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Here is the short, half day course on Empathy, Stress (Reduction) and Neural Science delivered at the Joe Palombo Center for Neuroscience at the Institute for Clinical Social Work. The image depicted is the punchline to a Richard Feynman (physicist) joke about the cosmos – “It’s turtles all the way down” – in the case of neuroscience “It is neurons all the way down!” Granted that the joke is not funny if one has to explain it, the video provides all the background you need to laugh (one way or the other!)
You can also watch directly on Youtube by cutting and pasting into your command line without the dash
A famous person once said: “Empathy is oxygen for the soul.” So if one is feeling shortness of breath, maybe one needs expanded empathy! This course will connect the dots between empathy and neuroscience (“brain science”). For example, empathic responsiveness releases the compassion hormone oxytocin, which blocks the stress hormone cortisol. [This is an over-simplification, but a compelling one.] Reduced stress correlates to reduced risk of such life style disorders as cardiovascular disease, diabetes, weak immune system, depression, and the common cold.
The session engages each of the following modules in the discussion segment, including suggested readings. Except for the first two topics, we can take them in any order and the participants will get to select:
- This is your mind on neuroscience – mirror neurons: do they exist, and if not, so what?
- Sperry on the split brain: the information is in the system: how to get at it
- The neuroscience of trauma – and how empathy gives us access to it
- MRI research: as when Galileo looked through the telescope, a whole new world opens
Image: The punch line is “turtles – all the way down” – well, likewise – “neurons – all the way down.”
Presenter: Lou Agosta, PhD, is the author of three scholarly, academic books on empathy, including A Rumor of Empathy: Resistance, Narrative, Recovery (Routledge 2015). He has taught empathy in history and systems of psychology at the Illinois School of Professional Psychology at Argosy University and offered a course in the Secret Underground Story of Empathy at the University of Chicago Graham School of Continuing Education. He is an empathy consultant in private practice in “on the forward edge in the Edgewater Community” in Chicago. If you need some empathy and want to get a good listening, talk to Dr Lou.
(c) Lou Agosta, PhD and the Chicago Empathy Project
Got to Empathy Lessons on Spotify: https://open.spotify.com/episode/1OvEwkDD9b3IH66erzehnM?si=MeQ6C1uTQDyYGuAUGbegBw ] [more episodes coming soon]
Go to all A Rumor of Empathy podcast(s) on Audible by clicking here: [https://www.audible.com/pd/A-Rumor-of-Empathy-Podcast/B08K58LM19]
A rumor of empathy (the podcast) hears of a report of an alleged example of empathy in the work, action, or conversation of a person or organization. I then reach out to the person and talk to them in detail about the work they are doing try to get the facts and confirm or disconfirm the validity of the rumor. Makes sense?
A Rumor of Empathy is committed to providing a gracious and generous listening, empathy, in conversation with its guests and listeners. Join the host in chasing
down and confirming or debunking an unsubstantiated report of empathy in the community and engaging in an on the air conversation in transforming human struggle and suffering into meaningful relationships, satisfying results and contribution to the community. When one is really listened to empathically and heard in one’s struggle and effort, then something shifts. Possibilities open up that were hidden in plain view. Action that makes a difference occurs so that empathy becomes less of a rumor and an expanded reality in your life and in the community. When all the philosophical arguments and psychological back-and-forth are over and done, in empathy, one is quite simply in the presence of another human being. Join Dr Lou for an empowering conversation in which empathy is made present.
Go to all A Rumor of Empathy podcast(s) on Audible by clicking here: [https://www.audible.com/pd/A-Rumor-of-Empathy-Podcast/B08K58LM19]
One of the misunderstandings of empathy is that “empathy means weakness.” Not so. Why not?
Empathy means being firm but flexible about boundaries. The most empathic people that I know are also the strongest and most assertive regarding respect for boundaries. Being empathic does not mean being a push over. You wouldn’t want to mess with them. Where such people show up, empathy lives—shame and bullying have no place. (For a working definition of empathy, see the note at the bottom of this post.)
Empathy thus solves the dilemma of how to deal with a bully without becoming a bully oneself. Bullies are notoriously causal about violating the boundaries of other people, because it is easier to cause pain than to feel pain. Bullies are taking their pain and working it out on other people. Bullies do not acknowledge their own vulnerabilities, and they work out their issues – I almost said “shxt” –on other people. Bullies are offloading their distress on other people. But what to do about it from an empathic perspective?
I am going to answer that question directly, but first take a short step back: Once the stones start flying back-and-forth, there is nothing to do but defend oneself or try to escape if outnumbered – retreat. If it is a school year brawl, hit ‘em back in self-defense if one is able. If the corporate boss is a bully, document and escalate – and update your resume just in case. If the bully is a politician, speak truth to power like Malcolm-X did: “You did not land on Plymouth Rock; Plymouth Rock landed on you” – use humor to bring down arrogance and privilege.
Once the stones start flying, the conversation is no longer about empathy or vulnerability. It is about who has the biggest cudgel or stone. Empathy did not work – empathy is in breakdown along with common courtesy and decency – call for backup! However, if things are still at the stage of name calling, remember what to my secular ears the ultimate empath of the spirit, Jesus of Nazareth, said and did. He was outnumbered with the woman “taken in adultery” confronting an angry mob of scribes, elders, and Pharisees, armed with large stones: “Let he who is without sin cast the first stone” (John 7:53 – 8:11). Nothing happened. No one dared be the first to assert his perfection. While the originality of this passage may be debated – did John really write it and who the heck is John, anyway – the pasage’s psychological power is beyond question.
In the face of loss of power, authority escalates to violence. Jesus dared to make himself vulnerable by aligning with the woman who had violated the community’s standards, which were so rigid that a case of infidelity threatened to below up the entire fabric of civilization. Otherwise, why would the authorities need to stone her to death? (And it really was all men who were about to do the stoning – so you can see there were many problems here!)
Always the astute practitioner of empathy, Jesus got inside their heads. He knew the authorities wanted to look good and claiming to be better than everyone else would make them look bad. Instead of shaming the woman Jesus turned the tables and put the authorities to shame. To get power over shame one has to allow oneself to be exposed and vulnerable to it. Be proud!
Thus, Brené Brown makes a parallel observation about vulnerability – she does research on vulnerability and shame – and asserts that it is a myth that “vulnerability is weakness.” Thus her project is to expand our appreciation of the power of vulnerability.
As Brené Brown uses the distinction “vulnerability,” she means living with uncertainty, living with risk, and living with emotional exposure. She understands vulnerability to mean letting go of “looking good” or fear of being ashamed. She means it to go in harm’s way emotionally or even physically and spiritually by having difficult conversations and taking actions about the things that make a difference – relationships, finances, careers, values, fairness, and so on. The inner game of vulnerability is different than the behavioral vulnerability that consists in leaving the password to your bank account on a yellow sticky pasted to your computer.
Brené Brown’s coaching is to expand vulnerability in the sense that I have my vulnerabilities; not my vulnerabilities have me. Her lesson “no courage without vulnerability” means that the courageous person goes forth into risk and danger in spite of being afraid. The person who imagines he is without fear is precisely the one who behaves in a foolhardy way, for example, Colonel Custer at the Little Bighorn, about to be wiped out, saying “We’ve got them now!” completely unaware of the risks he was taking. He did not have his vulnerability; his vulnerability had him – and did him in along with his regiment.
I hasten to add that empathy and vulnerability are different phenomena, not to be confused with one another. They are not either/or – the world needs more of each one – expanded empathy as well as the power conferred by expanded vulnerability.
You cannot do empathy alone. I get my empathy from the other individual. The other individual expands my empathy by giving me his; and I acknowledge the other individual’s humanity by giving him my empathy. The baby brings forth the parent’s empathy and is socialized by it – brought into the human community. The student brings forth the teacher’s empathy and is educated through it – brought into the educated community. The customer arouses the businessperson’s empathy and is served by it – brought into the community of the market. The list goes on.
Likewise, you cannot do vulnerability alone. The more armored up and defensive a person becomes, the less vulnerably, the less uncertainty, risk, and emotional exposure the person incurs. However, without uncertainty, risk, or exposure, such essential results as innovation, productivity, courage, relatedness, satisfaction, and, yes, empathy, get lost.
Even though empathy and vulnerability are distinct phenomena, when they occasionally breakdown and fail, the component fragments are remarkably similar. Empathic receptivity breaks down as emotional contagion; likewise, in vulnerability a person is overwhelmed by the emotions of the moment.
Empathic understanding breaks down as conformity. Instead of relating to the other person as an authentic possibility, one conforms to the crowd and what “one does.” Likewise with vulnerability, risk is replaced with playing it safe, not rocking the boat, and remaining as invisible as possible.
