Home » empathy training

Category Archives: empathy training

Empathy and Vulnerability

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.

Bibliography

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

The trouble with the trouble with empathy (this is not a typo)

Empathy flourishes in a space of acceptance and tolerance. But acceptance and tolerance have their dark side, too. People can be intolerant and unaccepting. Be accepting of what? Be accepting of intolerance? Be tolerant of intolerance? Yes, be tolerant, but set limits. But how to do that given that we may still have free speech in the USA, but many people have just stopped listening

“The Trouble With Empathy” is an article by Molly Worthen published in The New York Times on September 04, 2020. The author gets many things just right in an impressive engagement with the complexities of empathy, but in other areas, including the citations of certain academics, I have an alternative point of view. Hence, the trouble with the trouble with empathy is not a typo. The reply is summarized in the diagram (note that it is labeled “Figure 2,” but it is the only diagram – page down, please). For those interested in more detail, read on. 

Babies are not born knowing the names of the color spectrum. Children are taught these names and how to use them in (pre)Kindergarten; likewise, with the names of the emotions such as sadness, fear, anger, and high spirits. However, there is a lot more to empathy than naming one’s feelings and getting in touch with our mammalian ability to resonate with one another in empathic receptivity and understanding. 

As an adult, the fact that you failed to be empathic does not mean that your commitment to empathy is any less strong; just that you did not succeed this time; and you need to keep trying. Stay the course. It takes practice. The practice is precisely the empathy training. 

Often understanding emerges out of misunderstanding. My description of the other person’s experience as they lived it is clumsy and creates a misunderstanding. But when the misunderstanding is clarified and cleaned up, then empathy occurs. Thus, break throughs in empathy emerge out of breakdowns. So whenever a breakdown in empathy shows up, do not be discouraged, but rather be glad, for a break through is near.

Empathy breakdowns lead to breakthroughs

Evidence from the past rarely demonstrates what innovations are possible in the future. Just because people are not born with wings does not mean people cannot fly. If the Wright Brothers had accepted the evidence, we would all still be taking the train. I hasten to add there is nothing wrong with taking the train. People can be intolerant, and I too am people. Work on oneself is constantly needed. 

I open my mouth to be empathic and respond empathically—but instead of an empathic response, out jumps a frog: “I feel your pain.” What a fake! If I really felt your pain, then I would say “Ouch!” not “I feel your pain.” I find that I do frequently say “Ouch!” Or just shake my head and provide acknowledgement and recognition: “You’ve really been dealing with some tough stuff.” “Sounds like use could use some empathy.” 

The point is not to devalue the attempted empathic response, clumsy though it may be. The point is to acknowledge that the lazy person expands his empathy in a practice filled with examples of not getting it quite right. If empathy were a sport, it would be filled with strikeouts, fumbles, off sides, failures, and incomplete plays. There would even perhaps be examples of “unsportsman-like conduct.” 

Each of the four phases of empathy has characteristic breakdowns. This is not new news. The news is that if engaged with a rigorous and critical empathy, these breakdowns readily become breakthroughs in empathy. 

Breakthroughs in empathy arise from working through the breakdowns of empathy. The Big Four breakdowns of empathy are noted: emotional contagion, conformity, projection, and getting lost in translation. These are not the only breakdowns of empathy, which are many and diverse, but these are the most frequent ones. 

In the example of emotional contagion, one anxious person is telling the other person about all the reasons in the world that he is feeling out of sorts. Pretty soon, the person who is listening is starting to feel anxious too. The person’s receptivity—openness and availability—to the other individual’s emotions is working overtime and his empathic receptivity misfires, becoming: Emotional contagion. Emotional infection strikes again! 

Often it is not so obvious. Often people are caught up in the emotion of the moment. The emotion itself is so powerful that it just sweeps over everyone present like a tidal wave—an emotional tsunami. The person is flooded—emotionally.

If the listener realizes that listening to anxiety-inspiring stories causes his own anxiety to spike, then that is already going beyond emotional contagion and the start of an empathic processing of the emotion. 

If one stops in the analysis of empathy with the mere communication of feelings, then empathy collapses into emotional contagion. Empathic receptivity breaks down into emotional contagion, suggestibility, being over-stimulated by the inbound flood of the other person’s strong feelings.

