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Empathy is good for your health and well-being (The evidence)

Empathy is good for your health and well-being: Empathy is on a short list of stress reduction practices including meditation (mindfulness), Tai Chi, and Yoga. Receiving empathy in the form of a gracious and generous listening is like getting a spa treatment for the soul. But do not settle for metaphors.

For evidence-based research on empathy, empathy and stress reduction, and empathy training you may start by googling: Antoni et al. 2011; Ciaramicoli 2016; Del Canale et al 2012; Farrow et al. 2007; Irwin et al. 2012; Maes 1995, 1999; Pollack et al. 2002; Rakel et al. 2009; Segerstrom and Miller 2004; Slavich et al. 2013 [this list is not complete]. 

You do not have to buy the book, Empathy Lessons, to get the research, but if you would like more detail see especially Chapters Four and Six in Empathy Lessons (click here to get book from Amazon).

[Also included are chapters on the Top 30 Tips and Techniques for Expanding Empathy, Overcoming Resistance to Empathy, Empathy Breakdowns, Empathy as the New Love, Empathy versus Bullying, and more.] 

The healing powers of stress reduction are formidable. Expanding empathy reduces stress; and reducing stress expands empathy. A positive feedback loop is enacted. Expanding empathy expands well-being.  Here empathy is both the end and the means.

A substantial body of evidence-based science indicates that empathy is good for a person’s health. This is not “breaking news” and was not just published yesterday. We don’t need more data, we need to start applying it: we need expanded empathy.

Evidence-based research demonstrates the correlation between health care providers who deliver empathy to their patients and favorable healthcare

Well-being rides the wave of empathy

outcomes. What is especially interesting is that some of these evidence-based studies specifically exclude psychiatric disorders and include mainline medical outcomes such as reduced cholesterol, improved type 2 diabetes, and improvement in related “life style” disorders.

Generalizing on this research, a small set of practices such as receiving empathy, meditation (mindfulness), yogic meditation, and Tai Chi, promote well-being by reducing inflammation. These practices are not reducible to empathy (or vice versa), but they all share a common factor: reduced inflammation. These anti-inflammatory interventions have been shown to make a difference in controlled experiments, evidence-based research, and peer-reviewed publications.

Using empathy in relating to people is a lot like using a parachute if you jump out of an airplane or getting a shot of penicillin if one has a bacterial infection. The evidence is overwhelming that such a practice is appropriate and useful in the vast majority of cases. The accumulated mass of decades of experience also counts as evidence in a strict sense. Any so-called hidden or confounding variables will be “washed out” by the massive amount of evidence that parachutes and penicillin produce the desired main effect. 

Indeed it would be unethical to perform a double blind test of penicillin at this time, since if a person needed the drug and it were available it would be unethical not to give it to him. Yes, there are a few exceptions – some people are allergic to penicillin. But by far and in large, if you do not begin with empathy in relating to other people, you are headed for trouble.

Empathy is at the top of my list of stress reduction methods, but is not the only item on it. Empathy alongwith mindfulness (a form of meditation), Yoga, Tai Chi, spending time in a sensory deprivation tank (not otherwise discussed here), and certain naturally occurring steroids, need to be better known as interventions that reduce inflammation and restore homeostatic equilibrium to the body according to evidence based research.

Biology has got us humans in a bind, since the biology did not evolve at the same rate as our human social structures. When bacteria attack the human body, the body’s immune system mounts an inflammatory defense that sends macrophages to the site of the attack and causes “sickness behavior” in the person. The infected person takes to bed, sleeps either too much or too little, has no appetite (or too much appetite), experiences low energy, possibly has a fever, including the “blahs,” body aches, and flu-like symptoms. This response has evolved over millions of years, and is basically healthy as the body conserves its energy and fights off the infection using its natural immune response.

Now fast forward to modern times. This natural response did not envision the stresses of modern life back when we were short stature, proto-humanoids inhabiting the Serengeti Plain and defending ourselves against large predators. Basically, the body responds in the same way to the chronic stressors of modern life—the boss at work is a bully, the mortgage is over-due, the children are acting out, the spouse is having a midlife crisis—and the result is “sickness behavior”—many of the symptoms of which resemble clinical depression—but there is no infection, just inflammation. 

The inflammation becomes chronic and the body loses its sensitivity to naturally occurring anti-inflammatory hormones, which would ordinarily kick in to “down regulate” the inflammation after a few days. Peer reviewed papers demonstrate that interventions such as empathy reduce biological markers of inflammation and restore equilibrium. This is also a metaphor. When an angry—“inflamed”—person is listened to empathically—is given a “good listening” as I like to say—the person frequently calms down and regains his equilibrium. 

Empathy migrates onto the short list of inflammation reducing interventions. The compelling conclusion is that empathy is good for your well-being.

Bibliography, References, and Additional Reading

Adams, Tristam Vivian. (2016). The Psychopath Factory: How Capitalism Organises Empathy. London: Repeater Books.

Agosta, Lou. (1976). Intersecting languages in psychoanalysis and philosophy, International Journal of Psychoanalytic Psychotherapy, Vol. 5, 1976: 507–534.

____________. (1977). Empathy and Interpretation. Ph.D. Dissertation. Philosophy Department. University of Chicago. 

____________. (1980). The recovery of feelings in a folktale, Journal of Religion and Health, Vol. 19, No. 4, Winter 1980: 287–297.

____________. (1984). Empathy and intersubjectivity in Empathy I, ed. J. Lichtenberg et al. Hillsdale, NJ: Lawrence Erlbaum Press.

____________. (2010). Empathy in the Context of Philosophy. London: PalgraveMacmillan.

_____________. (2011). Empathy and sympathy in ethics, The Internet Encyclopedia of Philosophy, a peer reviewed online resource: www.iep.utm.edu/emp-symp/[checked 01/19/2018].

_____________. (2013). A rumor of empathy in psychology (the movie): http://empathyinthe contextofphilosophy.com/2013/04/28/a-rumor-of-empathy-in-psychology/ [checked 2018-01-20 (caution: an extract space may be inserted due to line break(s))].

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

____________. (2014a). A delicacy of empathy: The many meanings of ‘sympathy’ in Hume, Psicologia em Pesquisa, 8 (1): 3–14. DOI10.5327/Z1982-12472014000 10002. 

_____________. (2014b). A rumor of empathy: Reconstructing Heidegger’s contribution to empathy and empathic clinical practice, Medicine, Healthcare, and Philosophy, 17 (2): 281–292. DOI: 10.1007/s11019-013-9506-0.

______________. (2015). A Rumor of Empathy: Resistance, Narrative, Recovery in Psychoanalysis and Psychotherapy. London: Routledge.

____________ . (2016). Radio Empathy: Empathy: What It Is and Why It Is Important With David Howe: https://youtu.be/nUefHF2dt_Y [checked on 11/11/2017].

Angera, J. and E. Long. (2006). Qualitative and quantitative evaluations of an empathy training program for couples in marriage and romantic relationship. Journal of Couple & Relationship Therapy, 5(1): 1–26.

Antoni, M. H., Lutgendorf, S. K., Blomberg, B. (2011). Cognitive-behavioral stress management reverses anxiety-related leukocyte transcriptional dynamics, Biological Psychiatry, 2011, 15: 366–372. 

Axelrod, David. (2015). Believer: My Forty Years in Politics. New York: Penguin Books.

Babiak, Paul and Robert D. Hare. (2006). Snakes in Suits: When Psychopaths Go To Work. New York: Harper Publishing.

Baron-Cohen, Simon. (1995). Mindblindness: An Essay on Autism and Theory of Mind. Cambridge, MA: MIT Press.

______________________. (2011). The Science of Evil: On Empathy and the Origins of Cruelty. New York: Basic Books (Perseus). 

Basch, Michael Franz. (1983). Empathic understanding: a review of the concept and some theoretical considerations, Journal of the American Psychoanalytic Association, Vol. 31, No. 1: 101–126. 

Batson, C. Daniel. (2012). The empathy-altruism hypothesis: Issues and implications in Jean Decety, ed. (2012). Empathy: From Bench to Bedside. Cambridge, MA: MIT Press: 41–54. 

Battarbee, Katja and Jane Fulton Suri, and Suzanne Gibbs Howard. (2012). Empathy on the edge: Scaling and sustaining a human-centered approach in the evolving practice of design, IDEO: http://fliphtml5.com/gqbv/uknt/basic %5Bchecked on 11/31 /2017].

Bazelon, Emily. (2012). Sticks and Stones: Defeating the Culture of Bullying and Rediscovering the Power of Character and Empathy. New York: Random House.

Black, David S., Steve W. Cole, Michael R. Irwin, Elizabeth Breen, Natalie M. St. Cyr, Nora Nazarian, Dharma S. Khalsa, and Helen Lavretsky. (2013). Yogic meditation reverses NF-kB and IRF-related transcriptome dynamics in leukocytes of family dementia caregivers in a randomized controlled trial, Psychoneuroendocrinology, 2013 March 38(3): 348–355. 

Boyd, Robyn. (2008). Do people only use 10% of their brains? Scientific American, Feb. 8, 2008: https://www.scientificamerican.com/article/do-people-only-use-10-percent-of-their-brains/ [checked on 12/14/2017].

Breggin, Peter R. (1991). Toxic Psychiatry: Why Therapy, Empathy, and Love Must Replace the Drugs, Electroshock, and Biochemical Theories of the ‘New Psychiatry.’ New York: St. Martin’s Press.

Brunero, Scott, Scott Lamont and Melissa Coates. (2010). A Review of empathy education in nursing, Nursing Inquiry: Vol. 17, No.1, March 2010: 65–74. 

Canfield, Jack, Sally Burbank, Terri Elders, and Amy Newmark. (2003). Chicken Soup for the Soul. New York: Soul Publishing (Simon and Shuster).

Carnegie, Dale. (1936). How to Win Friends and Influence People. New York; Simon and Schuster, 1981. 

Carruthers, Peter and Peter K. Smith, eds. (1996). Theories of Theories of Mind. Cambridge: Cambridge University Press

Chiu, Tony, Ming Lam, Klodiana Kolomitro, and Flanny C. Alamparambil. (2011). Empathy training: Methods, evaluation practices, and validity, Journal of MultiDisciplinary Evaluation, Vol. 7, No. 16: 162–200. 

Ciaramicoli, Arthur. (2016). The Stress Solution. Novato, CA: New World Library.

Cohen, Ted. (1999). Jokes: Philosophical Thoughts on Joking Matters. Chicago: University of Chicago Press.

Coke, Jay S., Gregory Batson, and Katherine McDavis. (1978). Empathic mediation of helping: A two-stage model, Journal of Personality and Social Psychology36(7):752–766. DOI: 10.1037/ 0022-3514.36.7.752. 

