texte aus dem Nachlass: Dritter Teil: 1929-1935, I. Kern (ed.). HusserlianaXV. The Hague: Martinus Nijhoff, 1973. 

 Marco Iacoboni. (2007). “Existential empathy: the intimacy of self and other.” In Empathy and Mental Illness, Tom Farrow and Peter Woodruff (eds.), Cambridge, UK: Cambridge University Press, 2007: 310-21.

L. Jackson, A. N. Meltzoff, and J. Decety. (2005). “How do we perceive the pain of others? A window into the neural processes involved in empathy,” Neuroimage24 (2005): 771-779.

G. Jung. (1921). Psychological Types, tr. R. F. C. Hull. Princeton: Princeton University Press, 1971.

Susan Lanzoni. (2012). “Empathy in translation: Movement and image in the psychology laboratory,” Science in Context, vol. 25, 03 (September 2012): 301-327.

Vernon Lee [Violet Paget]. (1912). Beauty and Ugliness and Other Studies in Psychological Aesthetics. New York: John Lane, Co.

 Theodor Lipps. (1883). Grundtatsachen des Seelenlebens. Bonn: Verlag des Max Cohen und Sohns.

 _____________. (1897). “Der Begriff der Unbewussten in der Psychologie.” In Dritter internationaler Congress für Psychologie in München vom 4. bis 7 August 1896. München Verlag von J.F. Lehmann, 1897: 146-163.

 _____________. (1909). Leitfaden der Psychologie. Leipzig: Wilhelm Engelman Verlag.

 _____________. (1903). Aesthetik. Volume I. Hamburg: Leopold Voss.

 Lou Agosta. (2014). “From a Rumor of Empathy to a Scandal of Empathy in Lipps in A Rumor of Empathy: Rewriting Empathy in the Context of Philosophy: pp. 53 – 65: DOI: 10.1057/978113746534.0007.

 ____________. (2014). A Rumor of Empathy: Rewriting Empathy in the Context of Philosophy. New York: Palgrave Pivot.

Elizabeth Lunbeck. (2011). “Empathy as a Psychoanalytic Mode of Observation: Between Sentiment and Science,” in Histories of Scientific Observation, ed. Lorraine Daston and E. Lunbeck. Chicago: University of Chicago Press.

George H. Mead. (1922). “A Behavioristic account of the significant symbol,” Journal of Philosophy, 19 (1922): 157-63.

 Michael Morton. (2006). ‪Herder and the Poetics of Thought: Unity and Diversity in On Diligence in Several Learned Languages. London and University Park: Penn State University Press.

Lou Agosta, PhD and the Chicago Empathy Project

 

 

 

 

 

Review: “No Visible Bruises” refers to strangulation

The title of Rachel Louise Snyder’s eye-opening, powerful, page-turner of a book, No Visible Bruises, refers to strangulation [No Visible Bruises: What We Don’t Know About Domestic Violence Can Kill Us, New York: Bloomsbury Publishing, 2019: 309 pp, $28(US)].

Some sixty percent of domestic violence (DV) victims are strangled at some point during an abusive relationship (p. 65).  Turns out that only some 15% of the victims

Cover Art: No Visible Bruises by Rachel Louise Snyder - a picture of cracked plaster - not only of an enraged fist but of a damaged, fragmented self (?)

Cover Art: No Visible Bruises by Rachel Louise Snyder – a picture of cracked plaster – not only of an enraged fist but of a damaged, fragmented self 

in one study had injuries visible enough to photograph for the police report (p. 66). Most strangulation injuries are internal – hence, the title. 

Since 2012 when I completed the 40-hour training in Understanding Domestic Violence (DV) at the community organization ApnaGhar, several important innovations have occurred. Snyder presents the reader with these, including the distinctions of (1) a Fatality Review Board for Domestic Violence; (2) initiatives to provide treatment for the abusers; (3) the Danger Assessment (which leads back to the role of strangulation).

Lack of oxygen to the brain can cause micro-strokes, vision and hearing problems, seizures, ringing ears, memory loss, headaches, blacking out, traumatic brain injury (TBI) (p. 69). As the victim in near death due to strangulation – but so far there would only be red marks around the neck – the nerves in the brain stem lose control over sphincter muscles. So the urination and defecation were not mere signs of fear. They were evidence that the victim was near death (p. 67).  

Such victims may have poor recall of the event. They may not even be aware that they lost consciousness. The victim is not being difficult or drunk in being incoherent. The victim is fighting the consequences of a life-threatening event and may not know it at the moment.