Empathic interpretation breaks down as projection. Instead of taking a walk in the other person’s shoes to appreciate where they pinch the other person, one projects one’s own reactions and responses onto the other. Likewise with vulnerability, uncertainty is replaced with being right, making the other person wrong, and shutting down inquiry and innovation in the interest of not rocking the boat.
Empathic responsiveness breaks down in getting lost in translation. Instead of acknowledging the other person’s struggle as disclosing aspects of one’s shared humanity, one tries to “cap the rap,” get the last word in, and win the argument. Likewise with vulnerability, one talks about the other person instead of talking to them. Free speech is alive and well; but what has gone missing is listening. People are [mostly] speaking freely – no one is listening. It doesn’t work.
In each of the breakdowns of empathy, I do not have empathy – rather my break down in empathy has me. Instead of asking, what is wrong? Rather ask, what is missing? And, in this case, what is missing, the presence of which would make a difference, is a radical acceptance that empathy requires emotional exposure to the uncertainty and risk taking of related. That is precisely vulnerability.
When vulnerability is added to empathy the result is community. Since we are on a roll with our secular but empathic interpretation of spiritual readings, in the defining parable of community, empathy is what enables the Good Samaritan (Luke 10: 25–37) to be vulnerable to a vicarious experience of what the survivor of the assault and robbery is experiencing.
In contrast, the priest and Levi experience empathic distress – are armored up and defensive in the face of vulnerability – and have to cross the road. The Samaritan’s empathy tells him what the survivor is experiencing; and it is the Samaritan’s vulnerability and ethics that tell him what to do about it. The two are distinct. Yet empathy expands the boundary of who is one’s neighbor to be more-and-more inclusive, extending especially to those whose humanity has been put at risk by the vicissitudes of vulnerability. Be inclusive.
Note: the short definition of empathy is that it is a multi-phase way of relating to people individually and in community with receptivity to the other’s affects, understanding of the other as an authentic possibility, an appreciation of the other’s perspective, and responsiveness in acknowledgement of the other’s humanity in the other’s communication.
Brené Brown. (2012). Daring Greatly: How the Courage to Be Vulnerable Transforms the Way We Live, Love, Parent, and Lead. New York: Avery, a Division of Random House Penguin.
Lou Agosta. (2010). Empathy in the Context of Philosophy. London: PalgraveMacmillan.
_________. (2014). A Rumor of Empathy: Rewriting Empathy in the Context of Philosophy. New York: Palgrave Pivot.
________. (2015). A Rumor of Empathy: Resistance, Narrative, and Recovery in Psychoanalysis and Psychotherapy. London: Routledge.
_________. (2018). Top Seven Lessons on Empathy For Leadership (webcast): Chicago: 2018: https://youtu.be/GrgDWDt4uqg
________. (2018). Empathy Lessons. Chicago: Two Pears Press.
_______. (2018). A Critical Review of a Philosophy of Empathy. Chicago: Two Pears Press.
Lou Agosta and Alex Zonis (Illustrator). (2020). Empathy: A Lazy Person’s Guide. Chicago: Two Pears Press.
For further details and additional tips and techniques see Lou’s light-hearted look at the topic, Empathy: A Lazy Person’s Guide or one of his peer-reviewed publications see: Lou Agosta’s publications: click here (https://tinyurl.com/y8mof57f)
© Lou Agosta, PhD and The Chicago Empathy Project
Biology is not destiny. As Simone de Beauvoir noted in The Second Sex, woman is not a mere womb. Likewise, I note: man is not mere testosterone. [Note: This post is an excerpt from the final section of Chapter Seven on my book: A Critical Review of a Philosophy of Empathy, available here: click here to examine complete book.]
Biology is important, but biology is not destiny. That was one of the key points of the feminist revolution. Raising children is a job – a big job; and so is being the CEO of IBM as was Virginia Rometty until earlier this year.
The matter is delicate. These human beings – we human beings – are an aggressive species. It is usually the men that are doing the aggressing. That is indeed a function of testosterone – as well as upbringing [child rearing practices], enculturation, and the evaluation of the species.
Common sense suggests that woman is the more nurturing gender, given her role in giving birth and keeping the home fires burning in agricultural, hunting, and traditional indigenous cultures. Women are keeping the home fires burning, so what are the men doing? Men are out systematically doing battle with saber-toothed tigers and hostile neighbors. If this seems like an over-simplification, it is. Yet it is a compelling one, given the evolution and history of the species.
This issue of empathy and gender becomes controversial. Claims have been made that a man’s brain is different than a woman’s. In particular, men are “wired” for systematizing; and women are “wired” for empathy – for relating, especially relating to children and other human beings in general. This research – usually credited to neuropsychologist Simon Baron Cohen but also to Frans de Waal – has for sometime now been debunked – shown to be limited, distorted, and flat out wrong.
When one looks at the methods and the data in detail, no consistent gender difference in empathy have been observed – read on!
I provide the reference point upfront. As noted, the research by Simon Baron Cohen that men’s brains are “wired” for systematizing and women’s for relating and relationships are questioned and indeed debunked in Robyn Blum’s article in Heidi L. Maibom, ed. (2017). (For Bluhm’s original article see The Routledge Handbook of the Philosophy of Empathy. London/New York: Routledge (Taylor and Francis): 396 pp. )
Robyn Bluhm’s article probes the research on the evidential basis of this nurturing role and inquires: does it extend to empathy and how far?
Early gender-empathy studies were vulnerable to self-report biases and gender stereotyping that pervasively depicted females in a biased way as the more empathic gender. According to Bluhm, these early studies simply do not stand up to critical scrutiny. Case closed on them. Dismissed. Enter Simon Baron-Cohen and his innovative research, renewing the debate and shifting it in the direction of neural science as opposed to social roles and their self-fulfilling stereotypes.
Bluhm points out in detail that as Baron-Cohen’s work gained exposure and traction in the academic market place of ideas subtle shifts occurred in his presentation of the results. At first Baron-Cohen highlighted measures that were supposed to assess both cognitive and affective empathy, but later the affective dimension fell out of the equation (and the research) and only cognitive empathy was the target of inquiry and was engaged (p. 381).
Though Baron-Cohen’s initial research described the “male brain” as having “spatial skills,” his later publications, once he became a celebrity academic (once again, my term, not Bluhm’s), redescribe the male brain as “hardwired for systematizing”; likewise, the “female-type” brain, initially credited with being better at “linguistic skills,” was redescribed as “hardwired for empathy.” The language shifts from being about “social skills.” Baron-Cohen speaks of “empathy” rather than “social skills,” so that the two distinctions are virtually synonymous (p. 384).
As the honest broker, Bluhm notes that, as with the earlier research in gender differences, Baron-Cohen’s research has been influential but controversial. Men and women have different routes to accessing and activating their empathy; they respond to different pressures to conform to (or rebel against) what the community defines as gender-appropriate behavior; and men and women even have different incentives for empathic performance.
For example, “…[M]en’s scores on an empathy task equaled women’s when a monetary reward for good performance was offered” (p. 384). Monetary rewards up; empathy up? Though Bluhm does not say so, I came away with the distinct impression of a much needed debunking of the neurohype—what we would now call “fake news”—a job well done.
Bluhm’s work is especially pertinent in constraining celebrity, executive consultants (once again, my term), running with the neuro-spin, and publishing in the Harvard Business Review, who assert that brain science shows we need more women executives on corporate boards to expand empathy.
I hasten to add that we do indeed need more women executives, but that is not something demonstrated by brain science, at least as of this date (Q2 2020). We need more women executives because it is demonstrated by statistics (just one of many sources of reasons other than brain science) that to devalue the contributions to innovation, service, and productivity of slightly more than half the population is bad business practice—foolish, inefficient, and wasteful. The challenge is that the practices that make one good at business—beating the competition, engaging technology problems, solving legal disputes—do not necessarily expand one’s empathy, regardless of gender.
[In a separate, informal email conversation (dated July 2, 2018), Bluhm calls out Cordelia Fine’s fine takedown of “The Myth of the Lehman Sisters” in the last chapter of Fine’s book (not otherwise a part of Bluhm’s review): Cordelia Fine, (2017), Testosterone Rex: Myths of Sex, Science and Society. New York: W. W. Norton. It is a bold statement of the obvious – that the part of basic anatomy that differs between men and women is definitely NOT the brain. But that is missed due to lack of empathy which is committed to responding to the whole person – not just the brain or the sex organs.]
In an expression of insightful and thunderous understatement, Bluhm concludes: “With the exception of studies that rely on participants’ self-reports or on other’s reports of their behavior [which are invalid for other reasons], no consistent gender differences in empathy have been observed. This raises the possibility that gender differences in empathy are in the eye of the beholder, and that the beholder is influenced by gender stereotypes…” (p. 386). Just so.