Emotional contagion—basically the communication of emotions, feelings, affects, and experiences—can be redescribed as input to further down stream empathic processing. Then emotional contagion (communicability of affect) gets “normalized” and can very well make a contribution to empathic understanding.

Overcoming the breakdown of empathy into emotional contagion results in the breakthrough to vicarious experience. A vicarious experience is what a person has in going to the theatre, the movies, or a single-person player video game. I experience the fears and hopes of the character in the film, but I do so vicariously. Theatre, film, and the novel were “virtual reality” (VR) long before computers, special VR goggles, and social networking were invented.  

Vicarious experience is not empathy. It is input to the process of empathy. Vicarious experience is the grain of truth in the fake-sounding empathy meme, “I feel your pain.” I feel your pain—vicariously. I experience an after-image of your pain—like the visual after-image of the American flag that results from starring at a vivid depiction of the off-color image of the stars and stripes. I repeat: we gat an after-image of another person’s feelings and emotions. 

I am amazed that no one has as yet explicitly pointed out that we get after-images of other people’s feelings when we are exposed to those feelings for a sustained duration. A vicarious experience of emotion differs from emotional contagion in that one explicitly recognizes and knows that the other person is the source of the emotion. 

You feel anxious or sad or high spirits, because you are with another person who is having such an experience. You “pick it up” from him. You can then process the vicarious experience, unpacking it for what is so and what is possible in the relationship. This returns empathy to the positive path of empathic understanding, enabling a breakthrough in “getting” what the other person is experiencing. Then you can contribute to the other person regulating and mastering the experience by being there for him and responding with soothing words and acknowledgement of the situation.

The next breakdown of empathy is settling for conformity instead of striving for possibility. We might also say: settling for agreement instead of striving for possibility. 

People live and flourish in possibilities. Empathic understanding breaks down as “no possibility,” “stuckness,” and the suffering of “no exit” (the definition of Hell in a famous play of the same name by Jean Paul Sartre). You follow the crowd in responding to the other person; you do what “one does”; you validate feelings and attitudes according to what “they say”; you conform and express agreement; and, with apologies to Henry David Thoreau, you live the life of quiet desperation of the “modern mass of men.” 

When someone is stuck, experiencing shame, guilt, rage, upset, emotional disequilibrium, and so on, the person is fooling himself—has a blind spot—about what is possible. This does not mean that it is easy to be in the person’s situation or for the person to see what is missing. Far from it. We live in possibilities that we allow to define our constraints and limitations—for example, see the example of the friend who was married and divorced three times. This expresses a strong commitment to marriage, though empathy and husbanding skills are seemingly limited. 

If you acknowledge that the things that get in the way of your relatedness are the very rules you make up about what is possible in your relationships, then you get the freedom to relate to the rules and possibilities precisely as possibilities, not absolute “shoulds.” You stop “shoulding” on yourself. This brings us to the next break down—the break down in empathic interpretation. 

Taking a walk in the other person’s shoes—the folk definition of empathy—breaks down if you take that walk using an inaccurate shoe size. You then know where your shoe pinches, not hers. This is also called “projection.” The recommendation? 

Take back the projections of your own inner conflicts onto other people. Take back your projections. Own them. You get your power back along with your projections. Stop making up meaning about what is going on with the other person; or, since you probably cannot stop making up meaning, at least distinguish the meaning—split it off, quarantine it, take distance from it, so that its influence is limited. 

Having worked through your vicarious experiences, worked through possibilities for overcoming conformity and stuckness, and taken back your projections, you are ready to engage in communicating to the other person your sense of the other individual’s experience. You are going to try to say to the other what you got from what they told you, describing back to the other your sense of their experience. And what happens? Sometimes it works; sometimes you “get it” and the other “gets” that you “get it”; but other times the description gets “lost in translation.” 

This breakdown of empathic responsiveness occurs within language. You fail to express yourself satisfactorily. I believed that I empathized perfectly with the other person’s struggle, but my description of her experience failed significantly to communicate to the other person what I got from listening to her. 

My empathy remains a tree in the forest that falls without anyone being there. My empathy remains silent, inarticulate, and uncommunicative. I get credit for a nice empathic try; but the relatedness between the persons is not an empathic one. If the other person is willing, then go back to the start and try again. Iterate. Learn from one’s mistakes and incomplete gestures. 