Davis, Mark H., Laura Conklin, Amy Smith, and Carol Luce. (1996). Effect of perspective taking on the cognitive representation of persons: A merging of self and other, Journal of Personality and Social Psychology, Vol. 70, No. 4, Apr 1996: 713–726.

Darwin, Charles. (1872). The Expression of the Emotions in Man and Animals. Chicago: University of Chicago Press, 1965.

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

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

Decety, Jean, Chenyi Chen, Carla Harenski, and Kent A. Kiehl. (2013). An fMRI study of affective perspective taking in individuals with psychopathy: Imagining another in pain does not evoke empathy, Frontiers in Human Neuroscience, 2013; 7: 489; published online 2013 September 24. DOI: 10.3389/fnhum.2013.00489.

Dennett, Daniel. (1978). Beliefs about beliefs, Behavioral and Brain Sciences, 1, 568–570.

_________________. (1987). The Intentional Stance. Cambridge, MA: MIT Press.

de Waal, Frans B. M. (2009). The Age of Empathy. New York: Harmony Books (Random House).

Del Canale, Louis, V. Maio, X Wang, G Rossi, M. Hojat, and J.S. Gonnella. (2012). The relationship between physician empathy and disease complications: An empirical study of primary care physicians and their diabetic patients in Parma, Italy, Academic Medicine 2012, 87(9):1243–1249.

Dick, Philip K. (1968). Do Androids Dream of Electric Sheep? New York: Ballentine Books, 1981. 

Doyle, Arthur Conan. (1890a). The Resident Patient in Sherlock Holmes: The Complete Novels and Stories: Volume I. New York: Bantam Books, 1986: 578–591.

__________________. (1890b). The Adventure of the Abbey Grange in Sherlock Holmes: The Complete Novels and Stories: Volume I. New York: Bantam Books, 1986: 881–890.

Dreger, Alice. (2016). Galileo’s Middle Finger: Heretics, Activists, and One Scholar’s Search for Social Justice. New York: Penguin Books.

Editors of the Encyclopaedia Britannica. (2013). Henry Havelock Ellis. Britannica On-Line: https://www.britannica.com/biography/Havelock-Ellis [checked on 11/-06/2017].

Ekman, Paul. (1985). Telling Lies: Clues to Deceit in the Marketplace, Politics, and Marriage, New York, W.W. Norton; (2003); (2003).

__________. (2003). Emotions Revealed: Recognizing Faces and Feelings to Improve Communi-cation and Emotional Life, New York: Henry Holt.

___________. (2008). Conversations With HistoryPaul Ekman. YouTube: 

http://- http://www.youtube.com/watch?v=IA8nYZg4VnI %5Bchecked on 12/14/2017].

Ellenberger, Henri. (1970). The Discovery of the Unconscious. New York: Basic Books.

Ellis, Havelock. (1897/1915). Studies in the Psychology of Sex, Vol. II: Sexual Inversion, 3rd ed., Philadelphia, (1st Engl. ed., London, 1897).

Farrow, Tom and P. Woodruff, eds. (2007). Empathy and Mental Illness. Cambridge, UK: Cambridge University Press. 

Forster, Michael N. (2010), After Herder: Philosophy of Language in the German Tradition. Oxford, UK: Oxford University Press.

Frank, Jerome D. and Julia B. Frank. (1961). Persuasion and Healing: A Comparative Study of Psychotherapy. 3rd ed. Baltimore: John Hopkins University Press, 1993. 

Freud, S. The Standard Edition of the Complete Psychological Works of Sigmund Freud, XXIV Volumes. Translated under the guidance of James Strachey. Hereafter abbreviated as SE.

______. (1905). Three Essays on the Theory of Sexuality. SE, Vol. VII: 123–246.

______. (1912). On the universal tendency to debasement in the sphere of love (Contributions to the Psychology of Love II). SE, Vol. XI: 177–190.

______. (1912b). Recommendations to physicians practicing psycho-analysis: The dynamics of transference. SE, Vol. XII: 109–120.

______. (1913a). On beginning the treatment (further recommendations on the technique of psycho-analysis). SE, Vol. XII: 121–144.

______. (1913b). Zur Einleitung der Behandlung, Gesammelte Werke, VIII. London: Imago Press, 1955: 454–478.

Gallese, Vittorio. (2001). The ‘shared manifold’ hypothesis: From mirror neurons to empathy, Journal of Consciousness Studies, Vol. 8, No. 5-7, (2001): 30–50.

________________. (2007). The shared manifold hypothesis: Embodied simulation and its role in empathy and social cognition in Empathy and Mental Illness, eds. T. Farrow and P. Woodruff. UK, Cambridge University Press.

Gallese, Vittorio and Valentina Cuccio. (2015). The paradigmatic body: Embodied simulation, intersubjectivity, the bodily self, and language in Open MIND 14(T), T. Metzinger and J. M. Windt, eds. MIND Group. Frankfurt am Main: DOI: 10.15502/9783958570269. 

Garbarino, James and Ellen deLara. (2002). And Words Can Hurt Forever: How to Protect Adolescents from Bullying, Harassment, and Emotional Violence. New York: the Free Press (Simon and Shuster).

Gentry, William. (2016). Rewards multiply with workplace empathy, Businessolver: http://www.washingtonpost.com/sf/brand-connect/businessolver/rewards-multiply-with-workplace-empathy/%5Bchecked 12/14/2017 ].

Gentry, William and Todd J. Weber, Golnaz Sadri. (2007). Empathy in the workplace: A tool for effective leadership, Washingtonpost.com: http:// http://www.ccl.org/wpcontent/uploads/ 2015/04/EmpathyInTheWorkplace.pdf [checked on 03/31/2017].

Gladwell, Malcolm. (2008). Outliers. New York: Little Brown.

Golan, Ofer and Simon Baron-Cohen. (2006). Systemizing empathy: Teaching adults with Asperger syndrome or high-functioning autism to recognize complex emotions using interactive multimedia, Development and Psychopathology 18, 2006: 591–617. DOI: 10.10170S0954579406060305. 

Goldberg, Arnold. (2011). The enduring presence of Heinz Kohut: empathy and its vicissitudes, Journal of the American Psychoanalytic Association, Vol. 59, No. 2: 289–311. 

Gordon, Mary. (2005). The Roots of Empathy: Changing the World Child by Child. New York/Toronto: The Experiment (Thomas Allen Publishers).

Grandin, Temple. (1995). Thinking in Pictures. New York: Viking Press, 2006.

Gregory, Richard. (1968). Visual illusions in Perception: Mechanisms and Models: Readings from Scientific American, eds. Richard Held and Whitman Richards. New York: W.H Freeman: 241–251.

Gropnik, Alison, Andrew Meltzhof, and Patricia Kuhl. (2000) The Scientist in the Crib: What Early Learning Tells Us About the Mind. New York: William Morrow Paperback. 

Hacking, Ian. (1995). Rewriting the Soul: Multiple Personality and the Sciences of Memory. Princeton, NJ: Princeton University Press. 

___________. (1999). The Social Construction of What? Cambridge, MA: Harvard University Press.

Hadwin, J., Simon Baron-Cohen, P. Howlin, and K. Hill. (1997). Does teaching theory of mind have an effect on the ability to develop conversation in children with autism? Journal of Autism and Developmental Disorders, 27: 519–537. DOI:10.1023/A:1025826009731.

Halpern, Jodi. (2001). From Detached Concern to Empathy: Humanizing Medical Practice. Oxford: Oxford University Press.

Harcourt, Bernard E. (2015). Exposed: Desire and Disobedience in the Digital Age. Cambridge, MA: Harvard University Press.

Harley, Willard J. (nd). Marriage Buildershttp://marriagebuilders.com/index.html [checked on 11/02/2017]

Harlow, Harry F. (1958). The nature of love, American Psychologist, 13, 673–685.

Hatfield, E., J. Cacioppo, and R. Rapson. (1994). Emotional Contagion. Cambridge: Cambridge University Press.

Heidegger, Martin. (1927). Being and Time, trs. John Macquarrie and Edward Robinson, New York: Harper Row, 1962. [Note: “H” refers to pagination in the original Niemeyer German edition.]

Hickok, Gregory. (2014). The Myth of Mirror Neurons. New York: W.W. Norton. 

Hobson, Peter. (2002). The Cradle of Thought: Exploring the Origins of Thinking. New York: Macmillan. 

____________. (2005). What puts the jointness into joint attention? in Joint Attention: Communication and Other Minds: Issues in Philosophy and Psychology, N. Eilan, C. Hoerl, T. McCormack, and J. Roessler, eds. Oxford: Clarendon Press: 185–204.

Hojat, Mohammadreza, M. J. Vergate, K. Maxwell, G. Brainard, S.K. Herrine, and G. A. Isenberg. (2009). The devil is in the third year: A longitudinal study of erosion of empathy in medical school, Academic Medicine 84 (9): 1182–1191.

____________________, Daniel Z. Louis, Fred W. Markham, Richard Wender, Carol Rabinowitz, and Joseph S. Gonnella. (2011), Physicians empathy and clinical outcomes for diabetic patients, Academic Medicine Mar, 86(3): 359–64. DOI: 10.1097ACM.0b013e3182086fe1

Howe, David. (2012). Empathy: What It Is and Why It Is Important. London: Palgrave.

Howick, Jeremy. (2011). The Philosophy of Evidence-Based Medicine, Wiley-Blackwell, 2011.

Iacoboni, M. (2005). Understanding others: Imitation, language, and empathy in Perspectives on Imitation: From Neuroscience to Social Science, eds. S. Hurly and N. Chater, Vol. 1: 76–100. Cambridge, MA: MIT Press.

_________. (2007). Existential empathy: The intimacy of self and other in Empathy and Mental Illness, eds. Tom Farrow and Peter Woodruff. Cambridge, UK: Cambridge University Press.

Irwin, Michael R. and Richard Olmstead. (2012). Mitigating cellular inflammation in older adults: A randomized controlled trial of Tai Chi Chih, American Journal of Geriatric Psychiatry, 2012 September, 20(9): 764–722.

Isaac, Mike and Scott Shane. (2017). Facebook’s Russia-linked ads came in many disguises, The New York Times, Oct 2, 2017: https://www.nytimes.com/2017/10/02/technology/face book-russia-ads-.html [checked on Oct 15, 2017].

Jackson, Philip L., Andrew N. Meltzoff, and Jean Decety. (2005). How do we perceive the pain of others? A window into the neural processes involved in empathy, Neuroimage 24 (2005): 771–779. 

Kahneman, Daniel. (2011). Thinking, Fast and Slow. New York: Farrar, Straus, and Giroux.

Kantor, Jodi and David Streitfeld. (2015). Inside Amazon: Wrestling big ideas in a bruising workplace: The company is conducting an experiment in how far it can push white-collar workers to get them to achieve its ever-expanding ambitions, The New York Times, August 15, 2015: https://nyti.ms/1TFqcOG [checked on 06/30/2017].