Even medical professionals may overlook the signs of serious injury by strangulation unless they are altered to the circumstance of the visit to the emergency room. Fact: DV victims are not routinely screened for strangulation or brain injury in the emergency room. They are discharged without CT scans or MRIs. The assaults and injuries are not formalized and abusers are prosecuted under lesser charges, say, misdemeanors rather than felonies.

“What researchers have learned from combat soldiers and football players and car accident victims is only now making its way into the domestic violence community: that the poor recall, the recanting, the changing details, along with other markers, like anxiety, hypervigilance, and headaches, can all be signs of TBI” (p. 70).

Now the ultimate confronting fact: Strangulation often is the next to last abuse by a perpetrator before a homicide. The correlation is strong, very strong. Strangulation is a much more significant marker than, say, a punch or kick that the abuser will escalate to lethal violence. Strangulation dramatically increases the chances of domestic violence homicide (p. 66).

This leads directly to an important innovation in the struggle against DV, the Danger Assessment. Jacquelyn Campbell has quantified the Danger Assessment, which is especially effective when combined with a timeline of incident. In addition, to strangulation high risk factors in any combination that portend a potential homicide include: gun ownership, substance abuse, extreme jealousy, threats to kill, forced sex, isolation from friends and family, a child from a different biological parent in the home, an abuser’s threat of suicide or violence during pregnancy, threats to children, destruction of property, and a victim’s attempt to leave anytime within the prior year. Chronic unemployment was the sole economic factor (p. 65). None of these cause DV; but they make a bad situation worse – much worse – and add to the risk of a fatal outcome.

You can see where this is going. First responders, police, medical professionals, family, friends need to ask the tough questions – perform the assessment and have a safety plan ready to implement to get the potential victim out of immediate danger. Hence, the need for Snyder’s important book and its hard-hitting writing and reporting to be better known at all levels of the community.

Snyder reports on a second important innovation in the struggle against DV: the Fatality Review Board (FRB) for DV Homicide. Air travel has become significantly safer thanks to the Federal Aviation Administration commitment to investigate independently every airplane crash. The idea is to find out what sequence of things went wrong without finger pointing. No blame, no shame. The idea is to perform an evidence-based assessment of all aspects of the system – human, administrative, mechanical, procedural.

In a breakdown big enough to cause loss of life, multiple errors, anomalies, and exceptions are likely to have occurred in the system. Rarely is there is single cause of a disaster big enough to cause loss of life. “If systems were more efficient, people less siloed in their offices and tasks, maybe we could reduce the intimate partner homicide rate in the same way the NTSB [National Transportation Safety Board] had made aviation so much safer” (p. 85). The Fatality Review Board is born.

For example, the authorities knew the perpetrator. They had visited the home multiple times. The abuser was released from detention without notifying the potential victim. An order of protection was denied due to a paperwork error, or, if granted, the police could not read the raggedy document that the woman was required to have on her person at all times. The prosecutor was unaware of a parallel complaint by the victim’s mother because it was filed in the same docket and dismissed when the victim recanted in the hope of placating the abuser and saving her own life.

For example, multiple touch points occur at which victims and perpetrators interact with social services, healthcare facilities, community organizations, the veteran’s administration, law enforcement, and the clergy. The FRB is tasked with determining how the fatal outcome could have been avoided.

Chase down all the accidental judgments, missed cues, and blind spots. Talk to everyone able to talk. Gather all the data. Someone knew something, had actionable information that was not acted upon. Formulate recommendations to avoid repeating the mistakes.

That means building formal lines of permissioned communication between administrative siloes. For example, there as a restraining order against the abuser but it was in another state and the local authorities did not know about it.

In the age of the Internet there needs to be a central clearing database that preserves such data. Or, for instance, the shooter had no criminal record, but the victim had expressed fear for her life to the local pastor at church based on his statements. Who can he (or she) call? Who can intervene with a safety plan?

No one single factor can be singled out as causing the fatality; instead a series of relatively small mistakes, missed opportunities, and failed communications. The FRB looks for points where system actors could have intervened and didn’t or could have intervened differently (p. 86). Today more than forty states now have fatality review teams. Though the violence continues, this is progress.

Snyder makes an important contribution in clarifying why the victim does not run leave the abuser and the abusive relationship. Why does she return to the abuser, or recant her testimony in the police report, frustrating the attempt of the prosecution to get a conviction?

Though every situation is unique, Snyder builds a compelling narrative that often the victim is trying to save her own life. The system works much slower than a determined abuser, and the victim knows it. In short, the abuser knows how to work the system; and all-too-often the victim cannot rely on the system to protect her when she most needs protection. In addition, her judgment may be impaired due to being called every name in the book and slapped, punched, or strangled.  