The fact that you failed does not mean that your commitment to empathy is any less strong; just that you did not succeed this time; and you need to keep trying. Stay the course. It takes practice. The practice is precisely the empathy training. 

Often understanding emerges out of misunderstanding. My description of the other person’s experience as they lived it is clumsy and creates a misunderstanding. But when the misunderstanding is clarified and cleaned up, then empathy occurs. As that notorious bad boy of a certain 18th century enlightenment, Voltaire, is supposed to have said: Let not perfection be the enemy of the good. Thus, break throughs in empathy emerge out of breakdowns. So whenever a breakdown in empathy shows up, do not be discouraged, but rather be glad, for a break through is near.

Knowing Professor Worthen’s [the author of the NYT article that provoked this reply] interest in religious studies, I conclude with a reflection on empathy and the Good Samaritan. The Parable of the Good Samaritan speaks volumes (Luke 10: 25–37). The first two people, who passed by the survivor by crossing the road, experienced empathic distress. They were prevented from helping out by a breakdown of their empathic receptivity. They were overwhelmed by the suffering and crossed the road. In contrast, the Good Samaritan had a vicarious experience of the suffering. His empathic receptivity gave him access to the survivor’s pain. His empathy told him what the other person was experiencing and his compassion told him what to do about it. 

To get 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: https://tinyurl.com/y8mof57f

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

Empathy and Gender

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.]

Cover Art: A Critical Review of a Philosophy of Empathy
Cover Art: A Critical Review of a Philosophy of Empathy

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.

Further Reading

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.

ELPG Front Cover as jpg

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

Top 10 Trends in Empathy for 2020

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

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

Moutain path with sign in Rocky Mountain National Park

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Psychiatrists and many general practitioner MDs are perpetuating a fiction that the drugs they are prescribing are correcting biochemical deficiencies caused by disease, much as (say) a prescription of insulin corrects a biochemical deficiency caused by diabetes (for example see Anne Harrington’s The Mind Fixers, p. 273, which I have found essential in identifying this trend and whose language I paraphrase here). Such rhetoric is badly oversold. No one is saying that the medicines do not help the person tolerate distress, regulate emotions, or self-sooth. Often they do. However, the rhetoric is indefensible and the science is at best a work in progress.

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

The underlying science is not anywhere near the level the neurohype would have us believe. “You have a chemical imbalance” is a marketing position, not a scientifically established truth. “Schizophrenia is like diabetes and you have to take this antipsychotic drug for the rest of your life” is a rhetorical position, not a scientific fact. This is scientism, not science. This is psychiatry’s troubled search for the biological basis of mental illness. The trend being highlighted here is that, as a profession, psychiatry will focus on medical interventions in the context of culture and community.

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

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

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

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

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

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

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

Empathy is a dial, not an on-off switch

People treat empathy as if it were an “on-off” switch.

Turn it “on” for friends and family; turn it “off” for the “bad guys”. Turn empathy “on” for coworkers, customers, and insiders; turn empathy “off” for competitors, for compliance, and for efficiency and speed.  Turn empathy on for the hometown baseball team, the Cubs or Sox, if you are from Chicago like I am or turn it off for

Empathy is a dial, not an on-off switch

Empathy is a dial, not an on-off switch

the competition, especially New York teams such as the Mets or Yankees! If you have encountered die-hard fans, then you know that I am only partially joking. However, in business today—as in sports and as in dating with prospective romantic partners—you are competing in the morning and cooperating in the afternoon. Unfortunately, the switch tends to get stuck in the off position.

The guidance? Empathy is a tuner or dial, not an “on-off” switch. Engaging with the issues and sufferings with which people are struggling can leave the would-be empathizer (“empath”) vulnerable and exposed to burnout and “compassion fatigue.” As noted, the risk of compassion fatigue is a clue that empathy is distinct from compassion, and if one is suffering from compassion fatigue, then one’s would-be practice of empathy is off the rails, in breakdown.

Instead of practicing empathy, maybe you are being too compassionate. If you are flooded, maybe—just maybe—you are doing it wrong. In empathy, the listener gets a vicarious experience of the other’s issue or experience, including their suffering. The listener suffers vicariously, but without being flooded and overwhelmed by the other’s experience.

This is not to say that some accounts of trauma would not overwhelm and flood anyone. They would. They do. However, we are here engaging with the example of a committed listener who spends his or her day listening to a series of depressed, anxious, or otherwise upset people.