Katz, Jackson.(2013). Violence against women: It’s a men’s issue, YouTubehttp://www.you tube.com/watch?v=KTvSfeCRxe8 [checked 01/23/2016].

Kaufman, David and Mark Milstein. (2013). Clinical Neurology for Psychiatrists, 7th ed. London: Elsevier.

Kohut, Heinz. (1959). Introspection, empathy, and psychoanalysis, The Journal of the American Psychoanalytic Association 7 (July 1959): 459–483.

___________. (1971). The Analysis of the Self. New York: International Universities Press. 1971.

___________. (1972). Thoughts on narcissism and narcissistic rage, Psychoanalytic Study of the Child, 27: 360–400.

___________. (1977). The Restoration of the Self. International Universities Press. 1977.

___________. (1982). Introspection, empathy, and the semi-circle of mental health, International Journal of Psycho-Analysis, 63: 395–407.

___________. (1984). How Does Analysis Cure? Chicago: University of Chicago Press.

Kramer, Peter. (1993). Listening to Prozac: The Landmark Book about Anti- depressants and the Remaking of the Self. Revised edition. New York: Penguin, 1997.

Krumie, Matt. (2016). Ten companies putting empathy into action, Cornerstone On Demand: https://www.cornerstoneondemand.com/rework/10-companies-putting -empathy-action [checked on 07/03/2017].

Krznaric, Roman. (2014). Empathy: Why It Matters, and How to Get It. New York: Perigree Book (Penguin).

Kundera, Milan. (1984). The Unbearable Lightness of Being, tr. Michael Henry Heim. New York: Harper Perennial.

Lear, Jonathan. (2006). Radical Hope: Ethics in the Face of Cultural Devastation. Cambridge, MA: Harvard University Press.

Lerner, Claire and Rebecca Parlakian. (2016). How to help your child develop empathy, Zero to Three: Early Connections Last a Lifetime: https://www.zerotothree- .org/resources/5-how-to-help-your-child-develop-empathy [checked on 06/26/20 17].

Levine, Madeline. (2012). Teach Your Children Well: Why Values and Coping Skills Matter More than Grades, Trophies, or ‘Fat Envelopes’. New York: Harper Perennial.

Maes, M. (1995). Evidence for an immune response in major depression: A review and hypothesis, Progress in Neuro-Psychopharmaclogy and Biological Psychiatry19: 11–38.

_______. (1999). Major depression and activation of the inflammatory response system, Advances in Experimental Medicine and Biology 461: 25–46.

Mann, Thomas. (1902). Buddenbrooks, tr. H.T. Lowe-Porter. New York: Vintage Books, 1961.

_______________. (1912). Der Tod in Venedig in Der Tod in Venedig und Andere Erzaehlungen. Frankfurt am Main: Fischer Bucherei.

______________. (1912a). Death in Venice, tr. Stanley Appelbaum. New York: Dover.

Marcopolos, Harry. (2010). No One Would Listen. New York: Wiley.

Marinoff, Lou. (2000). Plato, Not Prozac! New York: Quill. 

McKee, Annie. (2016). If you can’t empathize with your employees, you’d better learn to, Harvard Business Review, November 16, 2016.

Milgram, Stanley. (1963). Behavioral study of obedience, Journal of Abnormal and Social Psychology. Vol. 67, No. 4: 371–378. DOI:10.1037/h0040525.

Miller, Geoffrey. (2000). The Mating Mind: How Sexual Choice Shaped the Evolution of Human Nature. New York: Anchor Books (Random House). 

Morrison, James. (2014). DSM-5 Made Easy: The Clinician’s Guide to Diagnosis. New York: The Guilford Press.

National Geographic Staff. (2004). The Genographic Project, The National Geographic Societyhttps://genographic.nationalgeographic.com %5Bchecked 06/27/2017]. 

Nelson, Katherine, ed. (1989/2006). Narratives from the Crib. Cambridge, MA: Harvard University Press.

Olden, Christine. (1953). On adult empathy with children, Psychoanalytic Study of the Child, Vol. 8 [annual]: 111–126.

Olweus, Dan. (1973/1993). Bullying in School: What We Know and What We Can Do. London: Wiley/Blackwell.

Ozcan, C. T., F. Oflaz, and B. Bakir. (2012). The effect of a structured empathy course on the students of a medical and a nursing school, International Nursing Review, Vol. 59, Issue 4, December 2012: 532–538. DOI: 10.1111/j.1466-7657.2012.01019.x.

Pace, Thaddeus W.W., Lobsang Tenzin Negi, Daniel D. Adame, Steven P. Cole, Teresa I. Sivilli, Timothy D. Brown, Michael J. Issa, and Charles L. Raison. (2009). Effect of compassion meditation on neuroendocrine, innate immune and behavioral responses to psychosocial stress, Psychoendocrinology, 2009, Jan: 34(1): 87–98.

Kathleen Parker. (2017). Welcome to the year of the groper, The Washington Post, November 17, 2017.

Parmar, Belinda. (2014), The Empathy Era: Woman, Business and the New Pathway to Profit, London: Lady Geek Press.

_________________. (2016). The most empathetic companies: 2016. Harvard Business Review, December 20, 2016: https://hbr.org/2016/12/the-most-and-least-empathetic-companies-2016 [checked on 06/30/2017].

Pavel, Thomas. (1985). Fictional Worlds. Cambridge, MA: Harvard University Press. 

PBS staff reporter. (2013). Using babies to decrease aggression and prevent bullying, PBS News Hour: http://www.pbs.org/newshour/rundown/using-babies-to-decrease-aggress- ion-prevent- bullying/ [checked 12/12/2017].

Pecukonis, E. V. (1990). A cognitive/affective empathy training program as a function of ego development in aggressive adolescent females, Adolescence, 25: 59–76.

Pigman, G.W. (1995). Freud and the history of empathy, International Journal of Psycho-Analysis, 76: 237–256.

Piper, Mary. (1994). Reviving Ophelia: Saving the Selves of Adolescent Girls. New York: Ballentine.

Plato. (no date (nd)).). Apology in Plato: The Collected Dialogues, ed. Edith Hamilton, Princeton: Princeton University Press (Bollingen Series): 3–26.

_____. (nd). Symposium in Plato: The Collected Dialogues, ed. Edith Hamilton, Princeton: Princeton University Press (Bollingen Series): 526–574.

_____. (nd). Theaetetus in Plato: The Collected Dialogues, ed. Edith Hamilton, Princeton: Princeton University Press (Bollingen Series): 845–919.

Prum, Richard O. (2017). The Evolution of Beauty: How Darwin’s Forgotten Theory of Mate Choice Shapes the Animal World – and Us. New York: Doubleday.

Prinz, W. (1990). A common coding approach to perception and action in O. Neuman and W. Prinz, eds., Relationships between Perception and Action: Current Approaches. Berlin: Springer-Verlag: 167–201. 

Pollak, Yehuda and Raz Yirmiya. (2002). Cytokine-induced changes in mood and behaviour: Implications for ‘depression due to a general medical condition’, immunotherapy and antidepressive treatment, International Journal of Neuropsycho- pharmacology, (2002), 5: 389–399. DOI: 10.1017/S1461145702003152.

Rakel, David P., Theresa J. Hoeft, Bruce P. Barrett, Betty A. Chewning, Benjamin M. Craig, and Min Niu. (2009). Practitioner empathy and the duration of the common cold, Family Medicine , Vol. 41(7): 494–501.

Rasmus, Daniel W. with Rob Salkowitz. (2009). Listening to the Future, Hoboken, NJ: John Wiley Press.

Riess, Helen. (2013). The power of empathy, TEDxMiddlebury: https://www.youtube .com /watch?v=baHrcC8B4WM [checked on 03/23/2017]. 

____________, John M. Kelley, Gordon Kraft-Todd, Lidia Schapira, and Joe Kossowsky. (2014). The influence of the patient-clinician relationship on healthcare outcomes: A systematic review and meta-analysis of randomized controlled trials, PLOS, Vol. 9, No. 4 | e94207: 1–7: https://doi.org/10. 1371/journal.pone.0094207.

____________, John M. Kelley, Robert W. Bailey, Emily J. Dunn and Margot Phillips. (2012). Empathy training for resident physicians: A randomized controlled trial of a neuroscience-informed curriculum, Journal General Internal Medicine, 2012 Oct; 27(10): 1280–1286. DOI: 10.1007/s11606-012-2063-z.

Rizzolatti, G. and M. Gentilucci. (1998). Motor and visual-motor functions of the premotor cortex in P. Rakic and W. Singer, eds., in Neurobiology of Neocortex. New York, Wiley. 

Sandler, J. (1960). The background of safety, International Journal of Psycho-Analysis, 41: 352–356. 

Satel, Sally and Scott O. Lilienfeld. (2013). Brainwashed: The Seductive Appeal of Mindless Neuroscience. New York: Basic Books (Perseus).

Segerstrom, Suzanne C. and Gregory E. Miller. (2004). Psychological stress and the human immune system: A meta-analytic study of 30 years of inquiry, Psychol Bulletin. 2004 July; 130(4): 601–630.

Selyuk, Alynia. (2017). Uber CEO apologizes over video of dispute with Uber driver. National Public Radio (NPR) All Things Considered: http://www.npr.org/2017/03/ 01/517988142/ uber-ceo-apologizes-over-video-of-dispute-with-driver [checked on 07/02/2017].

Slavich, George M. and Steven W. Cole. (2013). The emerging field of human social genomics, Clinical Psychol Science, 2013 Jul; 1(3): 331–348.

Spinelli, Ernesto. (2005). The Interpreted World: An Introduction to Phenomenological Psych- ology, 2nd Edition. London: Sage Publications.

______________. (2016). On existential therapy: A personal reflection on its defining features: https://www.youtube.com/watch?v=B 4rCuHpa5hE [checked on 12/10/2017].

Stolorow, Robert D. (2007). Trauma and Human Existence: Autobiographical, Psychoanalytic, and Philosophical Reflections. New York: Taylor and Francis. 

________________. and George E. Atwood. (1992). Contexts of Being: The Intersubjective Foundations of Psychological Life. New York: The Analytic Press (Taylor and Francis).

Therrien, Mark E. (1979). Evaluating empathy skill training for parents, Social Work, Vol. 24, No. 5 (Sep 1979): 417–19.

Titchener, Edward Bradford. (1909). Lectures on the Experimental Psychology of the Thought-Processes. New York: Macmillan. 

Tomasello, Michael. (2014). A Natural History of Human Thinking. Cambridge, MA: Harvard University Press.

Tutu, Desmond. (1999). No Future Without Forgiveness. New York: Doubleday.

van der Kolk, Bessel. (2014). The Body Keeps the Score: Mind, Brain and Body in the Transformation of Trauma. New York: Penguin Books.

