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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 is 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.

 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

 

 

 

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Review: Narrative Exposure Therapy – and empathy

Narrative Exposure Therapy (NET) was originally designed as a treatment for victims of war, persecution, and torture. Civil wars (e.g., Rwanda, Burundi, DR Congo, Iraq) often target civilians and include widespread atrocities and human

Narrative Exposure Therapy (NET) by Schauer, Neuner and Elbert

Narrative Exposure Therapy (NET) by Schauer, Neuner and Elbert

rights violations. For example, the widespread use of rape as a weapon of war and the recruitment of child soldiers in the civil wars of east Africa have left entire populations traumatized even after the cessation of hostilities.

Engaging with these survivors is not for the faint of heart. Therapists are at risk of compassion fatigue and burn out. Many survivors have had to run the gauntlet of multiple, complex traumas, requiring a raid on the inarticulate even to bring their suffering to language. NET is such a raid on the inarticulate.  

The colleagues at the Universities of Konstanz and Bielefeld have innovated in the matter of an intervention that aims at restoring the survivor’s humanity, does not leave the therapist overwhelmed, is scalable, is relatively brief, indirectly gathers data to pursue justice against the perpetrations, and is evidence-based in reducing the symptoms of post traumatic stress disorder (PTSD) even in populations with limited resources.

In a Grand Rounds session on NET at Rush Medical Center, Chicago, in March (2019), I raised the issue of empathy and the risk of burn out with Dani Meyer-Parlapanis Doctor of Psychology, University of Konstanz). Dr Dani is notone of the authors of the text under review here. However, she trains NET practitioners and is providing leadership in extending NET to other applications, including girls and women who embrace violence. I said to her: “If this is not empathy, I would not know it: Empathy LIVEs in NET and in the work you-all are doing. You are engaging with child soldiers and really tough cases. What about it?”

Dr Dani of course acknowledged that compassion fatigue (“burn out”) was a significant risk in engaging with large numbers of survivors of complex trauma, so the NET trainers, are, in effect, counseling the lay counselors notto go into unnecessary detail at first (or words to that effect). Just get the time-line and a label for what happened. But then acknowledging full well that the work was precisely to go into the details she said: “The idea is to be like an investigative reporter.” Though acknowledging the matter may be controversial, I took that to mean empathy in the sense of data gathering and sampling the survivor’s experience, not immersing oneself in it. The investigative reporter is not hard-hearted, but in tune with what the survivor is experiencing. That indeed is the heart of the investigation.

Thus, “empathy” is distinct from compassion. Empathy targets a form of data gathering about what the other person experienced, a sampling of the other’s experience. Such empathy is in tune with the boundaries between self and other and leaves each individual whole and complete in a context of acceptance and toleration. I believe the definition of empathy of Heinz Kohut (1959) as vicarious introspection aligns remarkably well with that employed in NET.

 In the face of compassion fatigue, dial empathy up or down by simulating the role of an investigative reporter. If one can say exactly what happens, the trauma begins to shift, lose power, and shrink, typically by being reintegrated in the context of everyday life and experience. In this case, the investigative reporter also uses vicarious introspection. Easier said than done; but necessarily both said and done.  

The reader in Chicago may say that’s fine, but what has it got to do with the situation here in the USA? We do not have child soldiers or wide spread traumatized populations.

Think again. Gangs are recruiting children of tender age not only as messengers but also as triggermen, because they know youngsters will face a different criminal justice system and process, generally more lenient, than adults.

 After two wars, stretching back to the consequences of the 2001 terrorists attacks, the population is peppered with wounded warriors, both men and women, with a diversity of untreated symptoms from subclinical substance abuse to PTSD, thought disorders, and depression. Violence against (and abuse of) women is no longer an issue in the inner city, but is acknowledged to be a challenge from Hollywood to corporations and the US Supreme Court. 

So, while NET has not received much application in the USA (or the first world), the unmet need is great and it deserves consideration. Hence, the value of this overview.

In some four to fourteen sessions of 90–120 minutes each, the therapist and client create an autobiographical time-line that names the events that have stimulated the most affective arousal in the person’s life. These include traumatic events such as aggression, sexual boundary violations, deaths of loved ones, becoming a refugee, and so on. Positive events are also included on the time-line such as births, marriages, graduations, and life successes. Fast forwarding through the process, the client is handed a copy documenting the narrative at the end of the sessions and a copy is retained just in case the client wishes/agrees to submit the report to the authorities for judicial, prosecutorial follow up.

One of the innovations and most challenging aspects of the narrative in working with former child soldiers (who have grown up in the interim) is to create a context of acceptance and tolerations. Naturally the therapist must employ empathy, but he or she does so as an investigative reporter gathering data about what happened. To become a child solider the survivor is generally required to commit an atrocity such as kill a member of his or her family. Issues of shame and guilt along with the deadening loss of one’s own humanity are powerfully present and evoked.

The first session begins. Diagnosis and psycho-education occur up front. The client may not even know what is PTSD. The client may be living a basically resigned and hopeless existence, and she or he must be enrolled in the possibility of recovery. The education includes information on symptoms, what is involved in the therapy, as well as a statement about the universality of human rights.