Empathy is like a dial, lever, or tuner—turn it up or turn it down. If one is overwhelmed by suffering as one listens to the other person’s struggles, one is doing it—practicing empathy—incorrectly, clumsily, and one needs expanded skill training in empathy.

The whole point of a vicarious experience—as distinct from merger or over-identification—is to get a sample or trace of the other’s experience without being inundated by it. Key term: sample the other’s experience. One needs to increase the granularity of one’s empathic receptivity to reduce the emotional or experiential “load.”

Another way of saying the same thing? Empathy is a filter—decrease the granularity and get more of the other’s experience or increase the granularity (i.e., close the pores) and get less.

The empathic professional can expect to have a vicarious experience of the other person’s experience. If the other person is suffering, then he will have a vicarious experience of suffering. He will have a sample of the other person’s suffering. He will have a trace affect of the sadness or grief or anger or fear (and so on) of whatever is a burden to the other person. It will be a toe or an ankle in the water instead of being up to the neck in it. The experience will just be a taste of brine rather than drowning.

The power in distinguishing between empathic receptivity and empathic understanding, empathic interpretation, and empathic responsiveness, is precisely so you can divide and conquer the practice and performance of empathy.  

If your “empathic distress” indicates too much openness, do not be “closed off,” but tactically reduce the openness. Increasing the granularity of your empathic receptivity reduces the empathic receptivity and reduces your empathy as a whole. If you are experiencing compassion fatigue, then you need to tune down your compassion and expand your empathy. If you are experiencing burnout, then it is likely that emotional contagion is leading to empathic distress. In this case, you need to tune down one’s empathy.

Interested in more best practices in empathy? Order your copy of Empathy Lessons, the book. Click here.

(c) Lou Agosta PhD and the Chicago Empathy Project

 

Compassion fatigue: A radical proposal for overcoming it

One of the criticisms of empathy is that is leaves you vulnerable to compassion fatigue. The helping professions are notoriously exposed to burn out and empathic distress. Well-intentioned helpers end up as emotional basket cases. There is truth to it, but there is also an effective antidote: expanded empathy.

For example, evidence-based research shows that empathy peaks in the third year of medical school and, thereafter, goes into steady decline (Hojat, Vergate et al. 2009; Del Canale, Maio, Hojat et al. 2012). While correlation is not causation, the suspicion is that dedicated, committed, hard-working people, who are called to a

Compassion Fatigue: Less compassion, expanded empathy?

Compassion Fatigue: Less compassion, expanded empathy?

life of contribution, experience empathic distress. Absent specific interventions such as empathy training to promote emotional regulation, self-soothing, and distress tolerance, the well-intentioned professional ends up as an emotionally burned out, cynical hulk. Not pretty.

Therefore, we offer a radical proposal. If you are experiencing compassion fatigue, stop being so compassionate! I hasten to add that does not mean become hard-hearted, mean, apathetic, indifferent. That does not mean become aggressive or a bully. That means take a step back, dial it down, give it a break.

The good news is that empathy serves as an antidote to burnout or “compassion fatigue.” Note the language here. Unregulated empathy results in “compassion fatigue.” However, empathy lessons repeatedly distinguish empathy from compassion.

Could it be that when one tries to be empathic and experiences compassion fatigue, then one is actually being compassionate instead of empathic? Consider the possibility. The language is a clue. Strictly speaking, one’s empathy is in breakdown. Instead of being empathic, you are being compassionate, and, in this case, the result is compassion fatigue without the quotation marks. It is no accident that the word “compassion” occurs in “compassion fatigue,” which is a nuance rarely noted by the advocates of “rational compassion.”

Once again, no one is saying, be hard hearted or mean. No one is saying, do not be compassionate. The world needs both more compassion and expanded empathy. Compassion has its time and place—as does empathy. We may usefully work to expand both; but we are saying do not confuse the two.

Empathy is a method of data gathering about the experiences of the other person; compassion tells one what to do about it, based on one’s ethics and values.

Most providers of empathy find that with a modest amount of training, they can adjust their empathic receptivity up or down to maintain their own emotional equilibrium. In the face of a series of sequential samples of suffering, the empathic person is able to maintain his emotional equilibrium thanks to a properly adjusted empathic receptivity. No one is saying that the other’s suffering or pain should be minimized in any way or invalidated. One is saying that, with practice, regulating empathy becomes a best practice.