Von Bergen, Jr., C.W. and Robert E. Shealy. (1982). How’s your empathy? Training and Development Journal, November 1982: 22–28.

Vul, Edward, Christine Harris, Piotr Winkielman, and Harold Pashler. (2009). Puzzlingly high correlations in fMRI studies of emotions, personality, and social cognition, Perspective on Psychological Science, Vol.4, No. 3 (2009): 274–290.

Vygotsky, Lev S. (1934). Thought and Language, tr. E. Hanfmann and G. Vakar. Cambridge, MA: MIT Press, 1963.

Wikipedia Contributors. (no date (nd)). Barack Obama supreme court candidates, Wikipedia: https://en.wikipedia.org/wiki/Barack_Obama_Supreme_Court_candidates [checked on 06/12/17].

Wimsatt, William C. (2007). Re-Engineering Philosophy for Limited Beings. Cambridge, MA: Harvard University Press.

Wittgenstein, Ludwig. (1951). Philosophical Investigations, tr. E. Anscombe. London: Basil Blackwell, 1968.

Zaffron, Steve and Dave Logan. (2009). The Three Laws of Performance: Rewriting the Future of Your Organization and your Life. San Francisco: Jossey-Base.

Zaki, Jamil and Mina Ciskara. (2015). Addressing empathic failures, Current Directions in Psych-ological Science, December 2015, Vol. 24, No. 6: 471–476. DOI: 10.1177/0963721415599978.

Zaki, Jamil. (2016). Does empathy help or hinder moral action, The New York Times, December 29, 2016: http://tinyurl.com/gwmfpxp [checked on 01/06/20Zimbardo, Philip. G., C. Haney, W. C. Banks. (1973). Interpersonal dynamics in a simulated prison, International Journal of Criminology and Penology, Vol. 1: 69–97.

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

Noted in passing: Arnold Goldberg, MD, Innovator in Self Psychology (1929-2020)

The passing of Arnold I. Goldberg, MD, on September 24, 2020 is a “for whom the bell tolls” moment. No doubt his family, students, friends, and colleagues feel the loss most acutely; however, the community is diminished, though in another sense irreversibly enriched by his contributions and innovations in expanding empathy.

Our loss is great, yet we breath easier thanks his lessons in empathy, which is oxygen to our souls.

Arnold I. Goldberg was an innovator in psychoanalysis and self psychology, a prolific author (really prolific!), an inspiring educator, and simply a wonderful human being.

My personal recollections are of Dr Goldberg inspiring my younger, graduate student self to pursue and complete a dissertation on empathy and interpretation at the

Arnold Goldberg, MD, enjoying Labor Day September 09, 2010 at his vacation home at the Indiana Dunes, illustration by artist Alex Zonis

University of Chicago Philosophy Department. I fondly recall introducing Arnold to one of my dissertation advisors, Paul Ricoeur, over a wine-enriched dinner at the middle eastern restaurant that used to be on Diversey Avenue (the Kasbah?). I was also lucky enough to take a year long case conference at Rush Medical that he taught to the psychiatric residents as part of the Committee on Research and Special Projects sponsored by the Chicago Institute for Psychoanalysis. Notwithstanding a multiyear gap during which our paths diverged, I have known him and his wife Connie (herself a Self Psychology power) since I was a twenty-something; and I still have in my possession a couple of his hand written letters to me regarding hermeneutics that I used to good purpose when “roasting” him at a retirement event at Rush Medical. What a privilege: I experienced Arnie’s deep listening, incisive and penetrating wit, the humor, the humanity, the remarkable learning and even-handedness in disagreement, and above all – his empathy. 

I choose to republish this book review from June 23, 2013 precisely because its provocative title best encapsulates the validity of Goldberg’s contribution to psychoanalysis and self psychology while subtly and humorously “sending up” some of his less flexible colleagues. Arnie, thank you for being you!

Read the complete review in the International Journal of Psychoanalytic Self Psychology: click here: GoldbergAnalyticFailureReview2014

The power of Arnold Goldberg’s approach in The Analysis of Failure: An Analysis of Failed Cases in Psychotherapy and Psychoanalysis (Routledge) is twofold. First, if a practice or method cannot fail, then can it really succeed?  If a practice such as psychoanalysis or dynamic therapy can fail and confront and integrate its failures, then it can also succeed and flourish.

Such is the point of Karl Popper’s approach to the philosophy of science in Conjectures and Refutations. For those who have not heard of hermeneutics, narrative, and deconstruction, and who are still suffering from physics envy, the natural science have advanced most dramatically by formulating and disproving hypotheses. Natural science is avowedly finite, fallible, and subject to revision, advancing most spectacularly within the paradigm of hypothesis and refutation by failing and picking itself up and pulling itself forward.

The Analysis of failure is inspired by this lesson without engaging in most of the messy details of the history of science. Second, for a discipline such as psychoanalysis (and psychodynamic therapy) that prides itself on the courageous exploration of self-deceptions, blind spots, self-defeating behavior, and the partially analyzed grandiosity of its practitioners (and patients), the well worn but apt saying “physician heal thyself” comes to mind.

The professional ambivalence about taking a dose of one’s own medicine upfront is a central focus not only in psychoanalysis (in its many forms) but in related area of psychiatry, psychopharmacology, cognitive behavioral therapy (CBT), social work, clinical psychology, and so on. Goldberg’s openness to alternative conceptions and frameworks along with his exceptional knowledge of and commitment to psychoanalysis (and self psychology) is an obvious strong point.

As a former colleague of the late Heinz Kohut, Goldberg studiously avoids (and indeed fights against) adopting the paranoid position with respect to failed analytic and psychotherapy cases – what’s wrong here? When a therapy case fails (the determination of which is a substantial part of the work) a series of blame-oriented questions arise: What’s wrong with the patient? What’s wrong with the therapist? What’s wrong with the treatment method(s)? What’s wrong!? And, yes, these questions must be engaged; but, Goldberg demonstrates, they must be put in perspective and engaged in the context of a broader question What is missing the presence of which would have made a difference? The answer will often, but not exclusively, turn in the direction of a Kohut-inspired interpretation of sustained empathy.

This leads to the part of Goldberg’s argument that is explicitly humorous. Having announced a case conference on failure and invited all levels of colleagues, Goldberg reports the casual laughter of many colleagues as they announced that they had no failed cases and so could not be helpful. “One person agreed to present but the following day he yelled across a long hall that he could not and quickly walked away (p. 41).

The list of excuses goes on and on, producing a humorous narrative that is definitely a defense against just how confronting the whole issue really is. Less humorous and more problematic is what happens when a case comes to grief and the candidate reportedly does exactly what the supervisor recommends. How one would know what is the “exact recommendation” is hard to determine, but relations of power loom large in such a triangular dynamic. Even Isaac Newton acknowledged that the “three body problem” of the (gravitational) relations between any three bodies is theoretically computable but practically intractable. The number of variables changing simultaneously is such that we are dealing with expert judgment rather than algorithmic results.

For my part I cannot help but think of the process for airline pilot reporting of errors in procedures, operations, and maintenance. Yes, pilots are part of a complex system and “pilot error” does occur – pulling back on the stick to get lift rather than pushing down – yet they are usually given more training and rarely blamed or faulted, absent illegal or blatantly unethical conduct (e.g., drinking on the job).

Goldberg calls for an ongoing case conference inquiring into failed cases, and thereby implicitly calls for taking our thinking to a new level of professional rigor, encompassing scientific objectivity that is consistent with talk therapy being a hermeneutic discipline. One might call it looking at the entire system, but not in the sense of family therapy –rather in the sense of the total professional-cultural-scientific milieu.

However, Goldberg’s approach differs decisively from a Check List Manifesto (a distinction not in Goldberg (he does not need it) but abroad in the land and by a celebrity MD, Atul Gawande) in that individual chemistry looms large between the therapist and the patient. In analysis or therapy, the number of unknown variables in fitting a prospective patient to a prospective treatment (whether analysis, therapy, psychoparm, CBT, etc.) is so large as to be nearly intractable. These are areas where we simply lack the super-shrink who has mastered the basics of all these methods and can make an objective, upfront call of what just might have the best odds of a favorable outcome without the usual trial and error. For the foreseeable future, mental health professionals can be expected to continue to “sell what they got.” If a person knows Talk Therapy, then that is most often what is initially recommended. If that does not work, try CBT or medication – and vice versa.

This reviewer does not agree that the crashes in the mental health area are usually not so spectacular – and they do make the papers in the form of suicides and inexplicable violence – though the track record is no where near the five-nines (one error in a million) that characterizes the airline industry. Goldberg’s subtext for mental health professionals is that we are still learning to live with uncertainty even as we organize case conference, postmortems, and the equivalent of crash investigations that strive to look objectively at outcomes without blame and without omniscient rescue fantasies in the service of healing and professional (“scientific”) development.

In some thirty cases that were reviewed by Goldberg, using the method of expert evaluation and feedback by the participants in the local case conference, the definition of failure included cases that never get off the ground; cases that are interrupted and so felt to be unfinished by the therapist or analyst; cases that suddenly go bad, characterized by a negative eruption whereas previously therapy was perceived to be going well; cases that go on-and-on without improvement; cases that disappoint whether due to the initial goal not being attained or being modified and not attained or endless pondering of what might have been.

Since this is not a “soft ball” review, one category of failure that is conceivable but missing from The Analysis of Failure is the example where treatment arguably left the person worse off (other than in terms of wasted time and money, which itself is not trivial). What about someone who did not experience impotence, writer’s block, or (say) hysterical sneezing until they tried psychoanalysis (psychotherapy)? What about compliance and placating behavior, reportedly a significant risk in the case of candidates for analytic training? What about regression in service of treatment that was initiated within the empathic context of the therapeutic alliance, but something happened and the regression got out of control and a breakdown or fragmentation occurred? Work was required to contain the fragmentation that was minimally successful, prior to an untimely termination that was a flight from fragmentation, a flight into health or a statement that in effect said “Let me otta here for my own good!” To his credit, Goldberg identifies “a patient who was getting worse off” (p. 162), but leaves the matter unconnected to regression mishandled or any other psychodynamic explanation. It is possible that such a scenario is already encompassed in the category of “cases that go bad,” at least implicitly, but in an otherwise through review of possibilities, this one was conspicuous by its absence.

The book itself is Goldberg’s answer to the question, given that failure occurs, what do we do about it? We inquire, define our terms, organize the rich clinical data, identify candidate variables, take the risk of making judgments about possible, probable, and nearly certain reasons, causes, and learn from our failures, pulling ourselves up by our boot straps in an operation that seems impossible until it succeeds. The role of lack of  sustained empathy, counter-transference, rescue fantasies, disappointments, uncontrolled hopes or fears, partially analyzed grandiosity (on the part of the therapist), lack of knowledge of alternative approaches to therapy, are towards the top of a long (and growing) list of issues to be engaged in the classification of causes for failure.