As the abuser senses he is losing power and the victim is getting ready to leave, the risk of violence to regain control escalates. The abuser is strangling her, escalating to deadly violence, and yet he is charged with a misdemeanor. He will be out on $500 bail in 24 hours – buying a gun and gasoline to burn down the house after killing her and the children. In fear for her life, the victim is makes up a story about love to try to placate the abuser – she is recanting to try to buy time – while she accumulates enough cash or school credits to escape and have a life. The victim recants her narrative in the police report and says she loves him because she wants to live.

A third major strong point of Snyder’s work is her report on interventions available for abusers. Incarcerating an abuser to protect the community is necessary. But that does not mean the abuser does not need treatment. He does. Absent treatment, jail just makes the abuser worse. The entire middle section of the book is devoted to the dynamics of perpetrator treatment.

At another level I found Snyder’s deep insight to be an extension of Simone de Beauvoir’s assertion circa 1959 that woman is not a mere womb. The enlightened man adds to de Beauvoir’s statement (which is notquoted by Snyder): man is not mere testosterone. In both cases, biology is important, but biology is not destiny. I repeat: biology is not destiny. Some men have not been properly socialized and need to get in touch with and transform their inner uncivilized cave man.

The recovery programs in jails on which Snyder reports sound rather like “boot camp” to me. The emphasis is on “tough love.” This is a function of the close association, if not identification, of masculinity with violence.

 In some communities, violence is how masculinity gets expressed. This extends from “big boys don’t cry” and if he hits you, hit him back all the way to a misogynistic gangster mentality that uses devaluing language to describe woman as basically existing for the sadistic sexual satisfaction of men. It may also be common (and justified!?) in a military context. As near as I can figure – and this is an oversimplification – the treatment groups are given lessons in cognitive or dialectical behavioral therapy: skills in emotional regulation, distress tolerance, self-soothing, and interpersonal negotiations.   

For those perpetrators, not incarcerated or suffering from post traumatic stress disorder (along with their victims), but rather brought up in relative privilege or affluence, Snyder has less to say. While the poverty, crime, and substance abuse of the inner city can intensify DV, DV is an equal opportunity plague, occurring in affluent neighborhoods too. Only here we are dealing with “snakes in suits” – think: Harvey Weinstein or Bill Crosby (“date rape” drugs) [granted, these individuals were sexual predators, not necessarily DV perpetrators]; perpetrators who are quite sophisticated in using the system to isolate and disempower their victims financially, legally, emotionally as well as physically (violently). This is an incompleteness rather than a flaw in an otherwise compressive study. Another chapter – or book – may usefully be written about DV scenarios among the rich and famous – or at least affluent. DV lives there too.

On a personal note, when I started reading this book, I knew it was not for the faint of heart. I said to myself: “Ouch! This is like the ‘ketchup scene’ in Shakespeare’s Hamlet.” At the end of Hamlet, the entire family gets killed. To deal with something as disturbing (and hope inspiring) as Snyder’s book, I had to go to Shakespeare.  

Indeed Hamlet begins with domestic violence. Hamlet’s uncle kills his own brother, Hamlet’s father, to seize the throne by marrying Hamlet’s mother. The latter is not technically DV, but a boundary violation. (This is the original Game of Thrones if there ever was one.) In turn, Hamlet perpetuates verbal and emotional abuse, whether fake insanity or genuine narcissistic rage, against his fiancé, Ophelia. Hurt people, hurt people. Sensitive soul that Ophelia is, she commits suicide. Ophelia’s brother then seeks revenge. Hamlet kills her brother as the brother simultaneously kills Hamlet with a rapier tipped with a deadly poison. The mother drinks the poisoned goblet, intended for Hamlet, and the uncle is run through by Hamlet – also with the poisoned rapier.  The point? 

Horatio’s provides a summary at the backend of Hamletwhich also forms a review of Snyder’s work: “So shall you hear – Of carnal, bloody, and unnatural acts – Of accidental judgments, casual slaughters, – Of deaths put on by cunning and forced cause, – And, in this upshot, purposes mistook, – Fall’n on the inventor’s heads. All this can I truly deliver.” Just so.

All too often the events seemed to me to unfold like a Greek tragedy – or in this case a Shakespearian one. You already know the outcome. The suspense is enormous. You want to jump up on the stage and shout, “Don’t open the door – therein lies perdition!” But everything the actors do to try to avoid the tragic outcome seems to advance the action step-by-step in the direction of its fulfillment.