Okay, having debunked the myth that men’s brains are different – and in particular less empathic – what to do about the situation that many men (and women?) struggle to expand their empathy? The recommendation is not to treat empathy and an on-off switch. Empathy is rather a dial – to be tuned up or down based on the situation. That takes practice.
Some men – many men – may start out with an empathic disadvantage in experiencing their feelings after having been taught such stuff as “big boys don’t cry.” But if people, including men, practice getting in touch with their experience, then they get better at it – experiencing their experience. Likewise, with empathy. If you practice, you get better at it. For those interested in practicing, but not working too hard, may I recommend: Empathy: A Lazy Person’s Guide: click here to examine (and buy!) the book.
Ickes, William & Gesn, Paul & GRAHAM, TIFFANY. (2000). Gender differences in empathic accuracy: Differential ability or differential motivation?. Personal Relationships. 7. 95 – 109. 10.1111/j.1475-6811.2000.tb00006.x.
(c) Lou Agosta, PhD and The Chicago Empathy Project
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.
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.
- 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.
- 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.
- 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 .
- 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])
- 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?
- 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.
- 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.
- 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
People want to know: Can empathy be taught? People complain and authentically struggle: I just don’t get it—or have it. In spite of the substantial affirmative evidence already cited, the debate continues.
The short answer is: Yes, empathy can be taught.
The one minute empathy training is: most people are naturally empathic. Remove the obstacles to empathy and empathy comes forth.
Remove the resistances to empathy and empathy expands.
Eliminate the obstacles to empathy and a space of acceptance and toleration spontaneously comes froth.
What happens is that people unwittingly have been taught to suppress their empathy. People have been taught to conform, follow instructions, and do as they are told. We are taught in first grade to sit in our seats and raise our hands to be called on and speak. And there is nothing wrong with that. It is good and useful at the time. No one is saying, “Leap up and run around yelling” (unless it is summer vacation!). But compliance and conformity are trending; and arguably the pendulum has swung too far from the empathy required for communities to work effectively for everyone, not just the elite and privileged at the top of the food chain.
Now do not misunderstand 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 not expand 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.
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.
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, injuries to self-esteem, and narcissistic merger—and empathy spontaneously expands, develops, and blossoms. Now that is going to require more than a minute!
Studying the Humanities and literature, art and music, rhetoric and languages, opens up areas of the brain that map directly to empathy and powerfully activate empathy. Read a novel. Publish a blog post. Go to the art museum. Participate in theatre. These too are empathy lessons, fieldwork, and training in empathic receptivity.
Reduce or eliminate the need for having the right answer all the time. Dialing down narcissism, egocentrism, entitlement (in the narrow sense), and dialing up questioning, motivating relatedness, encouraging self-expression, inspiring inquiry and contribution, developing character, and, well, expanding empathy.
Yes, empathy can be taught, but it does not look like informational education. It looks like shifting the person’s relatedness to self and others, developing the capacity for empathy, accessing the grain of empathy that has survived the education to conformity. Anything that gets a person in touch with her or his humanness counts as training in empathy.
(Note: Putting the “one minute” into the “one minute training” so that readers would not have to work too hard was hard work. I did the work of reviewing over a hundred publications on empathy training, the two dozen most significant of which are listed here: For evidence-based research on empathy training see the Bibliography and start with this list.
 Angera et al. 2006; Antoni et al. 2011; Brunero et al. 2010; Chiu et al. 2011; Coke et al. 1978; Davis et al. 1996; Decety et al. 2012; Del Canale et al. 2012; Golan et al. 2006; Gordon 2005; Hadwin et al. 1997; Halpern 2001; Hojat et al. 2009; Hojat et al. 2011; Levine 2012; Ozcan et al. 2012; PBS 2013; Pace et al. 2009; Pecukonis 1990; Riess 2013; Riess, Kelley et al. 2014; Riess, Kelley et al. 2012; Therrien 1975; Zaki and Cikara 2015 (Note – this required more than one minute!)
For those interested in more than one-minute of training: 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 EMPATHY Lessons from Amazon). Also of interest: A Rumor of Empathy.
Remove the resistance to empathy and empathy grows, develops, and blossoms. In every instance of resistance to empathy, the empathy training consists in identifying, reducing, or eliminating, the resistance to empathy. When the resistance is reduced, empathy has space to develop, and it does so spontaneously as well as through providing explicit practices, tactics, strategies, and training .
(c) Lou Agosta, PhD and the Chicago Empathy Project
Empathy is good for your health and well-being: Empathy is on a short list of stress reduction practices including meditation (mindfulness), Tai Chi, and Yoga. Receiving empathy in the form of a gracious and generous listening is like getting a spa treatment for the soul. But do not settle for metaphors.
For evidence-based research on empathy, empathy and stress reduction, and empathy training you may start by googling: Antoni et al. 2011; Ciaramicoli 2016; Del Canale et al 2012; Farrow et al. 2007; Irwin et al. 2012; Maes 1995, 1999; Pollack et al. 2002; Rakel et al. 2009; Segerstrom and Miller 2004; Slavich et al. 2013 [this list is not complete].
You do not have to buy the book, Empathy Lessons, to get the research, but if you would like more detail see especially Chapters Four and Six in Empathy Lessons (click here to get book from Amazon).
[Also included are chapters on the Top 30 Tips and Techniques for Expanding Empathy, Overcoming Resistance to Empathy, Empathy Breakdowns, Empathy as the New Love, Empathy versus Bullying, and more.]
The healing powers of stress reduction are formidable. Expanding empathy reduces stress; and reducing stress expands empathy. A positive feedback loop is enacted. Expanding empathy expands well-being. Here empathy is both the end and the means.
A substantial body of evidence-based science indicates that empathy is good for a person’s health. This is not “breaking news” and was not just published yesterday. We don’t need more data, we need to start applying it: we need expanded empathy.
Evidence-based research demonstrates the correlation between health care providers who deliver empathy to their patients and favorable healthcare
outcomes. What is especially interesting is that some of these evidence-based studies specifically excludepsychiatric disorders and includemainline 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.
The biology has got us humans in a bind, since it 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.
(c) Lou Agosta, PhD and the Chicago Empathy Project
When I say, reading Arthur Kleinman’s books changes one’s listening, I do not mean changes one’s listening the way reading Lacan or being hit on the head with a rolled up newspaper changes one’s listening. What I mean is, reading Kleinman expands one’s humanity, empathy, and capacity for engaged caring.
This is likewise the case with The Soul of Care: The Moral Education of a Husband and a Doctor (due out September 17, 2019 from Viking), the most important memoire by a psychiatrist since Carl Gustav Jung’s Memories, Dreams and Reflections (1962) [though with a different source and trajectory], an unsolicited prepublication copy of which showed up in my snail mail. It is a real page-turner.
Arthur Kleinman, MD, trained as a psychiatrist, is an innovator in medical anthropology, a discipline of which he is the virtual founder. He and his late wife Joan, also an academic, spent considerable time and effort doing cross cultural (anthropological) research in China on traditional medicine, modern medicine, and the connecting points (and divergences) thereof. Of particular interest were survivor of Mao’s Cultural Revolution, who suffered from the symptoms of “neurasthenia,” a disorder whose explicit diagnosis has declined in the west – including fatigue, dizziness, anxiety, demoralization, and hard to diagnose pain(s).
In the course of their time in China, Kleinman (Arthur) gets a combination of exhaustion and dysentery, which reaches life disabling and even life threatening, stages. Joan is the very soul of caring – nursing him back to health.
This provides one of the paradigms for Arthur when Joan eventually gets early onset Alzheimer’s and he decides to take care of her at home.
The Soul of Care is the memoir of Kleinman’s life’s work (to date) and what happens when he decides to practice what he preaches and takes on the task of carrying for his increasingly ill wife, Joan.
Kleinman does not use the word “empathy” much, but it lives in his work, and in this case, the man is living in an empathy desert and that includes the health care system that is relating to him as pain instead of a whole person. Kleinman’s listening, which creates a context for human relatedness, succeeds in moving the dial back a few notches, though no way exists of undoing the now fused spine.
I have frequently had my mind blown by the power and precision of Kleinman’s writings. For example (and now we are in The Soul of Care), another patient has intractable pain relating to her diabetes, yet the diabetes is under control. The numbers from the blood work and related tests show that the diabetes should not be producing such results. Something is not adding up. Is the patient faking? Is there some disorder that has been overlooked?