The turning point of Goldberg’s argument occurs in his chapter on “How Does Analysis Fail”? This is an obvious allusion to Kohut’s celebrated work on How Does Analysis Cure? Once again, failure is a deeply ambiguous term, and the ironic edge is that in contrast to an analysis gone bad where the patient leaves in a huff with symptoms unresolved, a successful self psychology analysis proceeds step-by-step by tactical, nontraumatic failures of empathy that are interpreted and used to promote the development of self structure. The short answer is that analysis cures through stepwise, incremental, nontraumatic breakdowns – i.e. failures – of empathy, which are interpreted in the analytic context and result in the restarting of the building and firming of psychic structure of the self. In turn, these transformations of the self promote integration of the self resulting in enhanced character traits such as creativity, humor, and expanded empathy in the analysand.

The entertaining and even heartwarming reflections on Goldberg’s relationships with his teachers Max Gitelson and Charles Kligerman, betrayed (at least to this reader) a significant critique of the “old guard,” resolutely defended against the possibility of any failure, thanks to a position that avoided any risk – analysis is about improving self-understanding. According to this position, the reduction of suffering and symptoms relief is a “nice to have” but not essential component. Analysis is a rite of passage into an exclusive club, where you are just plain different than the untransformed masses.

Though Goldberg does not emphasize the debunking approach, the reduction to absurdity of the description of the old guard makes psychoanalysis sound a tad like the est training from the late 1970s. You just “get it” or you don’t – in which case here is your money back and now go be miserable and unenlightened (only analysis does not give you your money back). In both cases failure is not an option, though not in the sense initially intended by the slogan, namely, that risk is analyzed and mitigated through interpretation. Failure is not an option because it is excluded by definition from the system of variables at the onset, thus, also excluding many meaningful forms of success. In short, many things are missing including sustained empathy, which, in turn, becomes the target of the analysis of failure in the remainder of the book

The net result of the compelling chapters on Empathy and Failure, Rethinking Empathy, and Self Psychology and Failure, is to challenge the analyst and psychotherapist to deploy sustained empathy in the service of structural transformation. While I personally believe that agreement and disagreement are over-valued in terms of creating authentic understanding, the section on Empathy and Agreement raises a significant distinction between the two terms. It is insufficiently appreciated by many clinicians how agreement becomes a smoke screen – and defense against – basic inquiry and exposure to the other’s affects in all their messiness and ambivalence. It remains unclear how sustained empathy undercuts agreement (or disagreement).For example, Dr. E. wants his analyst to agree with him that it is okay to sleep with his patient(s). For the sake of discussion, the analyst mouths the form of words, “Okay, given your marriage, okay, I agree.” But Dr. E. then asserts that he can tell the analyst does not really mean it (an accurate observation). So why not raise the question what is agreement doing here other than disguising Dr. E.’s own unacknowledged commitment to “being righteous and justified”. There is nothing wrong with being righteous, everyone does it. However, is it workable?

The resistance has to be engaged and interpreted at some point in order to make a difference in treatment. Agreement (or disagreement) remains a conversation with the superego, even in the mode of denying there is amoral issue. It may stop a tad short of moral justification, but it is on the slippery slope to it. There are many cases along a spectrum of engagements but the really tough one is empathizing with behaviors that are ethically and legally suspect such as doctors sleeping with their patients and other relations of power where one individual uses his or her position to dominate the other as a mere means not an end in him- or herself. This is a high bar in the case of empathizing with the child molester or Nazi who have used a form of empathy (arguably a deviant one) to increase his domination of the victim. This remains a challenge to our empathy as well as to our commitment to treating a spectrum of behavior disorders (where Goldberg has made a life-long contribution) that are significantly upsetting to large parts of the mental healthcare market. Keeping in mind the scriptures and the sayings of Jesus(the rabbi), which Goldberg does not mention but arguably is the subtext, we are still challenged to love the sinner but hate the sin.

In a concluding rhetorical flourish, Goldberg claims that the book is a failure. The prospective reader – a very wide audience as I am any judge of the matter – may see the many complimentary remarks that properly disagree with this rhetoric printed on the back cover (which this review endorses and agrees). In a further ironic and richly semantic double reverse in the title of the final chapter, failure has a great future. This is especially so when failure is scaled down from a global narcissistic blind-spot on the psyche of the therapist (where failure remains a valid research commitment) to an expanded tactical approach in the form of “optimal frustration … disappointment being real, tolerable, and structure building” (p. 200).

The concluding message is an admirably nuanced clarion cry for further study rather than condemnation, finger pointing, or blame of some particular therapeutic modality such as Talk Therapy versus CBT. The concluding message is a sustained reflection on de-idealization, the difficult process of taking responsibility for the inevitability of one’s parents’ lack of omnipotence. Failure is part of the development process in analysis and psychotherapy, and, by implication (and taken up a level), the study of failure in broad terms will be part of the development of the profession going forward. The analyst and therapist must give up the rescue fantasy, give up being right and justified, give up misplaced ambition, but also give up guilt, self-blame, disappointment, and embrace an approach that interpretation of the pathogenic situation of early childhood in which traumatic deidealization of the parent occurred, becomes inherently transformative. It reactivates the process of structure-building internalization. Learning to live within one’s limitations invites a process of risk taking that sometimes results in failure, sometimes results in success, and always results in – redefining one’s limitations outwards towards an endless horizon of progress in satisfaction and meaning making. Our thanks to Arnold Goldberg both for the journey and the end result.

Chicago Tribune Obit, Sept 29, 2020: https://www.legacy.com/obituaries/chicagotribune/obituary.aspx?n=arnold-i-goldberg&pid=196869091

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

Noted in Passing: Elizabeth Wurtzel, Author, Prozac Nation

Elizabeth Wurtzel (1967–2020) died at the age of 52 on January 7th in New York City of metastatic breast cancer. Wurtzel became a notorious “bad girl,” with a wicked sense of black humor, sparing few, least of all herself, and a disarming “tell all” candor in her break through memoir Prozac Nation.

Full disclosure: I am catching up on my reading. Triggered by Wurtzel’s passing

Elizabeth Wurtzel (her young self): Cover Art: Prozac Nation

Elizabeth Wurtzel (her young self): Cover Art: Prozac Nation

away, I had not read her best selling Prozac Nation until earlier this week (01/14/2020). I acknowledge I need to get out more.

Now I am familiar with pathographies – autobiographies and biographies of mental pathology – having read Kay Redfield Jamison’s An Unquiet Mind, Jamison’s “Robert Lowell: Setting the River on Fire: A Study of Genius, Mani, and Character,” and Elyn Saks’ The Center Will Not Hold, all worth reading – as is Prozac Nation. Thus, I bring an innocent reading – and eye – to a work that is anything but innocent.

Wurtzel is credited with putting the funny but self-lacerating memoir on the literary map, with its account of her emotional struggles against the Black Wave of depression, volatile internal conflicts, and acting out in the form of cutting, starting at age eleven. Subsequent attempts to attain emotional equilibrium through substance abuse and volatile relationships with members of the opposite sex, the narrative actually turns into a coming of age story. Some coming; some aging.

Not quite stream of consciousness, but definitely a rapid fire, back-and-forth conversation of Wurtzel with herself, it puts me in mind of the cliché: your mind can be a bad neighborhood; if you go there, you are going to get mugged, albeit in a comical way; mugged by negative self-talk, devaluing self assessments, and rage at the narcissistic slights inflicted by intimates, strangers, and intimate-strangers alike.

Wurtzel’s writing is shot from a cannon. The character sketches are wickedly funny and just as cutting as her own practices of self-injury. One example: “If Archer weren’t so good-looking, I’m not sure he’d exist at all, since he lacks most vital signs [….][H]e is the best opportunity to hang out with a gorgeous man and be certain that there will be no sexual tension whatsoever” (p. 224).

Wurtzel literally calls out the elephant in her family’s living room early in the narrative (p. 58): her parents are fighting, from the time Elizabeth is two years old, when her mom divorces her dad. The parents continue to fight (including in court) throughout her childhood, adolescence, and emerging adulthood, all the while “telling me that their [hostile] feelings for one another shouldn’t affect me,” blaming the victim if she feels affected, making the child an unwitting pawn.

Usually an emotion will shift after a few hours and a depression will shift after a few months, even if no intervention is undertaken other than good rest and good nourishment. To keep the disorder in place, active measure must be undertaken by the person, environment or both. The ongoing family situation is a significant contributor to the extraordinary duration of the distress.

It gets worse. The dad has access to health benefits through a good, albeit low level, corporate job; but it seems that every time the growing Wurtzel gets into an emotional crisis (chronic emergency would be more like it), the dad stops paying for psychotherapy, telling her its nothing personal. The real reason is usually a dust up with the mom.

Queue up the late rock-and-roller Stevie Ray Vaughn: Caught in the cross fire. Elizabeth is. She cannot help but internalize the conflict. Any kid would. This is the way it is. It starts so early and continues so unremittingly, that one must be positively as blind as the parents not to see it: this is an invalidating environment.

Another example of invalidation that might be straight out of Heinz Kohut, MD: “For instance, I’ll walk into her [mom’s] apartment and she’ll just blurt out, Those shoes are so ugly! And I never asked her. And I like my shoes […] The concept of Who asked you? does not exist in my family […] We’re all meshed together” (p. 231). Unremitting, serial breakdowns in empathy, resulting in emotional contagion, conflict, and enmeshment with the toxic self-object and hostile introject. Ouch!

Abandonment comes up early and often. In year-after-year of being sent off to a different camp, depending on which one offers a discount to her and her mom, who are living in a kind of genteel poverty. It induces a real panic about abandonment in the young Wurtzel, resulting in dozens of calls requesting rescue. Having been dutifully rehearsed during latency, this fear takes on a life of its own. “[…] [B]eing alone turns into a terrible fear that I will have no friends” (p. 89).

In several relationships with college BFs (at Harvard College) Wurtzel cries and cries sad tears, angry tears, at the prospect of separation such that the behavior creates the dreaded self-fulfilling prophecy. She goes well beyond “high maintenance” into the land of continuous confrontation, just plain crazy shit, and the bottomless pit of infinite upset all the time. Meanwhile, the guy wants a friend with whom he can go to the movies and party, maybe perform some consensual sex acts between reading about Derrida and Marxism. Enough.

Years later it comes out. The man Elizabeth thought was her dad, who was divorced after two years by the mom, and who also thought he was the dad, is not the biological father. Even though he did not have the DNA data, somehow he was never able to relate to Elizabeth in quite the proper parental way. (See the article by Wurtzel entitled Bastard, cited at the bottom of this post.)