Snyder provides a compelling narrative – and actionable interventions – of how to interrupt the seeming inevitability and create the possibility of survival and even, dare one hope, flourishing.

 

Further Reading

Wilson, K. J. (1996 [2006]). When Violence Begins at Home: A Comprehensive Guide to Understanding and Ending Domestic Abuse, 2ndEdition. Alameda, CA: Hunter House (Publishers Group West).

Websdale, Neil. (1999). Understanding Domestic Homicide. Northeastern University Press.

Campbell, Jacquelyn et al. (2003). “Risk Factors for Femicide in Abusive Relationships: Results from a Multisite Case Control Study. American Journal of Public Health93, no. 7 (July 2003).

Agosta, Lou. (2012). A Rumor of Empathy at Apna Ghar, the Videohttps://tinyurl.com/y4yolree [on camera interview with Serena Low, former executive director of Apna Ghar about the struggle against DV]

Agosta, Lou. (2015). Chapter Four: Treatment of Domestic Violence inA Rumor of Empathy: Resistance, Narrative and Recovery in Psychoanalysis and Psychotherapy. London: Routledge.

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

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.

 REFERENCES

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

Three books on empathy reviewed: The good, the bad, and the ugly

The first empathy book reviewed here is very good indeed. William Miller’s Listening Well: The Art of Empathic Understanding  (Wipf and Stock, 114pp, ListeningWellEmpathicUnderstandingCoverArt($18US)) is a short book. Admirably concise. My short review is that, as I am author of three academic and one “how to” book(s) on empathy, this is the book that I wish I had written.

Listening Well contains the distilled wisdom of Miller’s several decades of practicing listening as the royal road to expanding empathy. Listening Well is a “how to” book, but the author is adamant that such a skill lives and flourishes in the context of a commitment to being empathic. (I hasten to add that, though Miller’s is the book I wish I had written, my own publications on empathy are significant contributions, and I shamelessly urge the reader to get them on the short list, too.)

Being with the other person without judgments, labels, categories, diagnoses, evaluations, and so on, is what empathy is about most authentically. It is not that such assessments do not occur. They do, but they almost always get in the way. Listening Well is way too short to be a textbook, but I can see it as being useful in a workshop, seminar, or as exercises in a class.

In case you are unaware of William Miller’s background, he is the innovator behind Motivational Interviewing. Listening well – the practice, not just the title of the book – is at the heart of this approach. In turn, the practice of listening well is based on empathic understanding. Miller is explicit in invoking the work of Carl Rogers (1902 – 1987) Rogers was one of the founders of humanistic psychology, and Rogers’s person-centered psychotherapy provides the foundation for this results-oriented intervention.

Cris Beam is a would-be “bad girl,” who has written a very good book. In a world of constrained, limited empathy, the empathic person is a non-conformist. Beam is one of those, too, and succeeds in sustaining a nuanced skepticism about the alternatingIFeelYouCoverArt hype and over-valuation of empathy over against those who summarily dismiss it. Most ambivalently, she calls out the corporate infatuation with empathy. I paraphrase the corporate approach: Take a walk in the other person’s shoes in order to sell them another pair.

In Beam’s book I Feel You: The Surprising Power of Extreme Empathy (Houghton Mifflin, 251 pp. ($26 US$)), Cris Beam makes empathy present. She brings forth empathy her engagement with difficult cases that challenge our empathy, including her own conflicts. In the process of struggling with, against, and for empathy, she succeeds in bringing forth empathy and making empathy present for the reader. From an empathic point of view, I can think of no higher praise.

It gets personal. Beam reports that she is a survivor of a floridly psychotic mother and a father who, at least temporarily (and probably to save himself), abandoned Cris to her fate with that woman. As a teenager, Beam escapes to her father and his second marriage only to be rejected when she “comes out” as a lesbian some years later. Fast forward to Beam’s own second marriage [both to women].

Beam’s partner announces that the partner (at that time a “she”) is committed to transitioning to becoming a man. Beam decides to support her (becoming him) and sticks with it through the top surgery, administering the testosterone shots. The partner tells Beam: “I will love you always [regardless of my gender].” Beam decides to believe the partner. (See what I mean? You can’t make this stuff up.)

 Nor is this a softball review, and I decisively disagree with Beam when she says that empathy is “mutual vulnerability” and approvingly quotes André Keet: “there are no neat boundaries between victim, perpetrators, beneficiaries, and bystanders …” (p. 191). While such a statement is descriptively accurate, once the father walks, leaving the psychotic mother and child behind, the commitment of empathy is to respect boundaries and (re)establish them when the boundaries have broken down or been violated.