This fellow, Kleinman, sits down and has a conversation with someone with intractable pain. He is genuinely curious about the patient. He is interested. He nails it. He brings along a medical student on a home healthcare visit. The above-cited patient is a diabetic, and is eligible for Meals on Wheels, transportation to the hospital, alternative housing (p. 206). The medical team (notice: there is a team!) had no idea, because no one asked.
Time-after-time, Kleinman shows up and asks a few questions – it all comes tumbling out – in many cases out-and-out trauma; in other cases, subclinical post traumatic stress disorder; in most cases, life circumstances, stress, inaccurate or incomplete diagnoses being transformed into bodily symptoms.
Continuing the above example, the patient is a single working mother; poor; working the grave yard shift while simultaneously cooking, cleaning, getting her kid (who is doing quite well, thanks) to school, and managing everything else well enough – everything except her pain. The patient is not faking – the pain is authentic, but diabetic neuropathy is not the cause. The cause is a work life imbalance of virtually unimaginable proportions (once again, “work-life balance” is my summary description, not Kleinman’s). The patient is running flat out, and is eligible for food stamps and other support available within the system. But no one on the team even bothered to have the conversation, even bothered to ask.
What is happening is that a medical issue does indeed exist. But the human being is more than an insulin pump. If medicine wants to be a caring profession not a bureaucratic profit center, then the doctor may useful make inquiry as to what the patient thinks is going wrong (and right) in her life. What is happening is that the emotions, affects, cognition, personal spirit, are elaborating what is in effect the anatomical or organic lesion and defect.
One can appreciate that individual practitioners may well feel they are like the “Lone Ranger,” single-handedly arrayed against human suffering. One will do what one can, writing the prescription at the end of the session for something, anything, to at least get the placebo affect as a positive expectation itself sets off a cascade of neurotransmitters. Kleinman appreciates how devilishly tricky it is both to address the biological system and the suffering human being present in the space
Yet Kleinman is uncompromising – and with good reason. Time-after-time, simple inquiries as to what are the facts of the person’s life circumstances point powerfully in the direction of human interventions that shift the person out of suffering and stuckness and into action. Putting the pain in context enables the person(s) to improve their own health through life style adjustments.
After all, is this not the age of the informed, engaged, proactive health care consumer? Many medical doctors pay lip service to such engagement, yet are not prepared to answer questions or, just as importantly, help the patient formulate the half-formed questions they are struggling to express. Do the job, do it completely, and do it the way it was meant to be done on behalf of the patient and suffering humanity.
Pain is one of those things that sometimes one can’t live with, but one certainly can’t live without. The reflex that causes one’s hand to jerk off of a hot casserole dish is not yet pain. The reflex precedes the experience of pain by a couple of seconds.
The reflex does not go through the brain; the experience of pain does. To become pain, the sensory information in the nerves has to go through the brain. In short, pain is important to tell the person about damage to his or her body that requires attention. Pain powerfully focuses one’s attention on getting actionable results in addressing the problem. But pain can cause a member or organ to become hyper-cathected – a tight loop that creates pain in anticipating pain to avoid pain. By focusing on the pain, attention can expand pain, grow pain, and become a habitual pattern of pain stimulation to the organism. Focus one’s attention elsewhere? Easier said than done, though alternative interventions such as meditation, hypnosis, and self-soothing stress reduction activities (which Kleinman does not much discuss) aim to do just that.
Kleinman is himself something of a survivor: a son who never met his biological father, a grade school student who bore two utterly separate family names once his mother remarried, from two opposed sub-ethnic factions, one in public school, the other in religious school; a scion of a mysterious past about which his Victorian family was silent or whispered inarticulately, so that he had the extra developmental task of figuring out by himself, yet not announcing to others, lest they be hurt what identified me, which therefore could not be authorized (or denied). (See Writing at the Margin (p. 2).
I learned a lot about empathy from Kleinman, though he rarely uses the word. Nor would I consider Kleinman an advocate of empathy understood in the narrow sense of a psychological mechanism. Rather in a medical world (Kleinman is a psychiatric), in which diagnostic categories are mapped to psychopharm interventions, Kleinman is an articulate advocate for sitting down and talking to the individual about what is going on in the person’s life. What is working and what is not working? While it takes extra time upfront, such a conversation for possibility makes a profound difference in actually getting an accurate diagnosis as opposed to a good enough, makeshift band-aide.
Kleinman several times quotes the celebrated founder of sociology Max Weber in his studies on bureaucracy. As institutions become larger and more complex, rules and roles independent of individual charisma and personal genius are needed to scale up to deliver services to more people. Nothing wrong with that as such – serving more people with high quality medical care is everyone’s aspiration. Yet when I have a disorder whose cause or course are unclear, like most people, I want the brilliant diagnostician, the TV doctor from central casting whether Ben Casey or House or whoever is trending, not a functionary.
For those interested in additional diagnostic pyrotechnics or just plain background, The Illness Narratives, the essentials of which are recapitulated in The Soul of Care, is the place to look for expanded and amazing narratives. It too is a real page turner.
Kleinman’s The Illness Narratives: Suffering, Healing, and the Human Condition (Basic Books 1989) distinguishes incisively between the person’s experience of illness and the doctor’s concept of the disease as part of a biological system. To be sure, substantial overlap often exists between these two, but not always. What then opens up and becomes possible is an entire method and approach to healing that puts biological reduction in its proper place.
For example: When chest pain can be reduced to a treatable acute lobar pneumonia, the biological reduction[ism] is a success. When chest pain is reduced to chronic coronary artery disease for which calcium blockers and nitroglycerine are prescribed, while the patient’s fear, the family’s frustration, the job conflict, the sexual impotence, and the financial crisis go undiagnosed and unaddressed, it is much less of a success (The Illness Narratives, p. 6).
The Illness Narratives expanded my appreciation of how a physical injury can take on a life of its own. The injury is real enough and it becomes a grain of sand around which a misshaped black pearl is elaborated (my metaphor, not Kleinman’s). The physical issue is elaborated by the emotions, as unresolved personal issues in a person’s life seem to be magnetically drawn towards making meaning out of pain and suffering.
Another example, in The Illness Narrativesa self made assistant police captain, performing good work, helping a neighbor, throws out his back. The pain gets habituated. He just can’t shake it off – month after month. It is affecting his job performance. He needs even more down time, sick time. He starts to feel that people do not believe him – he is really suffering.
To demonstrate to others and to himself how serious the matter is – and in the hope of finding relief for his pain – he agrees to surgery. However, if one is in pain, surgery can be a deal with the devil (so be sure to read the fine print), because, at least in the short term, surgery is a cause of acute pain.
Several years – and surgeries – later, the person – now a picture of pain – walks into Dr Kleinman’s office. The patient is the walking embodiment of pain. His every more seems painful. A conversation reveals a life narrative not for the faint of heart. He was not quite abandoned as a child, but basically he had to raise himself. He would have starved as a kid of tender age if he had not learned how to scramble some eggs; his head barely reaching high enough to assess the progress of the food in the frying pain.
Culminating in his latest contribution, The Soul of Care, Kleinman’s career has spanned the Corporation Transformation of American Medicineas identified by Paul Starr (1984) during which the medical doctor has gone from being a sovereign authority, whose word was virtually the law, to being a functionary in a corporation optimized for capitation and revenue generation, all the while paying marketing firms to communicate how caring everyone really is.
In order to preserve the integrity of his commitment amidst the corporate transformation of American medicine, Kleinman innovates, inventing his own field of study, medical anthropology. It has legs. It works. A journal is founder. High quality articles are published. Institutions, funders, and financial support are forthcoming. He teaches it at Mass General – we pause to honor the storied name – and at Harvard – another pause. With all this pausing, we are never going to get through this review. Yet the broader lessons for healthcare as a whole of medical anthropology do not break out of its own resonant, transformational niche.
Kleinman is definitely not living in a cave. He spends seven continuous years doing cross cultural research in China with his wife Joan, who becomes fluent in Chinese and provides important auxiliary functions in team building, networking, and having a life. (I shall follow the convention of calling “Arthur” by “Kleinman” and “Joan Kleinman” by “Joan” for simplicity.)
Therefore when Kleinman’s own world is brought low as the love of his life and his professional partner, his wife of thirty years, Joan, is stricken with early onset Alzheimer’s, he find himself wrestling not only with the disease but with the medical bureaucracy and the fact that his innovations in medical education have definitely notbeen widely adopted.
First he learns how to perform household chores. He learns how to pay the bills. He takes over bathing Joan and preparing meals. He marshals support from his gown up children, who have kids of tender age of their own and are running flat out – all the while continuing teaching and research (albeit with a certain amount of flex time provided by his long-term employers – pause again to honor them – for whom Kleinman is a celebrity academic).