Wurtzel has a gift for zingy one-liners, coming out of the blue, and yet creating their own context instantaneously. As regards the above-cited elephant, “We went to Alaska and we froze to death” (58) – emotionally. More like the abandoning, ice box father and the bonfire mother. Things heat up, especially with her mom: “I come from a family of screamers” (p. 185). Balance is hard to find.

The subtitle is “Young and depressed in America,” and one can sees Wurtzel’s editor’s skillful hand in connecting the dots between individual suffering, of which there is an abundance, and the breakdown of communities, ongoing, whether due to globalization, an opioid epidemic, or the malling / mauling of America.

The reader learns the difference between sadness and negative self-talk and what we might call existential depression: “I’d been expelled from the place where possibility still existed” (p. 60). Depression is the loss of the possibility of possibility. It is not just that I lose love and long for love; I lose the possibility of the possibility of love. This is gonna be tough going.

This is definitely a page-turner. Hard to put down. However, there are also some loose ends. I mean in the narrative, looser than Wurtzel herself. 

The title is premised on the interpretation that Wurtzel suffered between the ages of eleven and twenty one from a hard to treat Black Wave. Tons of talk therapy – finally she can’t stop crying for days – and not for the first time – and her shrink prescribes an anti-psychotic – Mellaril [thioridazine] – and its anticholinergic effects promptly dry up her mucus membranes, allowing her “to get a grip on it.” She is able to stop crying.

I am reading this passage and scratching my head. This is an emergency measure, right? Wurtzel is a lot of things, but her reality testing of the everyday is good enough. I know nothing, really, and am not a prescriber. However, I have been know to echo Lou Marinoff’s saying, “Plato, not Prozac!” And yet: An actual antidepressant such as imipramine or disiprimine would have had the same anticholinergic effects, have dried up the tears physiologically, and it might actually also operate as an antidepressant, would it not?!

Perhaps it was because of the unremitting of suicidal ideation that Wurtzel endorsed and expressed that no medical doctor recommended a tricyclic antidepressant. A person can actually hurt themselves with the tricyclic antidepressants, as with any powerful drug, which can cause a fatal heart arrhythmia if consumed contrary to proper guidance and in volume. But if this is supposed to be an emergency measure, a small number of pills in small dosages, closely supervised, would also have been possible would it not? Was Wurtzel getting adequate medical treatment even by advanced 1994 care standards? We may never know.

I am not one noted to value psychiatric labels, seeing them as getting in the way of being fully present with the other person as a possibility. Yet Wurtzel has a breakthrough towards the end of her narrative when she gets one – a label – along with the newly available fluoxetine (Prozac). Her psychiatrist gives her a diagnosis of atypical depression. I would add, demonstrably treatment resistant. “Atypical” because years of talk therapy and first line antipsychotics have barely made a dent in her unremitting self-abuse, inclination to self-medicate with weed, alcohol, and acting out with a series of boy friends, a couple of whom are the target of an intense romantic idealization combined with a neediness calculated eventually to drive them all away. However, at this point, the Prozac seems to work – except that about two weeks after starting to take it, she is feeling a tad better, and her only serious suicide attempt reported in the book occurs. Hold that thought.

One thing lifted Wurtzel’s work head and shoulders above your average narrative of suffering and redemption for me. Wurtzel is working through her invalidating environment and she gets it: “…[M]y addiction to depression …involved the same mental mechanism as someone else’s alcoholism” (p. 23).

Suffering is sticky. The risk of suffering is that it becomes an uncomfortable comfort zone. The body and the mind adapt to chronic pain and chronic stress. Even when the result is still pain, not numbness, the entire messy complex takes on a life of its own and becomes: suffering. If you water the tree of your sorrows, the tree grows. It grows until the suffering becomes the man-eating plant in the back of the Broadway play Little Shop of Horrors. That seems to have been going on here.

Empathy lessons occur in abundance in Prozac Nation, but they are mostly in a privative mode – that is, empathy is conspicuously missing.

Wurtzel is hungry for someone to respond to her as a whole person, writing: “I love you and I support you just the way you are because you’re wonderful just the way you are. They don’t understand that I don’t remember anyone ever saying that to me” (p. 231).

Wurtzel’s mother “loves” her as long as (if) she is brilliant, gets into Harvard, and they can continue intermittently to tear at one another’s guts on special occasions. He dad “loves” her as long as she does not make herself too needy, will pose for his photos, and otherwise leave him alone. Her friends “love” her as long she as is funny and amazing and the life of the party. Her boy friends “love” her as long as she continues to put out, which she does all too casually, leaving her feeling cheap. The impingements come fast and thick; here “love” means acknowledging someone as a whole human being, i.e., empathy; but no one gets her as a possibility.  

My take on it? If, at any point, someone would have given her a good sustained listening, something important would have shifted. Nor is it quite so simple. Her suffering would not have been magically disappeared; but it would have been decisively reduced. Once again, we will never know for sure.

Page after page of this page-turner, Wurtzel is explicitly crying out for “love,” and people are trying to love this individual, who seemingly inevitably gets caustically cutting towards others or becomes a needy emotional sponge, an unlovable rag of self-pity, albeit with a sense of humor, driving them away. Thus, Wurtzel’s ultimate test of love: love me even when I am deep down unlovable. It doesn’t work that well.

One can have empathy with the loveable but loving the unlovable is a high bar, by definition impossible. This person needs the firm boundaries of a rigorous and critical empathy. But instead Wurtzel’s friends and counselors efforts are lost in translation and become emotional contagion, projection, and inconsistent efforts to force compliance and conformity.

Finally, Wurtzel does get some empathy from the shrink disguised in the narrative as “Dr Sterling.” She was. Wurtzel writes: “Dr Sterling knew that somewhere in my personality there was a giggly girl who just wanted to have fun, and she thought it was important that I be allowed to express that aspect of myself (pp. 211–212). Predictably the breakdowns and out-of-attunements are frequent. The cutting remits but the acting out – street drugs, sexual misadventures (including the “accidental blow job”), and repetitive, endless phone calls – ramp up.

So what happens? Along comes Prozac [fluoxetine] and Dr Sterling gives it to her. Wurtzel is feeling better as a result of the medicine. But “better” is relative. Wurtzel gets into it with her psychiatrist, and she locks herself in the bathroom and takes the whole bottle of Mellaril [thioridazine], knowing that her shrink is waiting outside the door for her. As Wurtzel feels herself going under from the effects of the drug and she hears her shrink shouting outside the door, she unlocks it.

Now never say that someone who threatens suicide or actually swallows the pills is not suicidal. Never. People have been known to be all-too-unlucky in such situations and succeed where they are using a bad method to try and solve the problem of their suffering. I suggest this was one of those, and arguably as a result of the un-inhibiting effects of the Prozac.

Those are such facts as reported in the narrative. Throughout the book, Wurtzel is plagued by suicidal thoughts, she cuts herself and engages in taking street drugs and crazy sex, but not until she gets the Prozac does she actually take action and make a serious attempt at suicide. Hmmm.

I am not making this up. It is in the book. Has anyone read it since 1994? This is the book entitled “Prozac Nation” and is regarded as some kind of strange endorsement for Prozac. Wurtzel subsequently and consistently denied it was an endorsement of fluoxetine [Prozac], emphasizing her commitment to being self-expressed. That she succeeds in doing in spades. Definitely. What some authors won’t do to move some copy!

I read Wurtzel’s memoir for the first time ever upon learning of her passing on January 7, 2020. We can measure the distance between the publication in 1994 and today in that of all the reviews between then and now no one – not one – mentioned that the fear of abandonment, the invalidating early environment and ongoing invalidating entanglement with the warring parents, the volatile emotions (especially atypical depression), volatile relationships, volatile self-identity, and para suicidal behavior are the check list for borderline personality disorder.  I hasten to add checklists are overrated, and I acknowledge I might have missed something.

However, it does put me in mind of a quotation from Marsha Linehan, innovator in Dialectical Behavioral Therapy (DBT), and who, in the  video cited below, is talking on camera with permission with an avowedly suicidal patient. Linehan says: “I think it is good that you see it as a problem that you feel suicidal and want to fix that; but suicide is not so much a problem as a solution.” Pause for jaw dropping effect. “People’s lives are so messed up that they want to check out as away of solving the problem. What our program does is help you find a better solution – so it is not really a suicide prevention program so much as a life worth living program.”

Elizabeth Wurtzel succeeded in having one of those lives worth living, even without a formal program and in spite of all the challenges put in her path by accidents of biology, early experience, and her own demons. She had gifts aplenty and she managed to use them to attain a good measure of power, freedom, and full self-expression. Above all, self-expression. We are enriched by Wurtzel’s comet-like trajectory through our post-modern modernity and diminished by her passing. It is truly an ask-not-for-whom-the-bell-tolls moment.


Elizabeth Wurtzel, (1994) Prozac Nation: Young and Depressed in America, New York: Mariner Books (Houghton Mifflin Harcourt (paperback edition), pp. 339, $16.99.

‘I believe in love’: Elizabeth’s Wurtzel’s final year, in her own words by Elizabeth Wurtzel, https://gen.medium.com/i-believe-in-love-elizabeth-wurtzel-s-final-year-in-her-own-words-e34320e41ee0 

Bastard Neither of my parents was exactly who I thought they were by Elizabeth Wurtzel, https://www.thecut.com/2018/12/elizabeth-wurtzel-on-discovering-the-truth-about-her-parents.html

Elizabeth Wurtzel by Liz Phair, June 16, 2017, https://www.interviewmagazine.com/culture/elizabeth-wurtzel

Lou Agosta, (2018), Empathy Lessons, Chicago: Two Pears Press: https://www.amazon.com/Lou-Agosta/e/B07Q4XX6PF/ref=dp_byline_cont_book_1

Marsha Linehan talks with a patient about borderline personality disorder and dialectical behavioral therapy: https://www.youtube.com/watch?v=tgzw50SbokM

© Lou Agosta, PhD and the Chicago Empathy Project

Review: The Collected Schizophrenias: Essays by Esmé Weijun Wang

Esmé Weijung Wang’s The Collected Schizophrenias: Essays (Gray Wolf Press, 2019: 210 pp.) are an articulate and clarion cry to bring empathy to an arena in mental health where it has been missing.

My take on it? Ms Wang seems not to have been one of those survivors whose mental disorder is inextricably entangled with her genius. She was already talented and successful, studying at Yale, before her first breakdown.

The disorder was a major curve ball, delivered at high velocity, and hitting her in

Cover Art: The Collected Schizophrenias

Cover Art: The Collected Schizophrenias

the head – and heart. She gets up, dusts herself off, and, with writing that knocks it out of the park, recovers her own humanity with compelling accounts of her experiences, both humorous and heart-rending, thereby enriching ours and expanding our empathy.