Interested in more best practices in empathy? Order your copy of Empathy Lessons, the book. Click here.

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

Review: The War for Kindness: Building Empathy in a Fractured World by Jamil Zaki

Short review: two thumbs up. Zaki and his work are the real deal. Zaki “gets it” as regards empathy. The most important take-away: empathy is trainable, teachable, malleable, acquirable, and an expandable competence and skill rather than an unchangeable personality trait that one either has or not.

The next most important take-away: the world needs expanded empathy and more kindness. As I read Zaki, empathy and kindness feed into one another in a fundamental way. Empathy provides a clearing within which compassion – which Zaki calls “kindness” – shows up.

 The battle for kindness, the title, is a real battle in which people have to decide whether aggression and greed get the upper hand or possibilities of human

Cover art: The War for Kindness: Building Empathy in a Fractured World

Cover art: The War for Kindness: Building Empathy in a Fractured World

flourishing are shared among members of the community. The “battle” – but here is scare quotes – is also about the optimum methods, given limited resources, for expanding empathy itself in the community through education, individual action, and community activism.

 The long review: Zaki throws down the gauntlet: “If you wanted to design a system to break empathy, you could scarcely do better than the society we’ve created” (p. 8).

Zaki’s Jeremiad creates a sense of urgency and a call to action by citing tribalism, intolerance, the unintended consequences of social networking such as bullying, fake news, pervasive human aggression, genocide, and the drowned, would-be Syrian migrant child, Alan Kurdi. Heart-breaking. I am already nearly vicariously traumatized.

By the end of Chapter One, the reader is starting to get a sense of the risk of compassion fatigue. Evidence-based research indicates that empathy peaks in the third year of medical school (Hojat et al 2011; Halpern 2001), and absent decisive intervention, the future holds, not expanded empathy but, compassion fatigue, burnout, and empathic distress. The remainder of the book provides the antidote in the context of the issues and ongoing debate about the relevance of empathy.

Zaki’s own evidence-based, peer-reviewed research as a professor of psychology – and his fundamental contribution – focuses on the notion of flexibility, malleability, and plasticity versus fixity of empathy. At the risk of over-simplification, when people believe that working at something makes a difference and when they actually work at it, then they get better at it. The something in question is empathy. In several ingenious experiments, those who have the mindset [key term: mindset] that practicing empathy expands empathy make progress with the empathic skill in question.

No one is saying that one can merely change one’s mind, the way one would rather order fish instead of steak at a restaurant. Not so simple. Work means work; and much of the subsequent debate about empathy – the “battle” in quotes – is about what actually does work: Contact with diverse individuals seems to expand empathy (unless it doesn’t); story telling (and what kind of stories!); reading fictional literature; skill exercises similar to cognitive behavioral therapy; mindfulness meditation; psychodynamic therapy [not one of Zaki’s examples]. Many conditions and qualifications apply. The list is long and not mutually exclusive.

One of the things that most impressed me about Zaki’s evidence-based research into empathy (on which his book is based) is the recognition of the ways in which empathy can misfire, breakdown, or otherwise go off the rails (e.g., Zaki and Ciskara, 2015, Addressing empathic failures, Current Directions in Psychological Science, Vol 24, no. 6: 471–476). 

Thus runs the standard critique of empathy that it is too parochial and ends up applying only to the in-group. The solution? To overcome the limitations of empathy, expand one’s empathy. There is nothing inherently limited in empathy such that it cannot be extended to strangers. That it does not automatically occur to many people, including high school students, to do so does not mean they would not be able to do so or even befit from doing so.  Hearing the story of the Good Samaritan might incent some. Some communities acknowledge the issue by making a moral imperative to welcome strangers without exception and provide for their well-being when asked. This results in real drama when the stranger who shows up is also otherwise regarded as an enemy.

That empathy can breakdown and misfire is not a problem for empathy as such; that you make arithmetical errors does not invalidate number theory. More likely such a breakdown in empathy means the practitioner of empathy needs more training, experience, and skill applying the relevant distinctions.