Empathy is all about boundaries, and Beam, like so many of us, has her share of struggles with them. No easy answers here. But one final thought as my personal response to Beam’s thought provoking and inspiring work on empathy. We may usefully consider the poet Robert Frost: “Good fences make good neighbors.” I add: There is a gate in the fence, and over the gate is written the word “Empathy.”

The third empathy book, The Routledge Handbook of the Philosophy of Empathy (Routledge, 410pp, $245 US$), has a truly ugly hardcover price of $151 even after the Amazon discount as publishers continue to respond to economic pressures by

Cover Art: The Routledge Handbook of the Philosophy of Empathy

Cover Art: The Routledge Handbook of the Philosophy of Empathy

squeezing the life out of traditional print books that one can hold in one’s hand. The recommendation? Have the library order a copy (the paperback is $54.95, a better price, but nothing to write home about).

I have read, reviewed, and sometimes struggled, not only with the tangled history of empathy from David Hume to mindreading to mirror neurons, but with all thirty-three articles as a would-be empathic contribution for those who come after me. In many cases, I resonated empathically with the article. Bringing a rigorous and critical empathy to the article based on my life and experiences, sometimes the article “clicked,” i.e., worked for me. In other cases, I had to activate “top down” empathy, trying to create a context for a conversation, in which all I can otherwise see is an effort to maximize the number of stipulations that can be made to dance on the head of a pin—the pin being “empathy” (seems like about two dozen).

In every case, I try to be charitable; but in some cases the “empathy meter” goes in the direction of “tough love.” In one or two cases, I acknowledge my empathy breaks down completely in the face of academic over-intellectualization—an obvious occupational hazard in philosophy, but one that needs to be firmly contained in an engagement with a critical and rigorous empathy—and I simply recommend hitting the delete button—or a rewrite from scratch.

A “Handbook” promises to be a comprehensive engagement with the issues. So it is with deep regret, that I call out the fundamental incompletenesses. Nothing on education. Philosophers are not educators? Socrates was not a teacher? Mary Gordon’s program The Roots of Empathy (also the name of her book) includes bringing a baby into the grammar school classroom. Too developmental? Too psychological? The Philosophical Baby (Gopnik et al 2009)?

Also missing is the alternative point of view. The neurohype around mirror neurons is well represented; but what about the alternative point of view that such an entity as a mirror neuron does not even exist in humans and that the neurological infrastructure has a different configuration.[1]

The evolutionary context of empathy is considered; but missed are the role of the human mother-child matrix in the development of affective empathy, the empathizing effect of female sexual selection on male aggression, and the development of perspective taking in group selection in empathy as a “cheater detection system” and “empathic cruelty.” Empathy and morals are well represented; but little about social justice, overcoming prejudice, building bridges between disparate individuals and communities, or the tough related issues.

I am just getting warmed up here. Other incompletenesses are more fundamental—methodological. Empathy is not just the object of the inquiry, but it also needs to be the subject of the inquiry. We get our humanity from the other individual—and the other’s artistic expressions and social contributions.

This is subtle; so let me give an example. Expand your empathy: go to the art museum. Deepen your empathy: attend the symphony. Broaden your empathy: study a foreign culture or indigenous community. Stretch your empathy: read literary fiction. The engagement with aesthetics expands, trains, and develops our empathy; likewise, with the engagement with the other person. How does that work? The contributors seem not to have considered the possibility.

Instead empathy is on the defensive in too many places in the Handbook under review. Empathy is not represented as something of value that needs no apology and is worthy—along with (say) compassion and motherhood—of active promotion and expansion as a benefit to the community. Strangely enough, the breakdowns, failures, and misfirings of empathy—emotional contagion, conformity, projection, and communications lost in translation—are mistaken for empathy itself as if empathy could not misfire or go astray.

Nevertheless, bright spots appear. As Shoemaker points out in his article, the solution to a so-called parochial empathy that is limited to the “in group” is empathy itself – expanded empathy. Expand the boundaries of the community to be inclusive of those previously excluded. No doubt, easier said than done, but that is not a limitation of empathy itself, but of our need for expanded training and practice of empathy.  

The battle is joined. Dan Zahavi, an otherwise impeccable and astute phenomenologist, enters into apologetic worrying about the conundrum: Can we really ever appreciate, understand, empathize with another person’s experience without having had a similar experience [or words to that effect]? Zahavi makes good use of Max Scheler to show that we can. With the exception of Jenefer Robinson (on “Empathy in music”), what is not called out (or even hinted at) is that the encounter with the other person, art, music, and literature enhances and expands our empathy.