He gets a home helper, who is indeed an essential part of the support system. With 20-20 hindsight, he second guesses his own agreement, requested by Joan, that she be allowed to decline (and die) at home. He has an important late insight, realizing that Joan is no longer the person who entered into that agreement, the dementia having robbed her of [essential aspects of] her identity. Nor is he the same person, who he was after the ongoing ten year long struggle. Between Joan’s agitation, loss of identity, intermittent fear or psychosis, and incontinence (wandering was less of an issue, because the patient became blind), all bets – and prior agreements – are problematic.
The couple consult many specialists. The neurological resident Kleinman and his wife visit is interested in talking with them again – in six months – and in following the irreversible course of the disease, not in engaging with the human impact and cost for the wife and husband.
Confidentiality is important; but it becomes yet another obstacle as the well-intentioned neurology resident insists on addressing Joan, even though her expressed wishes are that Arthur be included in all the decisions. Queue up the living will and health care power of attorney. All well and good. But the problem is that the patient does not want to have a legal conversation, she wants to have one about caring. Noticeably absent is guidance as to caring. Key term: caring.
Kleinman matriculates in the college of hard knocks. As caring – and empathic – has he already is, it is all used up by the progressive dementia. He gets a home helper since, though relatively well off, he must keep working to pay the mounting bills – and for his own sanity. Towards the end of the middle stage of the disease, he actually takes her with him to Shanghai, China, in order to fulfill academic obligations and complete a stalled project in cross cultural health care.
The reader cannot help but wonder, “What is this guy thinking?” as he takes Joan, by then an easily agitated person developing Capgras (“imposter”) syndrome, through airport security to Shanghai. Somehow he pulls it off. The quality of care in China and the support for the family is truly inspiring, especially given how eager his Chinese colleagues are to be supportive with both traditional and modern medicine (and given that no one really has the answer regarding Alzheimer’s).
Without using the word “empathy,” Kleinman was already operating at an advanced level in relating to others in a caring way. He is the Other whose listening brought relatedness to suffering individual in one case after another. Now he faces new, life-defining challenge.
A recurring theme becomes how his ten years of care giving becomes a descent to the hell of irreversible dementia without the prospect of rebirth. As near as I can figure, his is a journey of the hero, with ample commitment and tragic struggle, but without heroism.
Even given his training as a psychiatrist and anthropologist, a well-connected professorial network with high quality, [relatively] responsive support, he is brought low, isolated, at the brink of emotional despair. But how could it be otherwise? He is losing his wife to a disease that robs a person of her identity (i.e., dignity), but she is still physically present and intermittently coherent. Even so he struggles to get straight answers from the medical professionals about the course of the disease, about the trade-offs between home care and assisted living.
The back story is that at some point early on in their relationship Joan decided that her life project was to take care of him (Arthur), the family, the kids, even supporting his research – they published academic papers together – while also mastering the Chinese language and immersing herself in that culture. She got good at it – very good indeed.
Kleinman decides that he wants to return the favor. Of course, it is not as simple as that. Kleinman talks about his own guilt and what he had to survive coming up. The point is that this man Arthur Kleinman is already the soul of caring; but he takes his caring to a new level through the refiner’s fire of caring for Joan.
It is a heart-warming and inspiring narrative – the ultimate illness narrative (also the title of Kleinman’s most impactful work prior to this one) – but also a harrowing one. Not for the faint of heart. Apparently at some point, [many] advanced Alzheimer’s patients stop eating. A morphine drip and lip moistening are the palliative measures recommended.
If you need a good cry, you will get one by the time Kleinman realizes there is no way to take care of Joan at home even with a full time assistant. The end is not
quick, but given the morphine drip, neither is it painful. What it is is impossible to put into word. The image of suffering of Shakespeare’s Lear, blind and wandering in a storm of agitated emotions towards the edge of the cliff, looms large. It’s her; it’s him; it’s both, though he ends up being a survivor. What is painful is the loss – the loss of humanity of the Alzheimer’s patient.
When Kleinman uses the word “moral” – it occurs in the subtitle of The Soul of Care as well as in the subtitle of his What Really Matters(Oxford 2007) – of course, he is referring to value judgments, candidate categorical imperatives, and assessment of ethically right and wrong behavior and character. At times, I doubt that the word “moral” adds to the discussion, since it is mainly about preserving one’s sanity in the face of the disintegration of the skills needed for the activities of daily living.
“Humanity” and “morality” overlap extensively and I doubt it makes sense to ask which came first. Yet they are not identical. There is a conflictual aspect to our humanity that morality attempts in vain to capture and make right by judging. Lear, blind and stumbling towards the edge of the precipice, is also wandering at the edge of morality, though arguably he never stops being a struggling human being. Neither does Kleinman.
Nor at any time does Kleinman become a moral relativist, though he is keenly in touch with the fuzzy, grey areas. The problem is that the space of human action and engagement becomes so thick with judgments and evaluations that one can hardly think, much less take action in the face of urgent emergencies.
Most of the tough (and narratively engaging) cases involve fraught decisions where fundamentally good people actually perform bad actions. In some cases the consequences of the action escape from the agent – as when the soldier follows the sergeant’s orders and blows up the car supposedly containing the suicide bomber, but it is actually a family of five on the way to deliver a baby. That is moral trauma. But in other cases individuals actually, intentionally commit war crimes (e.g., Winthrop Cohen in Kleinman’s What Really Matters) and spend the remainder of their lives twisted in knots over what happened, what does it mean, and how to go on.
Taking matters up a level, one such looming moral trauma is the ongoing corporate transformation of American medicine.
Kleinman channels some of his well-founded anger into targeting the systematic breakdowns of the American Healthcare system in the face of revenue incentives, corporate metrics, and devaluing caring. His jeremiad – I mean, argument – may usefully be made required reading – not only for doctors but especially for administrations and managers – in medical schools and systems. It is often the administrators who are taking advantage of the medical professional’s empathy in demanding more patients per period with no compromise of quality or attention to the demands of addressing human suffering in its physical as well as emotional and spiritual aspects.
Kleinman throws down the gauntlet, demonstrating just how far main stream, neoliberal, bio-political health care has diverged from his humanistic vision: “The problem, as some suggest, is not that we fail to quantify these experiences [of caring], but that they cannot be quantified, because they are essential human interaction, the soul of what health care is” (p. 238).
Many long term advantages exist in reducing spending upfront by life style changes in nutrition, exercise, stress management – and avoiding expensive medical technologies and interventions once the damage is done. A compelling quantitative case can be made that an ounce of prevention is worth a pound of cure.
Nevertheless the fact remains: quality health care is expensive. Though I am just a citizen, the Siemens Magnetic Resonance Imagining (MRI) device that took a picture of the torn cartilage in my knee looks to be almost as large and as complex, though in totally different ways, as the lunar excursion module (LEM) that landed two men on the moon in 1969. It turns out to be Rocket Science, so why should it be less expensive? Imaging, genomics, proteomics, personal medicine, personalized treatment using the most advanced technologies are quite simply expensive.
What is a lot less expensive – though by no means totally without cost – is sitting down and having a conversation for possibility with another human being – about her pain, disorder, and her life. And this conversation is one of the sources of quality healthcare and human flourishing, or at least pain management. This provides a powerful picture, too.
Read an excerpt from the book, quoted in Time Magazine: https://time.com/5680723/doctor-wifes-alzheimers/
A rumor of empathy is no rumor in The Soul of Care and Kleinman’s works. Empathy LIVES in Kleinman’s contribution. Kleinman does not emphasize this point about the power of ordinary language, though it is near enough to the surface of his text, but rather calls out the moral imperative: we must think deeply and with integrity about the kind of society and community we want to be. The extreme wealth being generated by innovations in technology make possible maximizing acts of humanity that advance community well-being. Whether that happens to the USA, as a healthcare nation is an existential choice of the highest order on the part of the individual and the community.
Lou Agosta, PhD and the Chicago Empathy Project
Narrative Exposure Therapy (NET) was originally designed as a treatment for victims of war, persecution, and torture. Civil wars (e.g., Rwanda, Burundi, DR Congo, Iraq) often target civilians and include widespread atrocities and human
rights violations. For example, the widespread use of rape as a weapon of war and the recruitment of child soldiers in the civil wars of east Africa have left entire populations traumatized even after the cessation of hostilities.
Engaging with these survivors is not for the faint of heart. Therapists are at risk of compassion fatigue and burn out. Many survivors have had to run the gauntlet of multiple, complex traumas, requiring a raid on the inarticulate even to bring their suffering to language. NET is such a raid on the inarticulate.
The colleagues at the Universities of Konstanz and Bielefeld have innovated in the matter of an intervention that aims at restoring the survivor’s humanity, does not leave the therapist overwhelmed, is scalable, is relatively brief, indirectly gathers data to pursue justice against the perpetrations, and is evidence-based in reducing the symptoms of post traumatic stress disorder (PTSD) even in populations with limited resources.