That empathy does not automatically extend to the tribe in the valley on the other side of the hill does not mean there is anything wrong with empathy. It just means without training some people suck at being empathic [my term, not Zaki’s]. The solution is simply stated: expanded empathy. This apparent limitation just means the local tribe may usefully expand its empathy. That takes work – which is Zaki’s point.

If these seem like a bold statement of the obvious to you, dear reader, then that is good news, for Zaki’s research is getting traction. However, I can still cite many examples of average citizens, natural empaths, people on the autistic spectrum, or just ordinary citizens, who regard empathy as a fixed personality trait with which they are born or that is fixed in adolescence.

Such a perspective is a subset, though not a logically necessary one, of the view that human nature is static and fixed. For Marxists, people are essentially workers, producing a community; for Freudians people are essentially conflicted containers of sex and aggression striving to love and work; for Max Weber, people are driven by grand ideologies such as the world religions; for authentic Christians, people are sinners, yet God’s children, redeemed by the sacrifice of their Lord; for neo-Darwinians, people are survivalist, gene-producing mechanisms. This is list is long and not complete.

Zaki’s point – that empathy can be expanded, improved – is one that has been around for but not received the attention it has deserved. Empathy is not an “on off” switch, but rather a dial or tuner. Tune it up and tune it down based on circumstances. From that perspective empathy can even provide a filter that provides protection against being overwhelmed by the suffering of others while still remaining engaged with their humanity.

Thus, one has to be careful to believe the hype in the marketing material as regards “a bold new understanding of empathy.” As early as 1971, a man named Heinz Kohut, MD, published extensively that the results of a treatment using self-psychological methods he pioneered produced improved humor, wisdom – and expanded empathy. Thus, a footnote from the history of empathy.

Using what was the prevailing paradigm at the time, psychoanalytic talk therapy, Kohut treated his patients empathically. He gave them a good listening. Just as important as a good listening, when the listening broke down and was restored in a committed empathic relatedness, then the gains in empathy were consolidated and driven into the personality as reliable, repeatable competencies.

Along with Carl Rogers, PhD, of “unconditional positive regard” client-centered fame, and who Kohut apparently never read, separately and together, Kohut and Rogers put empathy on the map. The person’s empathy is expanded by restoring and working through the breakdowns in empathy that seemingly inevitably occurred as two human beings tried to relate to one another. The devil is in the details, but you have got to get empathy, struggle with it, and practice it, in order subsequently to be able to be empathic and use it to relate to other people.

Since this is not a softball review, the controversial issue is engaged:  is empathy inherently prosocial or, in the wrong hands, can empathy be used antisocially, harmfully, even diabolically, and under what conditions and qualifications. In short, does empathy have a dark-side and what is it?

Empathy clears away judgments, evaluations, biases, and prejudices and allows one person to respond to another as a whole human being. I assert that is what happened to Tony – one of Zaki’s examples – when, already a broken and isolated individual, Tony discovered the camaraderie of the white supremacists community. They “got him” as a whole person – at least initially – before further filling his head with dehumanizing memes about nonwhites and other marginalized groups. Hmmm.

You see the issue? Humanity is supposed to show up in the clearing created by empathic relatedness. But what if it doesn’t. Human beings are empathic and kind. They are also aggressive and greedy. Human beings are tolerant and accepting. They are also intolerant and biased. Human beings are a clearing for possibilities – some good, others, less so.

The wisdom of Zaki’s guidance: hey, guys, you are gonna have to work at it – i.e., expanding empathy. More problematic is what will happened if you don’t. If you do not do so, then the empathy will contract and the bad guys will misuse what little empathy they do in fact have and probably kill (or enslave) all the good guys before unwittingly blowing themselves up with nuclear bombs, biological weapons, or climate catastrophe(s).

The cure through empathy is exemplified by Zaki’s example of Tony, the racist, fascist, white supremacist, skinhead-type, who (it turns out) created a surface of hatred to cover his shame and loneliness (p. 60). Zaki gives survivors of abuse a bad name, though it is indisputable that Tony was one of those too. Not fitting in for sooo many reasons, Tony finds acceptance and toleration in a community built on hate, the white Aryan resistance.