 In a world of limited empathy, the empathic person is a nonconformist. I wish I could write this Handbook is overflowing with nonconformists. Happily there are some and they produce several excellent articles—Zahavi, Gallagher, Ickes, Denham, Debes, Hollan, and John (Eileen); but it is otherwise filled with over-intellectualization, stipulations, neurohype, inaccurate phenomenological descriptions (mostly by the neuro-philosophers, not the phenomenologists), and tortured conceptual distinctions lacking in empathy. Seven out of thirty-three is a modest harvest.

One expects a Handbook on empathy would make empathy present for the reader. In the long, dreary march through 397 pages, thirty-three articles, I thirsted for it. Eileen John comes closest to doing so, and she is able to marshal the resources of empathy in the context of literature to help her get over what is admittedly a high bar. The scandal of this Handbook is that amid so many conceptual distinctions relating to empathy, empathy itself—empathy as a presence in the encounter with the reader—goes missing except in this one out of thirty-three articles.

What I am saying is that, with a few exceptions, largely concentrated in the contributions of Heidi Maibom and issues with her editing, there is nothing wrong with this Handbook; but there are so many things missing it is hard to know where to start with them. The practice of empathy is the source out of which emerge the ten thousand empathic distinctions in this Handbook. Key term: practice. Thinking and writing informed by the practice of empathy is the ultimate missing link.

Reviewing each of the thirty-three articles in the Handbook requires a book length treatment in itself. Therefore, I have provided one entitled A Critical Review of a Philosophy of Empathy (Two Pairs Press, 162pp. $10US (Amazon)), in which extensive background on the issues is also engaged. In short, this is a book about the book, and is the complete book review. Each of the articles is reviewed in detail with a seven separate and substantial sections orienting the reader to the issues, pro and con, engaged under core problems, history, understanding (mindreading), morals, aesthetics, and cultural issues, all relating to empathy. The recommendation? Check out the review, priced to cover printing plus a latte and biscotti for the reviewer, prior to engaging with the Handbook. You may get 80% of the value in the review; and you will not be bored.

[1]For example, see Gregory Hickok. (2014). The Myth of Mirror Neurons. New York: W. W. Norton. For further debunking of the neurohype see Decety et al. 2013, Vul et al. 2009, and Satel and Lilienfeld 2013.

REFERENCES

Complete, expanded Review of William Miller’s Listening Well: The Art of Empathic Understanding: Review-of-William-Miller-Listening-Well

Complete, expanded Review of Cris Beam’s I Feel You: The Surprising Power of Extreme EmpathyReview-of-Cris-Beam-I-Feel-You-Extreme-Empathy

Completed, expanded Review of Lou Agosta’s A Critical Review of a Philosophy of EmpathyAbout-Lou-Agosta-A Critical-Review-of-a-Philosophy-of-Empathy

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

Poverty is bad for your health: Review of Ansell’s The Death Gap: How Inequality Kills

Poverty is bad for your health.  Inequality causes poverty. In turn, poverty causes illness and death. Therefore, inequality kills. The evidence is extensive. The data is compelling. The logic is impeccable. But is this not just correlation, not causation?

A causal account comes into view. When the evidence is vast and deep enough, we can

The Death Gap: How Inequality Kills

The Death Gap: How Inequality Kills

connect the dots between the correlated items – in this case, poverty, inequality, and bad healthcare outcomes (i.e., death) – and provide a causal account.

While it remains true that correlation is not causation, a flood of evidence is available – and overwhelming: The high correlation between poverty and ill health points to numerous causes intimately related to low socioeconomic standing, being poor.  For example, poverty is stressful. Extremely stressful: “People who are exposed to constant high levels of stress do have biological reactions that can shorten their lives [….] [E]xposure to chronic environmental stress causes biological changes within the body that predispose individuals to develop premature disease” (pp. 66 – 67).

For instance, a person at risk for Type II Diabetes benefits from regular exercise and a balanced, healthy diet, high in protein, fruits, vegetables, and low in “bad fat.” Living in a high crime zip code likely also means they live in a “food desert.” Not only is there no Whole Foods or other high-end grocer available but “convenience stores” are long on junk foods and short on fruits and vegetables. When someone gets hungry, unhealthy calories are a likely outcome – nothing wrong with a Twinkie once in a while, but there is a reason the term “junk food” was invented. The person cannot go out for a vigorous, healthy walk because that results assault by local criminals. This is not a problem that can be fixed by the good advice of a medical doctor in an office visit, beneficial though that advice may be. It requires social change and a confrontation with values that privilege profit and cost reduction over people and their well-being.