At risk of mixing the metaphor, life handed her lemons. By my estimate, about a bushel. She did not merely make lemonade. She has concocted a kind of electric cool-aide. This is a beverage which perhaps will leave one feeling a tad trippy and vertiginous, but one which expands one’s empathy, not only for survivors of mental illness, but for our humanity at large. The rumor of empathy in Wang’s work is no rumor – empathy lives in Wang’s The Collected Schizophrenias.

The celebrated psychiatrist-philosopher Karl Jaspers (1883–1969) wrote in his seminal two volume psychiatric text General Psychopathology (1913/1959) that lack of empathy was diagnostically significant for a diagnosis of schizophrenia. If one is having trouble empathizing with the other person, the diagnosis of schizophrenia is by no means certain, but belongs on the short list.

The doctor and therapist struggle to have empathy for the often-bizarre constellation of symptoms characteristic of schizophrenia – hallucinations, delusions, incoherent “word salad” speech. The care-takers, from their own perspective, experience a lack of out-bound empathy from the patient, whose suffering is thereby aggravated in being further cut off from human connectivity and isolated. 

One thing Ms Wang’s memoir of her disorder makes crystal clear is that her empathy is functioning full throttle. Even if her empathy is sometimes inaccurate  (as is everyone’s) or misfires (as does everyone’s), Wang’s empathy lives as a commitment to appreciating the other’s point of view and relating to the other with affinity and appropriate affection. Wang fully experiences the dignity violations, lack of respect, and objectifications on the part of the medical system and professionals trying to help her, leaving her alternatingly in despair and enraged.

Paradoxically a dimension of her reality testing continues to function even as she is fearfully hiding in the closet due to psychotic symptoms that demonstrate to her the break down of her reality testing.

While it is true that most sufferers and survivors of the collected schizophrenias do not present as “high functioning” as Ms Wang, growing evidence is available that, even in the acute phase of the disorder, most psychotic persons appreciate that the hallucinated voices and ideas of reference are somehow subtly and significantly distinct from everyday reality. This awareness, however tentative it may be, can be leveraged and made the target of therapeutic conversation. This has clinical significance for cognitive behavioral and emotional interventions in the acute and the survivor phase. This is the empathic moment of which even so celebrated a shrink as Jaspers missed.

“High Functioning” is itself the title of an chapter in which Ms Wang is in recovery. She is giving presentations on mental health to interested citizens and professionals as part of some gig and good work she has landed after her professional career was ruined by the disorder. The reader gets background on Wang’s earlier career as a fashion journalist. We get a reading list of other “high functioning” individuals who have struggled with mental illness and go on to get PhDs, McArthur “Genius” Grants, and endowed chairs in psychiatry at major universities such as Kay Redfield Jameson, Elyn Saks, and other notable authors of “pathographies.” Pathographies are an emerging but not really new category of biographies and memoirs of survivors of mental illness.

This paradox of reality testing within the breakdown of reality testing has also been pointed out by thinkers whose critical inquiries into mental illness need to be better known.  I am thinking especially of the work of Louis A. Sass (1) and Matthew Ratcliffe (2), whose books are cited at the bottom of this review. (See also my related blog reviews of Ratcliffe: https://wp.me/pXkOk-8g and Sass: https://wp.me/pGb20-pp.)

There is something for everyone in Ms Wang’s collection.

She acknowledges that she takes her anti-psychotic medications on schedule, and, moreover, the medications that work for her right now are so-called first generation, haloperidol and quetiapine (Seroquel). She argues that the National Alliance on Mental Illness (NAMI) takes positions dear to the heart of the families of the mentally ill (take your meds, allow for involuntary incarceration in an emergency (5150: code for involuntary commitment), be a good “mental patient” conforming to the hierarchy in which psychiatrists are I authority).

At the same time, Wang is an evangelist and a strong advocate for RAISE (Recovery After an Initial Schizophrenia Episode) and the need for autonomy for the mentally ill: “Rarely did I experience such a radical and visceral imbalance of power as I did as a psychiatric inpatient amid clinicians who knew me only as illness in human form (p. 57).

The anti-psychiatry movement will find comfort and is well-represented in Wang’s work. Not only do the mentally ill have to survive the illness, they also have to survive the system that is supposed to help them: “Though nearly all the statements a psychiatric patient can make are not believed, proclamations of insanity are the exception to the rule” (p. 101). Crazy making rules and treatments. If that is not a double bind, I would not know one.

Wang takes a position: “I maintain, years later, that not one of my three involuntary hospitalizations helped me. I believe that being held in a psychiatric ward against my will remains among the most scarring of my traumas” (p. 110). A bold statement of the obvious: That is tragic – and an outrage.

The honest broker, Wang then reports on individuals who committed violent crimes and/or killed themselves while in the grips of psychotic episodes. No easy answers here.

The social justice dimension is not pervasive in Wang’s memoir – perhaps because Wang’s family and husband were able to be supportive enough to arrest her slide into the abyss of insanity just short of the edge – but explicitly surfaces periodically and powerfully: “nearly 1.3 million people with mental illness are incarcerated in state and federals jails and prisons” (Department of Justice) (p. 110). Wang does not say what percentage is getting the treatment they need in accordance with professional diagnostic guidelines. I am going to be optimistic: 25%?

Since this is not a softball review, a point occurred at which I was about to put down the book with the admittedly devaluing, objectifying judgment: This individual is a walking laboratory of psychiatric (and medical) curiosities.

Wang endorses the Cotard delusion, in which the person claims that I part of his

Esmé Weijun Wang, author: The Collected Schizophrenias: Essays

Esmé Weijun Wang, author: The Collected Schizophrenias: Essays

body does not belong to him or that he as a total person is dead and should be disposed of properly. My empathic understanding of this disorder – and this is not the truth with a capital T but consider the possibility – is that the person’s emotional life has been short-circuited. The person is emotionally “dead,” for without emotions and affects we lack vitality and aliveness. Wang’s credibility (with this review) is restored as she reports she was so desperate she was considering ECT (electro shock therapy), but did not go through with it. The disorder spontaneously remits.

In an ongoing and increasingly desperate search to regain her power over the seemingly endless series of (un)related disorders, Wang suspects she may have an autoimmune disorder. Whether late stage Lyme disease is one of those, I do not know.

By this time, Wang is a relatively well-informed professional patient with limited but apparently sufficient resources, and she manages to go on a kinda of new age medical retreat to Santa Fe, New Mexico, for the treatments with a “lyme literate” medical doctor (LLMD).

Always the honest broker, Wang reports the writings of Leslie Jamison, author of The Empathy Exams, in which Wang compares Lyme is to the problematic, hard-to-pin-down, possibly delusional disorder, called having “Morgellons.” Jameson gives an account of the person who has Morgellons, in which the individual experiences worms or worm-like sensations, crawling beneath his flesh, which, apparently, sometimes pops out. Yikes.

At this point, I abandon any skepticism I might have about Wang’s suffering as a medical patient as my own limitations or arrogance. I decide to acknowledge once again there are more things in heaven and earth than are dreamt of in our philosophies (note: “philosophy” meant “natural science” in Shakespeare’s time).


(1) Louis A. Sass, (1994), The Paradoxes of Delusion: Wittgenstein, Schreber, and the Schizophrenic Mind, Ithaca, NY: Cornell University Press.

(2) Matthew Ratcliffe, (2017), Real Hallucinations: Psychiatric Illness, Intentionality, and the Interpersonal World, Cambridge, MA: MIT Press, 290 pp.

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

Top 10 Trends in Empathy for 2020

10. Empathy is the new love. You know how in fashion gray is the new black? Same idea. Empathy is the new love. What people really want is to be “gotten” for who they authentically are as a possibility. In hoping to be understood for who they really are as a possibility, people are not asking for love; they are asking for empathy. If empathy is the new love, what then was the old love?

According to philosophers and poets, the old love is akin to a kind of madness—sometimes divine madness, sometimes just plain earthly madness. The one who is in love is semi-hypnotically held in bondage by an idealization of the beloved. In one way, love shows up as animal magnetism, a powerful attraction; in another way, in a quasi-hypnotic trance, love idealizes the beloved, and, blindly and madly overlooks the would-be partner’s failings and limitations.

Moutain path with sign in Rocky Mountain National Park

Mountainous empathy paths ahead for 2020 with sign in Rocky Mountain National Park

Folk wisdom, as noted, suggests that love is blind; Bob Dylan, that love is just a four letter word; Plato, that love is a kind of madness. So far, love sounds like tertiary syphilis.

The goal of love is to erase the boundary between the self and other. Merger of one’s mind and body with the beloved’s mind and body is the sought after result. In contrast to love, empathy navigates or transgresses the boundary between oneself and other such that the merger is temporary and the integrity of the self and other are maintained. One has a vicarious experience of the other—but the difference and integrity of the self and other are preserved.

So from the relational perspective of too much or too little merger and engagement with the other person—love shows up as a breakdown in empathy. It is now love versus empathy. In contrast with empathy, love is a boundary transgression, but one that is permissioned, invited, welcomed. Thus in empathy one creates a space of acceptance and toleration in which love lives.

  1. Empathy and politics: this is an election year in the USA. Politics in this age of polarization is characterized by bullying. How does empathy speak truth to power?

How to deal with bullying without becoming a bully? Set firm limits – set firm boundaries – thus far and no further. Being empathic does NOT mean giving up the right to self defense.

Still, without naming any names, the problem with mud wrestling with a pig is that everyone gets dirty – and the pig likes it! No easy answers here. One modest proposal:

Empathy is the emotional equivalent of jujitsu – use the aggressor’s energy to send him flying the other way. Being empathic does not mean being nice, agreeable, or even being disagreeable. It means knowing what the other person is experiencing because one experiences it too as a sample or trace affect.

As discussed further below in the trending one-minute empathy training, drive out cynicism, aggression, polarization, bullying, and the result is that empathy spontaneously comes forth, expands, and develops.

Power and force are inversely proportional. As the bully’s power goes down, the risk of the use of force [violence] increases. Empathy is powerful, and if necessary it meets force with force. But then it is no longer an empathy; it is empathy in the form of a breakdown of empathy. Empathy consists in restoring the boundaries and integrity to the situation.

  1. Empathy, capitalist tool: Empathy is the ultimate capitalist tool: No business or enterprise can operate for long, much less flourish, without empathy to facilitate teamwork, coordination between customers and sales persons, employees and employers, leaders and staff, and stake-holders at all levels. Even the cynical sales person understands the value of taking a walk in the customer’s shoes, if only to sell him another pair.

Unfortunately, business leaders lose contact with the human dimension of business in solving legal problems, meeting information technology breakdowns,  reacting to the competition, or dealing with the latest accounting crisis.

Yet empathy is never needed more than when it seems there is no time for it.

Sometimes leaders don’t need more data, leaders need expanded empathy. I hasten to add that, ultimately, both empathy and data are on the path to satisfied buyers, employees, and stakeholders. If the product or service is wrappered in empathy, has an empathic component as part of the service level agreement, gets traction in the market, and beats the competition’s less empathic competing offering, then we have the ultimate validation of empathy. “CEO” now means “chief empathy officer.” We do not just have empathy. We have empathy, capitalist tool.