Fast-forward a couple of years. Tony is now a parent – a life-transforming event in itself. Things are not going well and Tony is about to lose custody of his children, for whom he seems to have the standard parental love, even amidst all the emotional disregulation. Tony gets some empathy from Dov Baron, a trainer that Tony did not realize was Jewish, and Tony gets better. Wouldn’t it be nice? Get some empathy, one gets better. What this misses is that the transformation effects are a function of restoring empathy that has broken down in the relationship. And that is a lot of work (as indeed Zaki has assured us). It is probable that something like that breakdown-restore process is what happened between Dov and Tony.

Empathy reliably de-escalates anger and rage. I hasten to add that I am in favor of creating a space of acceptance and toleration by setting firm empathic boundaries; but the challenge is that, unless one is careful, the bad guys are just going to pump hatred and negativity into the space.

The bottom line for Zaki? Given a cleared space of acceptance and toleration, Zaki aligns with Batson’s and de Waal’s and (perhaps) the folk definition that empathy is inherently prosocial. Basically, empathy includes caring. Empathy includes compassion (see the definition p. 178). People want to reduce the pain and suffering of others. Why? Because people experience a trace of the pain and suffering of others as vicarious experience, shared experience, or emotional contagion (these are not the same thing!).

Even if one allows that the psychopath uses his alleged empathy the better to manipulate his victim, one can argue back that it is a misuse of empathy that is not inherently empathic.

However, an even tougher case, because it hits closer to home regarding the dark-side of empathy, what about the professional hazard of compassion fatigue?

I came away from Zaki’s account of the neonatal intensive care unit experiencing more than a little bit of vicarious suffering. Nothing wrong with that as such, but that is challenge to all the helping professions – and to empathy as such. This is also a credit to Zaki’s ability as a narrator. The story was compelling. The pain and suffering significant.

Reading Zaki reminded me of a radical proposal. If you are experiencing compassion fatigue, regardless of your profession, maybe you are being too compassionate. It is no accident that the term is “compassion fatigue,” not empathy fatigue. I hasten to add that at no point does Zaki say “you are being too compassionate,” but it seems to me to be implied.

No one is saying be unkind or hard-hearted. But if empathy is a dial or stereo tuner (as Zaki notes), not an “on off” switch, then dial it down. The nurse in the neonatal intensive care unit finds herself confronted by innocent suffering and decides to think about her feet rather than the suffering around her. She thinks “this tragedy is not mine” (p. 116) rather than taking on all the emotions of the family of the dying preemie.  She dials down the emotion suffering, and lives emotionally to fight the good fight for another day. I repeat: dials empathy down rather than gets overloaded and has to turn it off. People are not necessarily born knowing how to do this, which is why practice is required. This is the world of tips and techniques for those on the front lines.

This is the age of evidence-based everything. In Appendix B, Evaluating the evidence, Zaki lists the claims made in each chapter and evaluates the evidence to support the claim on a 1 to 5 scale. Thus, for those claims for which the evidence is limited (rated 1 to 3), Zaki (and Kari Leibowitz) discuss the limitations. Perhaps this comment is one for the “no good deed goes unpunished fie,” and yet I would have appreciated reading why the positive evidence is so positive (nor do I disagree with the overall assessment).

The thing that is overlooked in an approach that regards evidence as based on people’s report’s of their mindsets is that people are self-deceived, limited in their ability to change perspectives, and just flat out at the effect of significant blind spots, prejudices, biases – i.e., mindsets. The bad guys will try to use empathy to create a space for white supremacy or other distorted, diabolical mischief in the space. Zaki makes a strong case that empathy is at risk of declining precipitously and specific steps such as training and education in empathy, conflict resolution, mindfulness, and other spiritual disciplines can make a profound difference in reversing this worrisome trend.

But this work overlooks resistance to empathy. Empathy is supposed to be like motherhood and apple pie. So why is there so much resistance to it? To use Zaki’s term, so why is there such an intense war for kindness? I am starting to sense that it is just too much work. The mindset is that it is just too hard and what is really needed is a lazy person’s guide to empathy. Who knows what tomorrow may bring?

The issue with Zaki’s approach (and this should be read in the context of the otherwise highest assessment of his contribution), is the single-minded focus on kindness. Empathy creates a clearing [my phrase, not Zaki’s]; and on a good day, we can create the possibility of kindness (and related positive human phenomena) in the space that opens up. All good. No one is saying, be unkind or uncaring. But is caring really a part of the definition of empathy?