This leads the author, David Ansell, MD, to a key distinction, which is itself controversial and unavoidable: structural violence. “It is the cumulative impact of laws and social and economic policies and practices that render some Americans less able to access resources and opportunities than others. This inequality of advantage is not a result of the individual’s personal abilities but is built into the systems that govern society” (p. 8).

Ansell gives a powerful example of one of his patient’s, Windora, who eventually suffers but survives a life-changing stroke that costs her the ability to speak. Ansell becomes her voice in this work.

Windora has a “good job” in the school system but not one that pays enough for her to move out of her impoverished zip code. She has hypertension and would benefit from a vigorous walk everyday, but she can’t go out because the neighbor is unsafe. Joining a gym is too expensive, and there is no YMCA within miles. She would benefit from a healthy diet of fruits and vegetables, but she lives in a food desert with a lot of convenience stores selling junk foods. A double bind? Blame the victim? After a certain point, no amount of personal initiative can overcome the obstacles. But a rental voucher might help.

Part of the “back story” for creating areas of overwhelming poverty, educational disadvantage, and social stress were “racially restricted covenants” in real estate. Even after the US Supreme Court outlawed such real estate deeds in 1947, billions of dollars continued to be spent in building public housing in or near impoverished areas. This virtually guaranteed segregated housing, resulting in de facto segregation in schools, and the resulting loss of upwardly mobile educational opportunities for (mostly) black or underprivileged children. The cycle continues. The examples of stable integrated neighborhoods such as Oak Park or stable black communities such as Chatham were overwhelmed by the unethical, fear inspiring but profitable practices of “block busting,” based on distorted, negative racial stereotypes. (For details on the back-story here see Polikoff’s Waiting for Gautreaux: A Story of Segregation, Housing, and the Black Ghetto (2).)

The media share responsibility for perpetuating stereotypes. In the wake of Hurricane Katrina, white people wading through chest high water, carrying groceries from abandoned food stores are described as survivors “finding” the food they needed in order not to starve whereas people of color doing exactly the same thing with the same bags in the same chest high flood waters are described as “looters” (p. 87). Hmmm.

In addition to structural violence, there is actual violence. Ansell writes: “Between 2007 and 2012, Chicago police shot over four hundred people. There were seventy police fatalities during that period, the most in the nation. Between 2004 and 2014, the cash-strapped city dished out $662 million in police brutality settlements” (p. 164).

Ansell imagines all the good things that could be done with that money for school and health-care. I would add to the list: expanded police training. I do not mean target practice or armored cars. I mean training in conflict de-escalation, community relations, courtesy and conversation. Just because deadly force can be used, does not mean it must be used. Empathy is distinct from compassion (though the world needs more of each). Empathy is a method of data sampling, telling a person what the other person is experiencing. In a police context, this would include whether the other is afraid or angry and, most importantly, is at risk of escalating to an aggressive response. No guarantees, but the widows and orphans of fallen heroes are looking for alternatives to shoot first and ask questions later (my phrase, not Ansell’s).

Meanwhile, Dr Ansell’s recommendation to fellow doctors? A bold statement of the obvious: Follow the Hippocratic oath (Ansell cites the modern version called “the Declaration of Geneva, Physicians Oath”). This action may be more confronting and difficult than most physicians imagine. The language about “consecrating one’s life to the service of humanity” and the first consideration being the health of one’s patients is the critical path. This extends beyond the walls of the office or hospital to personal advocacy.

For example, Ansell cites Paul Farmer reporting that when patients living in poverty took their tuberculosis medication, they got better, but they also got very hungry. The TB actually eliminated their hunger. They were too sick to feel hungry – a well disguised “blessing” indeed – so they stopped taking the medication because they were overwhelmed with hunger. The solution was not to call the patient’s “stupid” for not complying with their doctor’s orders. Once food was delivered with the medications, the patients became adherent with the treatment regime. Is the doctor then responsible to feed the hungry? Well, he who wills the end (health) wills the indispensably necessary means to the end (food + TB medicine). 

Ansell makes a powerful case that any doctor refusing to treat a patient who presents with symptoms is violating the Hippocratic oath. Health care is an inalienable human right, along side life, liberty, and the pursuit of happiness (except that it has been alienated to enable monopoly rents to insurance companies, Big Pharma, and the corporate transformation of American medicine). “Health care” is a component of the “life” part of the enumeration of rights with which the Declaration begins.