In a Grand Rounds session on NET at Rush Medical Center, Chicago, in March (2019), I raised the issue of empathy and the risk of burn out with Dani Meyer-Parlapanis Doctor of Psychology, University of Konstanz). Dr Dani is notone of the authors of the text under review here. However, she trains NET practitioners and is providing leadership in extending NET to other applications, including girls and women who embrace violence. I said to her: “If this is not empathy, I would not know it: Empathy LIVEs in NET and in the work you-all are doing. You are engaging with child soldiers and really tough cases. What about it?”
Dr Dani of course acknowledged that compassion fatigue (“burn out”) was a significant risk in engaging with large numbers of survivors of complex trauma, so the NET trainers, are, in effect, counseling the lay counselors notto go into unnecessary detail at first (or words to that effect). Just get the time-line and a label for what happened. But then acknowledging full well that the work was precisely to go into the details she said: “The idea is to be like an investigative reporter.” Though acknowledging the matter may be controversial, I took that to mean empathy in the sense of data gathering and sampling the survivor’s experience, not immersing oneself in it. The investigative reporter is not hard-hearted, but in tune with what the survivor is experiencing. That indeed is the heart of the investigation.
Thus, “empathy” is distinct from compassion. Empathy targets a form of data gathering about what the other person experienced, a sampling of the other’s experience. Such empathy is in tune with the boundaries between self and other and leaves each individual whole and complete in a context of acceptance and toleration. I believe the definition of empathy of Heinz Kohut (1959) as vicarious introspection aligns remarkably well with that employed in NET.
In the face of compassion fatigue, dial empathy up or down by simulating the role of an investigative reporter. If one can say exactly what happens, the trauma begins to shift, lose power, and shrink, typically by being reintegrated in the context of everyday life and experience. In this case, the investigative reporter also uses vicarious introspection. Easier said than done; but necessarily both said and done.
The reader in Chicago may say that’s fine, but what has it got to do with the situation here in the USA? We do not have child soldiers or wide spread traumatized populations.
Think again. Gangs are recruiting children of tender age not only as messengers but also as triggermen, because they know youngsters will face a different criminal justice system and process, generally more lenient, than adults.
After two wars, stretching back to the consequences of the 2001 terrorists attacks, the population is peppered with wounded warriors, both men and women, with a diversity of untreated symptoms from subclinical substance abuse to PTSD, thought disorders, and depression. Violence against (and abuse of) women is no longer an issue in the inner city, but is acknowledged to be a challenge from Hollywood to corporations and the US Supreme Court.
So, while NET has not received much application in the USA (or the first world), the unmet need is great and it deserves consideration. Hence, the value of this overview.
In some four to fourteen sessions of 90–120 minutes each, the therapist and client create an autobiographical time-line that names the events that have stimulated the most affective arousal in the person’s life. These include traumatic events such as aggression, sexual boundary violations, deaths of loved ones, becoming a refugee, and so on. Positive events are also included on the time-line such as births, marriages, graduations, and life successes. Fast forwarding through the process, the client is handed a copy documenting the narrative at the end of the sessions and a copy is retained just in case the client wishes/agrees to submit the report to the authorities for judicial, prosecutorial follow up.
One of the innovations and most challenging aspects of the narrative in working with former child soldiers (who have grown up in the interim) is to create a context of acceptance and tolerations. Naturally the therapist must employ empathy, but he or she does so as an investigative reporter gathering data about what happened. To become a child solider the survivor is generally required to commit an atrocity such as kill a member of his or her family. Issues of shame and guilt along with the deadening loss of one’s own humanity are powerfully present and evoked.
The first session begins. Diagnosis and psycho-education occur up front. The client may not even know what is PTSD. The client may be living a basically resigned and hopeless existence, and she or he must be enrolled in the possibility of recovery. The education includes information on symptoms, what is involved in the therapy, as well as a statement about the universality of human rights.
An initial pass through the client’s autobiography occurs. A time-line, the life span history, is completed during the second session. The task is to name or label the event in the course of one 90–120 minute session without calling forth the details and hot emotional impact of the traumatic incident. A rope line is used with a variety of stones for traumas, flowers for positive events, and sticks for when the client perpetrated a dignity violation against another. The subsequent work of sessions three through fourteen is to engage sequentially with the events. The work at hand is to find words to express what has previously been unexpressible.
The narrative work consists of going through the events of the time-line. When? Where? And what? The five senses are invoked. Hot memory, sensation, cognition, and emotion are called forth. What did the background look like? What were the people wearing. Small, cold details call forth powerful hot emotions.
The idea is to put into words and capture verbally the hot affect and experience. The session is not over until the client (often with the support of the therapist) is able to describe what happened in words – that is the narrative.
Now “what a person made it mean” also starts to emerge at this time, and those meanings will naturally be compared with reasonable (or unreasonable) assessments of what to expect of children or people literally with a gun or machete to their necks.
Talking about what happened in the course of the traumatic events calls forth the hot experiences. Talking about what happened following the traumatic events put the hot events back into the context of cold experience. Talking about what happened following the trauma enables the client to reintegrate the trauma into the all-encompassing, greater life narrative. The client is reoriented in time and space to the present, the trauma is contextually situated as to emotional meaning. Before the session ends, the therapist verifies and validates that the client’s arousal has subsided to standard levels and is oriented to the present.
Cognitive restructuring occurs automatically in the days after the story telling. The client may return to the next session with new insights, meanings, and understanding of her or his own behavior in the trauma. Formerly inaccessible details (memories) may emerge and should be included in the narrative.
For example, one child soldier reported that he killed his sister by cutting her neck with a machete as part of the initiation, for which he bore a great emotional and moral burden; but he subsequently remembered that one of the paramilitaries hit his sister in the head with his rifle butt, a fatal blow, prior to his own action. Therefore, though he did in fact cut his sister, he did not kill her. Small comfort; and not a choice anyone should have to make; yet a significant step in recovering this individual’s dignity and humanity.
In the final session, the client is given a document of her or his narrative lifeline with the details filled in. Where appropriate, the client is asked if he wants to forward the data to the authorities for prosecution of the high level authorities and perpetrators who organized the war crimes. Follow up occurs at six months and a year, often documenting further improvement in symptom reduction, acquisition of life skills, and accomplishments.
NET is trauma focused but unlike many trauma focused therapies that require the survivor to identify thetrauma or select the worst trauma (“good luck with that”), NET acknowledges that survivors of war, torture, and persecution have encountered a sequence of traumas. This is call a “life span” approach.
Granted NET evokes a grim calculus, the number of traumatic event types – beating, rape, killing, torture, branding, amputation, witnessing these, destruction of home by paramilitaries, domestic violence and/or substance abuse by family member, perpetrating or participating in these, and so on – predicts the symptoms of PTSD over and above the actual number of traumatic events.
The results? Studies showing the effectiveness of NET have been independently conducted (Hijazi et al 2014, Zang et al 2013). Centrum 45 in the Netherlands and the Center for Victims of Torture in Minnesota use NET in treating survivors and refugees. NET manuals are now available in English, Dutch, French, Italian, Slovakian, Korean, and Japanese and are also available from the authors in Spanish and Farsi.
Further detailed evidence of the effectiveness of NET is at hand. Reorganizing traumatic memories seems to be inherently stress reducing. Chronic stress causes a weakening of the body’s resilience and defenses against disease and emotional disorder. Reducing stress improves one’s health and well-being. “Morath, Gola et al. (2014) showed that symptom improvements caused by NET were mirrored in an increase in the originally reduced proportion of regulatory T cells in the NET group at a one-year follow-up.” “These cells are critical for maintaining balance in the immune system and regulating the immune response to infection without autoimmune problems. This finding fits with the observation that NET reduces the frequencies of cough, diarrhea, and fever for refugees living in a refugee settlement (Neuner et al. 2008, Neuner et al 2018).”
NET works. NET produces positive results for those suffering from PTSD. This brings us to the question: Why does it work? Thereby hangs a tale – and a theory.
NET conceptualizes PTSD and related disorders as disorders of memory.
For example, hot memories include the sounds of people screaming for help, the sight of dead or wounded persons, the smell of the perpetrator pressing his body against the victim, the taste of one’s own vomit, the experience of being unable to move and helplessness, and so on. These are “hot memories.” These occur or occurred in a context of coldmemories of place, time, and standard activities.
For example: “We were working in the garden behind the house when the paramilitaries drove up in a truck.” In the case of an individual trauma or series of traumas of the same type, as a defensive measure to preserve the integrity of one’s personal experience, the individual may take himself out of the situation in thought automatically, watching and experiencing the situation as if he was an observing third party. How this occurs is not well understood, but it seems to support survival of the organism in extreme situations.