7. Your brain on empathy: “It’s all in your head” is a necessary truth, but not in     the sense that you are imagining your experience of joy, fear, anger, pain, or suffering. It’s in your head because it—your experience—is in your brain, that is, your nervous system. We are neurons “all the way down.”

A word of caution. This scientific discovery of mirror neurons and mirroring phenomena should be distinguished from the neurohype occasioned by the application of the functional magnetic resonance imaging machine (fMRI) to issues that extend from the pseudo-disciplines of neuro-law to neuro-aesthetics to neuro-marketing and even neuro-history.

Show a jury in court a picture of a person’s brain and it gives the argument credibility (whether for or against conviction). But it is just a picture. Monitoring the neurological activation of individual brains in response to such conditions as videos of painfully impacted limbs, legal arguments, classic paintings, advertisements, and so on, has reached the point where an alternative point of view is being offered on statistically questionable, “voodoo correlations” in fMRI research.

The debate is whether or not mirror neurons exist in human beings. Even if they do not, mirror neurons in monkeys have completed the work that needs to be completed. Some kind of mirroring system exists. It is highly probable that there is an analogous system, even if more complex and diffuse, in humans that functions in mirroring emotions and behavior and that underlies our relationships in empathic community.

However, what the debate has suggested, entirely independently of the status of mirror neurons, is that human beings are connected biologically in a way, not completely understood, such that we resonate with one another affectively. The debate over whether human beings have mirror neurons in the narrower sense continues. The neuro-hype is dialed down in the year ahead.

  1. Empathy is good for you health and well-being. Empathy is on a short list of stress reductionpractices including meditation (mindfulness), Tai Chi, and Yoga. Receiving empathyin the form of a gracious and generous listening is like getting a spa treatment for the soul.   

The healing powers of stress reduction are formidable. Expanding empathy reduces stress; and reducing stress expands empathy. A positive feedback loop is enacted. Expanding empathy expands well-being.  Here empathy is both the end and the means.

A substantial body of evidence-based science indicates that empathy is good for a person’s health. This is not “breaking news” and was not just published yesterday.

We don’t need more data, we need to start applying it: we need expanded empathy. Note: the list of evidence-based articles and peer-reviewed publications is long, not repeated in this short blog post, and can be found in Chapter Four of my Empathy Lessons .

  1. Online empathy in cyberspace: While nothing can substitute for an in-person conversation, after two people get to know one another, an online conversation is a good option in case of relocation, bad weather, or unpredictable scheduling dynamics. You know that resistant client who just can’t seem to get to his session due to traffic, rain, or other tenuous excuse? The possibility of an online session, which requires a computer and the privacy of a closed door, shows up the resistance for what it is.

Psychotherapy invokes a virtual reality all of its own – even without cyber space. This is especially the case with dynamic psychotherapy that activates forms of transference in which one relates to the therapist “as if” in conversation with a past or future person or reality, the latter not physical present. Indeed, with the exception of being careful not to step in front of a bus while crossing the street on the way to therapy, we are usually over-confident that we know the reality of how our relationships work or what people mean by their communications. This is less the case with certain forms of narrowly focused behavioral therapies, which are nevertheless still more ambiguous than is commonly recognized.

Think about it: Those who complain about the lack of reality in a conversation over Zoom may usefully consider the amount of fiction and fantasy in any psychodynamic conversation, full stop. Never was it truer that meaning – and emotions such as fear – are generated in the mind of the beholder.

(Note: This trend is in part an excerpt from: Lou Agosta’s article “Empathy in Cyberspace: The Genie is Out of the Bottle” in Theory and Practice of Online Therapy: Internet-delivered Interventions for Individuals, Groups, Families, and Organizations edited by Haim Weinberg and Arnon Rolnick. London and New York: Routledge: To order the complete book, click here: Theory and Practice of Online Therapy [https://tinyurl.com/yyyp84zc])

  1. Empathy and law enforcement: My friends, associates, and colleagues on the police assure me that posters branded with the logo of the local police and a pitch for expanded empathy are showing up in police station locker rooms, break rooms, and behind the scenes facilities. At this point in time, these are for the police, not the public.

Street smart police “get it” that empathy is distinct from compassion or “being nice.” Empathy is a method of data gathering about the experience of the other person. The police officer’s emotional radar has to be out about what the would-be suspect or citizen or fellow officer is experiencing if the officer is to avoid making a potentially bad situation worse.

If the would-be suspect is enraged and about to escalate such a scenario requires a distinct response than if the suspect is afraid and literally shaking in his shoes. Empathy provides  valuable and indispensable emotional intelligence about the mental status of the other person. The police are already guided by their common sense, intuition, and gut feeling in approaching other people. Why not provide explicit training in what to do with one’s empathic receptivity, for that is what this “gut feeling” and intuition amount to? Police departments are realizing that practice in empathy lessons can refine and fine tune the intuition and gut feeling so these actually become powerful tools literally in keeping the peace or when necessary minimizing the appropriate use of force.

All this is important and communities will benefit from expanded empathy on the part of the law enforcement. However, there is another reason that indicates this trend has traction. The public does not always hear about the multi-million dollar financial settlements that municipalities are required to pay for wrongful death or excessive use of force, because these agreements come with rigorous confidentiality clauses. Police who lack training turn out to be extraordinarily expensive to the tax payers. In this context, “lack of training” does not mean insufficient time taking target practice. It means the need for practice in putting oneself in the other person’s shoes and considering possibilities for conflict resolution, de-escalation, and community building. In short, empathy is an important part of the gear deployed by law enforcement as the warrior cop, which will still be needed in extreme situations, gives way to community policing. Really, is there any other kind?

  1. Natural empaths get expanded empathy. This continues the trend from last year. Paradoxically, natural empaths suffer from a lack of empathy. Natural empaths are so sensitive to the pain and suffering of the world that they must isolate themselves, cutting themselves off from the emotional life sustaining recognition and support that people require to flourish and be fully human.

The Natural Empath falls into a double bind, and her suffering seems inevitable. She is swamped by too much openness to the suffering of the other person or overcome by guilt at not living up to her own standards of fellow-feeling and ethics.

But the suffering is not inevitable. Such statements imply that empathy cannot be regulated through training, albeit a training that goes in the opposite direction (from too much empathy in the moment to less empathy) than that required by the majority of people, who are out of touch with their feelings and need to “up regulate” their empathy.

The empathy lesson for the Natural Empath is to “tune down” her empathic receptivity and “tune up” her empathic understanding and interpretation, while being more flexible about her ethical standards. Here “flexible” does not mean be unethical, but rather allow for the possibility that one needs to work on the balance between one’s own well-being and that of others in helping others.

Now please do not jump to conclusions. That does not mean the Natural Empath should become hard-hearted or unkind. That would definitely not expand empathy. In order to overcome the breakdown of empathic receptivity, what does one actually do in order to expand or contract one’s empathic receptivity?

The empathy lesson for such individuals? Practice methods of “down regulating” one’s empathy. For example, focus on mentalizing, top down empathy, placing oneself in the other person’s shoes, rather than imaginatively evoking the vicarious emotions of the other person’s experiences. Perspective-taking exercises—imaginatively putting oneself in the other’s point of view—expand the participant’s empathy during training sessions. Perspective taking incidentally promotes helping, “pro social” behaviors when it indirectly activates pro-social emotions such as compassion.

Instead of complaining about being an overly sensitive, Natural Empath (however accurate that may be) do the work of practicing empathy by “down regulating” one’s empathic receptivity in a given situation, transforming empathic distress into a vicarious experience. Do the work of “up regulating” empathic interpretation whereby one imaginatively puts oneself in the other person’s position and considers the experiences thereby inspired vicariously, reducing the “load” on the emotions. This is different than intellectualizing, compartmentalizing, or distinguishing in thought, but perhaps not different by much. The differences are nuanced, but of the essence.

The recommendation regarding training? Most people need to expand their empathy; some people—Natural Empaths—need to contract (or inhibit) their empathy. Empathy regulation—learning to expand and contract empathy—is the imperative in either case.

  1. Empathy and psychiatry: The mind engage fixing their own professional house: The psychiatrists with whom I talk advocate a deep and authentic appreciation of the practice of empathy—in order to get the patient to take the medicine. I express agreement—if you are thinking of stepping in front of a bus, don’t! Take the medicine and live to fight another day.

However, this points to the blind spot in psychiatry: A conversation for possibility with another empathic human being also changes one’s neurons and does so in a different but as deep and powerful a way as a psychopharmacological intervention. The mechanism is complex is not fully understood, but neither is the mechanism for lithium salts or antipsychotic medications.

Psychiatrists and many general practitioner MDs 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 (for example see Anne Harrington’s The Mind Fixers, p. 273, which I have found essential in identifying this trend and whose language I paraphrase here). Such rhetoric is badly oversold. No one is saying that the medicines do not help the person tolerate distress, regulate emotions, or self-sooth. Often they do. However, the rhetoric is indefensible and the science is at best a work in progress.

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

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. The trend being highlighted here is that, as a profession, psychiatry will focus on medical interventions in the context of culture and community.

  1. The one-minute empathy training is trending: Remove the obstacles to empathy such as cynicism and bullying—and empathy comes forth. Remove the resistances to empathy and empathy naturally and spontaneously expands. Most people are naturally empathic.

Eliminate the obstacles to empathy and a space of acceptance and toleration spontaneously comes froth.

Now do not sufficiently appreciate this: people are born with a deep and natural capacity for empathy, but they are also born needing to learn manners, respect for boundaries, and toilet training. Put the mess in the designated place or the community suffers from diseases. People also need to learn how to read and do arithmetic and communicate in writing. But there is a genuine sense in which learning to conform and follow all the rules does notexpand our empathy or our community. It does not help the cause of expanded empathy that rule-making and the drumbeat of compliance are growing by leaps and bounds.

The work at hand? Remove the blocks to empathy such as dignity violations, devaluing language, gossip, shame, guilt, egocentrism, over-identification, lack of integrity, inauthenticity, hypocrisy, making excuses, finger pointing, jealousy, envy, put downs, being righteous, stress, burnout, compassion fatigue, cynicism, censorship, denial, manipulation, competing to be the biggest victim, insults, injuries to self-esteem, and narcissistic merger—and empathy spontaneously expands, develops, and blossoms. Now that is going to require some work!

Teaching empathy consists in overcoming the obstacles to empathy that people have acquired. When the barriers are overcome, then empathy spontaneously develops, grows, comes forth, and expands. There is no catch, no “gotcha.” That is the one-minute empathy training, pure-and-simple. 

Okay – I have read enough and I want to order the book Empathy Lessons to learn more about expanding my empathy: I want to order the book HERE.

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