However, the point is not to force an outcome. No one can force anyone to do something that they do not want to do. (For detailed background on the role of profit in the bio-psychiatry of major mental disorders and “Big Pharma” (a once devaluing term that is now accepted), a vexing trend that Ansell does not engage, see Robert Whitaker (3).)

The point is not to force doctors to make excuses for not treating the poor, which risks impacting the doctors’ livelihood and revenue model. The point is advocacy: to mobilize doctors to take on a system that treats health care as an economic transaction. The point is to mobilize doctors to push back against a system that rations scare resources such that the system, in spite of complex algorithms to determine fairness (see The National Organ Transplant Act (1984)), frequently results in the transplants being allocated to middle-aged white males. It is a disturbing statistic that the poor and people of color are frequently the organ donors while rarely being the recipient of life-saving transplants. Once again, there is something very wrong with this picture.

I hasten to add that Ansell reports a compelling example of community activism resulting in Illinois enacting legislation allowing the undocumented to receive kidney transplants and lifetime medications with State financial support “in part because we listened and tried to help” (pp. 107, 108). 

Now I have read Ansell’s book cover-to-cover, including the extensive footnotes as well as the back cover. The one, flat out error I have found is on the back cover. Contra to the back cover, nowhere does Dr Ansell write “Inequality is a disease” or that it must be treated as a disease.

Ansell does indeed argue at length that inequality causes poverty and that poverty and inequality (and a host of related social injustices) set off a sequence of events that, like the falling dominoes, create a death gap, causing poor people, especially people of color, to die prematurely. For example, carbon monoxide can kill you, too, but carbon monoxide is not a disease (my example, not Ansell’s). It is a substance that the human beings cannot process. It is inimical to life. An environment of poverty is like carbon monoxide for the human body and soul. It chokes the life out of the person, albeit slowly, preventing binding with life-giving resources that the person needs to survive and flourish.

As noted, neither poverty, starvation, arsenic, lead, nor similar phenomena are diseases. Structural violence is not a disease; it creates a negative clearing for disease in the context of social injustice.

Contra the back cover, Ansell’s point is precisely that no medical treatment in itself will cure poverty, prevent the resulting fatalities, or undo the death gap. Reducing and eliminating the death gap requires advocacy: structural reforms and political engagement to combat structural violence. It requires honoring one’s commitment to social justice in the community. It requires a redistribution of sometimes scare resources – health care, education, jobs, law enforcement – from the wealthiest and most privileged on the Gold Coast a couple of miles west and south to neighbor whose numbers read like they were from the third world. It seems the editors of the back cover were blinded by privilege, too.   

Ansell has recommendations. Practical proposals are forthcoming: “[Concentrated reinvestment in impoverished communities] will require a redistribution of wealth through taxation from the affluent back to the poor in the form of living wages, access to higher education, health care, and safe housing” (p. 54). “These structural reforms could take many forms, from tax and job policy to the ending of mass incarceration. From the perspective of health reform, the adoption of a single-payer health care system is the only way to create equity in health care. Single-payer health care will be vigorously opposed by the profit-driven private health insurers and by those who will insist it is too costly or not feasible” (p. 182). Speaking personally, I am at a loss as to why certain politicians and parties seem unwilling for people to get health insurance and health care at a cost that also enables them to pay rent, eat, and so on.

One final thought. Today evidence-based medicine is the dominant paradigm and with good reason. Evidence is superior to guess work. In peer-reviewed article after article we can read about a 3% improvement of one pharmacological, procedure, or laparoscopic intervention versus another. Well and good. Empathy and compassion are in short supply in the world, and, in any case, are not enough. Leadership is also required, and Ansell provides that here.

If this book, Ansell’s work, dense with evidence, data, facts and figures that support the subtitle (“Inequality Kills”), does not become the conscience of the medical community and a blue print for transformation and reform, then not only am I a monkey’s uncle, but the collective blind spot of the medical community is the size of the dark side of the moon.

We end where Ansell ‘s book begins. Ansell’s opening quote from Martin Luther King is as true today as it was in 1964: “History will have to record that the great tragedy of this period of social transition was not the strident clamor of the bad people, but the appalling silence of the good people” (p. vii). This book is addressed to the good people. Drop what you are doing and get the book: read it, honor your commitments, follow the recommendations.

References

(1) David A. Ansell, MD, (2017), The Death Gap: How Inequality Kills. Chicago: The University of Chicago Press.

(2) Alexander Polikoff, (2006), Waiting for Gautreaux: A Story of Segregation, Housing, and the Black Ghetto. Evanston, IL: Northwestern University Press.

(3) Robert Whitaker, (2010), Anatomy of an Epidemic. New York: Broadway Paperbacks (Random House).

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