This disconnects the “hot” and “cold” contexts. In the case of an individual surviving multiple trauma types, beating, rape, loss of home, the cumulative traumatic load causes the traumas to be grouped into a network disconnected from the standard, cold context of everyday life. Fear generalizes forming a fear network. Emotional, sensory, cognitive and physiological representations interconnection with the excitatory force of hot memories. Ordinary, random events become triggers of this network.
The trauma LIVEs. It takes on a life of its own as the fear network. PTSD survivors learn to avoid triggers that act as activators of hot memories. The client isolates. He or she has difficulties with the cold context of autobiographical memory. A negative cascade of experiences is mobilized as symptoms suck the life out of the individual, leaving him or her as an emotional zombie. “Shut down” replaces intrusive thoughts and hyper-arousal with passive avoidance and disassociation.
The effectiveness of NET consists in reestablishing the connections between hot and cold memories, the hot traumatic events and the cold, everyday occurrences that situate them in place and time. In a context of acceptance and toleration (i.e., non-judgment and empathy), the client is supported in reliving the details of what happened by putting them into words without losing the connection to the here and now. If one can say what happened, the emotion is called forth and reintegrated into the context of the person’s life. The trauma starts to shrink.
The imagined exposure to the traumatic event is maintained long enough for the affect, especially the fear, to be called forth and allowed to begin to fade in intensity. The narrative is essential. Absent words, retraumatization – invoking the trauma in an uncontrolled way – is the risk to the client. Even if time is running short, the session must not end until the client (with the help of the therapist (as appropriate)) has found some words to describe what happened. (If the trauma involves organized or domestic violence, the testimony may be recorded or documented for forensic purposes.)
Two of the strengths of NET are the low drop out rate and the scalability due to building a network of lay therapists. Lay therapists?
The World Health Organization endorses this approach for those communities with limited resources (Jordans, Tol 2012). Given the limited resources of third world countries or even many communities in the USA due to the monopoly-like rents being collected by healthcare insurance providers, NET embraces “task shifting.” “Task shifting” consists in training lay therapists to perform the intervention.
Regarding the training and use of lay therapists to deliver NET, it is scalable, affordable, and workable. It is also controversial. In the State of Illinois (USA) one needs a license to cut hair. However, so far as I know, one does not need a license to have a structured conversation for possibility with another human being about what they had to survive. No doubt the graduates of PsyD programs may have an opinion about that; but personally having taught in two PsyD programs, I know the dedication, commitment, and hard work of the students and teachers; and I also know that one cannot take a course entitled (or with the content of) “empathy lessons” or with “empathy training” in any of these programs. I know because I proposed to do so, but it simply did not get approval due to other priorities.
NET offers significant potential not only to treat PTSD survivors of violence and trauma. Anxiety and panic disorders, depression, eating and substance abuse disorders, borderline personality disorder (BPD), all report intrusive memories filled with upsetting content but lacking cold memory context.
One final thought. Those suffering from PTSD are suffering from reminiscences – disorganized, toxic memories. The astute reader may recall this is what Freud said, in slogan-like sound byte, about hysteria (Breuer, Freud 1893). Each memory has to be transformed into words, into a narrative. Each memory has to be expressed in speech so that the body no longer has to function as the corporeal narrator in flashbacks, startle response, panic attacks, intrusive ideas, emotional numbing and overstimulation. Narrative exposure therapy gives new meaning to the phrase “the talking cure,” and it is one. How shall I put it delicately? My “French” fails me: The more things change, the more they stay the same.
Breuer, Josef and Freud, Sigmund. (1893). Studies on Hysteria. Translated from the German and edited by James Strachey. (The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. II.) Hogarth Press, London 1955.
Hijazi, A. M., Lumley, M. A., Ziadni, M. S., Haddad, L., Rapport, L. J., & Arnetz, B. B. (2014).Brief narrative exposure therapy for posttraumatic stress in Iraqi refugees: A preliminary randomized clinical trial. Journal of Traumatic Stress, 27(3), 314–322. https://doi.org/10.1002/jts.21922
Jordans, M. J., & Tol, W. A. (2012). Mental health in humanitarian settings: Shifting focus to care systems. International Health, 5(1), 9–10.
Kohut, Heinz. (1959). Introspection, empathy, and psychoanalysis. Journal of the American Psychoanalytic Association7. (July 1959): 459–407.
Morath, J., Gola, H., Sommershof, A., Hamuni, G., Kolassa, S., Catani, C., … Elbert, T. (2014).
The effect of trauma-focused therapy on the altered T cell distribution in individuals with PTSD: Evidence from a randomized controlled trial. Journal of Psychiatric Research, 54, 1–10. https://doi.org/10.1016/j.jpsychires.2014.03.016
Neuner, F., Onyut, P. L., Ertl, V., Odenwald, M., Schauer, E., & Elbert, T. (2008). Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 76(4), 686–694. https://doi.org/10.1037/0022-006X.76.4.686
Neuner, Frank, Elbert, Thomas, Schauer, Maggie. (2011).Narrative Exposure Therapy: A Short-Term Treatment for Traumatic Stress Disorders, 2ndEdition, Göttingen, Germany: Hofgrefe Verlag.
Neuner, Frank, Elbert, Thomas, Schauer, Maggie. (2018).Narrative Exposure Therapy (NET) as a Treatment for Traumatized Refugees and Post-conflict Populations: Theory, Research and Clinical Practice. 10.1007/978-3-319-97046-2_9.
Zang, Y., Hunt, N., & Cox, T. (2013). A randomised controlled pilot study: The effectiveness of narrative exposure therapy with adult survivors of the Sichuan earthquake. BMC Psychiatry, 13(1), 41. https://doi.org/10.1186/1471-244X-13-41
(c) Lou Agosta, PhD and the Chicago Empathy Project
[Note: the podcast and the blog post are both about the natural empath and the challenges faced by the natural empath; but they do not map one-to-one, and podcast is not the book review, so you may want to start there.]
Empaths don’t get enough empathy.
An empath is a person who is naturally endowed with an overabundance of empathy. As I understand the term, a “natural empath” (my term, not Orloff’s) is an individual who is naturally endowed from birth or genetically “loaded” with a deep and extensive empathy, a hypersensitivity to the experiences of others.
This gift of empathy shows up as a mixed blessing, since the natural empath experiences the pains and sufferings of the world more intensely and deeply than do other individuals. Less charitable people redescribe the “natural empath” as someone who is “irritable” or “overly sensitive.”
Granted, the natural empath brings a deep sensitivity to the experience of human suffering and joy, the natural empath also lives through the nuances and delicate details of the experiences intensely. Too intensely?
Granted that the empath seems to be protesting, at least sometimes, that her empathy is working overtime and causing suffering—a breakdown—a book such as Judith Orloff’s The Empathy’s Survival Guide is a timely antidote. 
Such empaths seem to be challenged—lack skill—in tuning down their empathy. Indeed they often do not think of the possibility of such skillful tuning. They do not acknowledge such a possibility. There is nothing wrong, but there seems to be something missing. Hence, the need for Orloff’s guidance. Granted, individuals are born a certain way, and that, no doubt, can represent a challenge, but being born a certain way does not mean one always has to stay that way.
Meanwhile, the empath is experiencing a breakdown in empathic receptivity (my term, not Orloff’s). According to Orloff, instead of a well-rounded, mature, developed empathy, the empathy of the natural empath breaks down into emotional contagion (at least on a bad day). The suffering of the other person floods her or his empathy; indeed the suffering of the world inundates the individual. But that is not all, and the dominoes start falling.
Orloff gets into the details. Overwhelmed and under stress, the natural empath engages in defensive gestures that ultimately are self-defeating. These include isolating oneself, turning to alcohol or street drugs in an attempt to self-medicate, enacting other addictive behaviors (over-eating, restricting., sexual acting out), and so on. Furthermore, the chronic social stress experienced by the natural empath is a source of inflammatory disorders such as autoimmune diseases, allergies, clinical anxiety, depression, and so on, to which we are all susceptible, but the empath especially so. The result is a form of emotional burnout, compassion fatigue, empathic distress, emotional contagion, not empathy.
The empath is just being what she or he calls “empathic”; but it is not working for the individual in question. Why not? Orloff explains that due to natural endowment and/or adverse childhood experiences, the empath lacksexperiential filters and sensory inhibition. The glass is both half empty and half full. The empath is endowed with intuitive abilities that may be exceptional. However, the trouble is that the empath’s empathy lacks inhibition. He is too open to the pain and suffering of the world. Heck, even a succession of sunny days can become burdensome, though in a different way.