Empathic concern is a modification of empathy; but it is just one of many possible empathic responses. Acknowledgement of the other person, recognition of the other’s humanity, giving the other person back his experience in a form that he recognizes it as his own, are arguably the basic empathic responses born of empathic data gathering. We are related. Period. For an evidence-based approach, there is nothing wrong, but what is missing is that empathy is a form of data gathering about the experience of the other person. Empathy falls out of the equation if, regardless of the other’s experience, one should always be kind.

From an empirical perspective, no necessary connection exists between empathy and kindness. It might well be more practical and the line of least resistance to link empathy with human dignity, toleration of diversity, or respect for boundaries. There are some people who just do not feel very charitable or altruistic, but if they behaved so as not to hurt others, respected boundaries, paid their taxes, then the world would still be much better off than it is now. Now one may argue back that such a non-kind [not unkind!] person would be logically inconsistent since he relies on the kindness of strangers (at least indirectly) while not providing such kindness to others in return. Strange to imagine paying taxes as an empathic gesture – and yet perhaps it is one. The debate is joined.

Zaki’s book is fully buzzword-compliant. He gives a shout out to mirror neurons as the neurological infrastructure of empathy; the history of empathy in the work of Adam Smith, Theodor Lipps, and Edith Stein; and Gregory Batson’s experiments that provide evidence that empathy is inherently prosocial, creating (as I like to say) a clearing for altruism to show up.

Less charitable (but not necessarily less empathic) thinkers argue that Batson’s empathy-altruism hypothesis is actually the “no good deed goes unpunished” hypothesis in a world in which ethical conflicts are common. Why? After priming seminary students to commit to giving a lecture on The Parable of the Good Samaritan, they are sent off across campus. They encounter a man flat on his back (actually an actor and confederate in the experiment) at the entrance to the lecture. They have to decide whether to help him or keep their commitment to give the lecture. Never was it truer that the urgent drives out the important. The debate continues.

Zaki’s mindset is basically a product of the enlightenment – however crooked the timber of which mankind is made, we are susceptible of improvement.  Agree. Expect people to succeed, they just might do so. Expect them to fail, they start living into one’s low expectations of them. Yet Zaki’s approach also aligns well with the rather negative, post-modern idea that no governing metanarrative exists. (See the stuff on Marx, Freud, and so on for “grand meta narratives.”) Given the examples of human behavior so far, especially in the 20th century, the slide towards the abyss seems to be accelerating. His is a call to action that demands a response – an empathic one.

Zaki shares powerful personal anecdotes, about which I would have liked to have heard more. That’s where the empathy LIVEs. As a kid, between the ages of 8 years old and 12, young Jamil is caught in the cross fire of the years long divorce between his hard charging Pakistani father, working 18 hour a day to escape the poverty and deprivation he survived, and a kinder, gentler, Hispanic mother, who, nevertheless, struggled with her own emotional disregulation.

Zaki credibly asserts that he had to take his own initially limited empathy up a couple of levels to navigate the emotional mine field [and mind field?] of two parents blaming one another and trying to enroll him – the kid – in their perpetrations.

Fast-forward to Zaki’s building a family of his own, and his first-born is born with a condition that has the baby (and the family) in the neonatal intensive care unit. Not for the faint of heart. Zaki subsequently returns to the NICU to do qualitative research on empathy and the risk of burnout and compassion fatigue. I know nothing (really!), but my sense of it all? In a world in which neither empathy nor kindness is particularly abundant, this book is Zaki’s way of creating expanded empathy for himself. Once again, my take? Zaki struggles; the reader – and the community – benefit. Our thanks to Jamil Zaki for his penetrating analysis – and his empathy!

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

 

 

Empathy: The one-minute training [no kidding!]

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 - illustration (c) Alex Zonis

The one-minute empathy training – illustration (c) Alex Zonis

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.  

[1] 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

The Evidence: Empathy is good for your health and well-being

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

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

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

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

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

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

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

Well-being rides the wave of empathy: sketch by Alex Zonis (AlexZonisArt.com)

Well-being rides the wave of empathy: sketch by Alex Zonis (AlexZonisArt.com)

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

 

Review: The Soul of Care by Arthur Kleinman

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.

Arthur and Joan Kleinman in a happier time (circa 1996)

Arthur and Joan Kleinman in a happier time (circa 1996)


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

Joan Kleinman (Obituary Photo)

Joan Kleinman (Obituary Photo)


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