In contrast to the natural empath, most people are too inhibited, including being inhibited as regards their empathy. Most of us are not sufficiently in touch with our feelings and experiences in relationships.
Not so, the natural empath. The natural empath endures too much “in touchness” with feelings and experiences of the pain and suffering of others. In this one respect, empathy, the natural empath is too uninhibited. In this one particular area of openness to the suffering and pain of other people, the natural empath may usefully increase her inhibition. Consider the example of Dr Brecht in Thomas Mann’s celebrated novel Buddenbrooks, a dentist who deeply experiences the pain of his dental patients, so that he has to sit down, exhausted by the suffering of his patient, and wipe his brow after each procedure. Dentistry – perhaps not the best choice of profession for a natural empath.
A sound scientific basis exists for this a predicament. (We will shortly get to the scientifically debatable aspects of Orloff’s work.) People who are “natural empaths” have an acute sensitivity to in-bound sensations and perceptions. The function of what physiologists call “lateral inhibition” of sensory perception seems to be “lazy” and under-performing in these people. Lateral inhibition enables the nervous system to filter out the distracting background noise and intensify the relevant, salient sensations in the environment.[i]
That does not mean the natural empath should become hard-hearted or unkind, though paradoxically that is sometimes the sad result of burnout, compassion fatigue, or empathic distress. In order to overcome the breakdown of empathy, what does one actually doin order to expand or contract one’s empathic receptivity?
Orloff’s work is rich in tips and techniques for the struggling empath. Many of her best tips can be summarized in one phrase. Set firm limits and boundaries. The empathy lesson for such individuals consists in: Practice methods of “down regulating” one’s empathy. State a request; and use humor (p. 122). Remember that “No” is a complete sentence (p. 222). “Don’t try to fix others” (p. 230).
In a different category of tips and techniques are a long list of self-soothing, distress tolerance, and emotional regulation skills. Since this is self-help book, expect to encounter numerous recommendations about proper nutrition, regular exercise, sleep hygiene, and so on. All good recommendations, every one, but not specific to empathy as such. More problematic is the writing heavily weighted in the direction of “new age” interventions such as burning incense, holding healing gems, telepathic communication with plants and animals, and Epsom salt baths.
I hasten to add that I am a big advocate of Epsom salt soaking, especially in the form of sensory deprivation, though it tends to expand openness and sensitivity. More on the other “new age” interventions shortly. Empathy works to create a space of acceptance and toleration, so if the practice in question helps one regulate one’s emotions, do it.
The empath definitely can feel like he needs a survival guide – and Orloff’s work is a good place to start for the magical thinking free spirit. However, from the perspective of a rigorous and critical empathy, some real problems and issues are going to get in the way of a serious appropriation of this book, outside the confines of a weekend retreat on telepathy and intuitive energy healing.
There are more things on heaven and earth than are dreamt of in our philosophies – and Orloff points at many of them. How shall I put it delicately?, Orloff’s discussion proceeds as if subtle communications are undisputed medico-scientific-therapeutic facts not compelling puzzles that should alert us to a depth of our emotions and thoughts that may usefully be plumbed in a rigorous and critical empathy.
For example, in 1779 the Viennese physician Anton Mesmer published a treatise on animal magnetism, describing a subtle physical “magnetic” fluid – analogous to but different than Newtonian gravity – that permeates the universe, connecting, men, the earth, and the heavens. The imbalance of this hypothesized fluid in the body is responsible for such emotional disorders as hysteria and obsessive-compulsive behavior. Mesmer conducted “magnetic banquets” that provided the nobles and aristocracy with substantial relief from their physical and psychosomatic symptoms.
At about the same time, one of Mesmer’s students, Viscount Jacques Maxime de Castenet de Puységur, differentiated “magnetic sleep,” which we would today call “hypnotic suggestion” and seemed to offer relief, not to the nobles, but to soldiers, workers, and peasants. The word “hypnosis” does not occur in the text, but I speculate that many of Orloff’s tips and techniques are forms of self-hypnosis. Might be worth a try.
Animal magnetism, psychic energy, libido, the energetic Chi practiced in Tai Chi, the instincts or vasanasliberated in Yogi, the mystical heat generated by the Shaman, emotional contagion, and so on, are not grounded in any conventional scientific theory or practice. So such energy work is not exactly an objective fact, and yet it is not a fiction.
Speaking in the first person plural, since Orloff has diagnosed herself as an empath, she writes: “Since everything is made of subtle energy, including emotions and physical sensation, we energetically internalize the feelings, pain, and various physical sensations of others [….] [and] are even able to connect with animals, nature, and their inner guides” (p. 6).
Any one who owns a dog or cat knows from experience that we communicate with animals – exchanging feelings and experiences. But what Orloff has in mind is much more specific and goes well beyond provocative metaphors to questionable material instantiation.
Orloff is captured by the materialist fallacy and forgets that factual reality itself is permeated with fictions and fantasies. Ignoring the power of fiction, she wants to make a compelling linguistic locution such as “psychic energy” into a fact, thereby losing its power to enable us to describe and transform feelings and behavior. As demonstrated by many of Orloff’s imaginative and ”out there” statements, an idea does not need physical or factual reality to be effective – it just has to be expressed in a performative language.
There is a fancy name for Orloff’s main fallacy – reification – making into a thing that which is otherwise an abstraction. The idea of psychic energy is a compelling one, and it does have many applications in describing the mental status, awareness, or ability to be present in a conversation, of a person in a would-be empathic relationship. But it is the name of a problem and a deep issue, not a physical reality.
For example, neurology assures us that the brain – and indeed the body – gives off an electro-magnetic field. But this is a blunt instrument enabling us to tell whether an individual is conscious or in a coma, aware of his surrounding or experiencing an epileptic seizure. Orloff does not say that perhaps someday the granularity and specificity will improve. This is not a “some day” survival guide. No, she is claiming to have that skill now in her practice and workshops – and perhaps you can get it, too, if you work with her and follow her guidance .
Ironically, Orloff’s empathy is off. Empath’s are also naturally endowed with intuition, and Orloff consistently confuses intuition and empathy. Intuition and empathy are closely related, but they are inverselyrelated. More intuition often occasions less empathy, and vice versa. Intuition is the ability to make inferences, educated guesses, based on nuanced clues that are often barely over the threshold of perception. It is the kind of thing at which Sherlock Holmes excelled, and he was a notoriously hard case.
In contrast, empathy is the ability to take a vicarious experience, based on sustained listening to another person, and process it further cognitively, resulting in an empathic response. The properly empathic empath uses his empathic receptivity as to who the other person is as a possibility. The empath takes a walk in the other’s shoes with the other’s foot size, giving back and responding to the other individual her experience in a form of language such that the other person recognizes it as her own. As the empath learns to set firm boundaries and limits, her intuition is transformed into sustainable, usable empathy in the full sense from which both she and the community benefit.
Ours is a world in which pain and suffering are abundant. This does not make the would-be empath cold-hearted or the object of moral condemnation. Indeed such people might be more willing to engage in helping behaviors such as volunteering or donating money based on cognitive appreciation of the other person’s predicament rather than the experience of vicarious suffering. It means that the natural empath should practice taking distance from his own feeling in such a way that he gets a sample or trace of the other person’s feeling without being overwhelmed.
Expressed positively, if distance (or inhibition) were a medical drug, the natural empath may usefully increase the dosage. Take more of it. However, this is at best an imperfect analogy. Recall that inhibition is what enables the average person to get results in a world that the individual subsequently experiences as causing boredom precisely because inhibition is doing such a good job of down regulating the wave of stimulations that potentially wash over the person; and likewise the natural empath, hypothetically lacking such a filter, needs to down-regulate her empathy through self-distraction and abstraction to sustain emotional equilibrium rather than over-stimulation. The natural empath is an important and engaging case, and he may actually increase his good deeds in a particular situation by contracting his empathic receptivity, one particular part of empathy.
Note that Orloff considers herself an empath. She shares childhood experiences that indicate this was so as long as she can remember. I consider myself to be one of those “neuro typical” individuals, who used simply to be called “normal” (except that we no longer know what is “normal’). I hasten to add that I have expanded my empathic capabilities through extensive practice and training discussed elsewhere.
Being an empath is surely a mixed blessing – as is this book. If one can expand one’s empathy, one can also contract it. The power of the empath – and the ordinary person – consists in doing both in their proper time and place. That is an important point from the perspective of a rigorous and critical empathy, about which Orloff may usefully be more explicit. Empathy in all its forms works to create a space of acceptance and toleration, so I acknowledge Orloff’s commitment to empathy.
(c) Lou Agosta, PhD and the Chicago Empathy Project