An initial pass through the client’s autobiography occurs. A time-line, the life span history, is completed during the second session. The task is to name or label the event in the course of one 90–120 minute session without calling forth the details and hot emotional impact of the traumatic incident. A rope line is used with a variety of stones for traumas, flowers for positive events, and sticks for when the client perpetrated a dignity violation against another. The subsequent work of sessions three through fourteen is to engage sequentially with the events. The work at hand is to find words to express what has previously been unexpressible.

The narrative work consists of going through the events of the time-line. When? Where? And what? The five senses are invoked. Hot memory, sensation, cognition, and emotion are called forth.  What did the background look like? What were the people wearing. Small, cold details call forth powerful hot emotions.

The idea is to put into words and capture verbally the hot affect and experience. The session is not over until the client (often with the support of the therapist) is able to describe what happened in words – that is the narrative.

Now “what a person made it mean” also starts to emerge at this time, and those meanings will naturally be compared with reasonable (or unreasonable) assessments of what to expect of children or people literally with a gun or machete to their necks.

Talking about what happened in the course of the traumatic events calls forth the hot experiences. Talking about what happened following the traumatic events put the hot events back into the context of cold experience. Talking about what happened following the trauma enables the client to reintegrate the trauma into the all-encompassing, greater life narrative. The client is reoriented in time and space to the present, the trauma is contextually situated as to emotional meaning. Before the session ends, the therapist verifies and validates that the client’s arousal has subsided to standard levels and is oriented to the present.

Cognitive restructuring occurs automatically in the days after the story telling. The client may return to the next session with new insights, meanings, and understanding of her or his own behavior in the trauma. Formerly inaccessible details (memories) may emerge and should be included in the narrative. 

For example, one child soldier reported that he killed his sister by cutting her neck with a machete as part of the initiation, for which he bore a great emotional and moral burden; but he subsequently remembered that one of the paramilitaries hit his sister in the head with his rifle butt, a fatal blow, prior to his own action. Therefore, though he did in fact cut his sister, he did not kill her. Small comfort; and not a choice anyone should have to make; yet a significant step in recovering this individual’s dignity and humanity.

In the final session, the client is given a document of her or his narrative lifeline with the details filled in. Where appropriate, the client is asked if he wants to forward the data to the authorities for prosecution of the high level authorities and perpetrators who organized the war crimes. Follow up occurs at six months and a year, often documenting further improvement in symptom reduction, acquisition of life skills, and accomplishments.

NET is trauma focused but unlike many trauma focused therapies that require the survivor to identify thetrauma or select the worst trauma (“good luck with that”), NET acknowledges that survivors of war, torture, and persecution have encountered a sequence of traumas. This is call a “life span” approach.

Granted NET evokes a grim calculus, the number of traumatic event types – beating, rape, killing, torture, branding, amputation, witnessing these, destruction of home by paramilitaries, domestic violence and/or substance abuse by family member, perpetrating or participating in these, and so on – predicts the symptoms of PTSD over and above the actual number of traumatic events.

The results? Studies showing the effectiveness of NET have been independently conducted (Hijazi et al 2014, Zang et al 2013). Centrum 45 in the Netherlands and the Center for Victims of Torture in Minnesota use NET in treating survivors and refugees. NET manuals are now available in English, Dutch, French, Italian, Slovakian, Korean, and Japanese and are also available from the authors in Spanish and Farsi.

Further detailed evidence of the effectiveness of NET is at hand. Reorganizing traumatic memories seems to be inherently stress reducing. Chronic stress causes a weakening of the body’s resilience and defenses against disease and emotional disorder. Reducing stress improves one’s health and well-being. “Morath, Gola et al. (2014) showed that symptom improvements caused by NET were mirrored in an increase in the originally reduced proportion of regulatory T cells in the NET group at a one-year follow-up.” “These cells are critical for maintaining balance in the immune system and regulating the immune response to infection without autoimmune problems. This finding fits with the observation that NET reduces the frequencies of cough, diarrhea, and fever for refugees living in a refugee settlement (Neuner et al. 2008, Neuner et al 2018).”

NET works. NET produces positive results for those suffering from PTSD. This brings us to the question: Why does it work? Thereby hangs a tale – and a theory.

NET conceptualizes PTSD and related disorders as disorders of memory.

For example, hot memories include the sounds of people screaming for help, the sight of dead or wounded persons, the smell of the perpetrator pressing his body against the victim, the taste of one’s own vomit, the experience of being unable to move and helplessness, and so on. These are “hot memories.” These occur or occurred in a context of coldmemories of place, time, and standard activities.

For example: “We were working in the garden behind the house when the paramilitaries drove up in a truck.”  In the case of an individual trauma or series of traumas of the same type, as a defensive measure to preserve the integrity of one’s personal experience, the individual may take himself out of the situation in thought automatically, watching and experiencing the situation as if he was an observing third party. How this occurs is not well understood, but it seems to support survival of the organism in extreme situations.

This disconnects the “hot” and “cold” contexts. In the case of an individual surviving multiple trauma types, beating, rape, loss of home, the cumulative traumatic load causes the traumas to be grouped into a network disconnected from the standard, cold context of everyday life. Fear generalizes forming a fear network. Emotional, sensory, cognitive and physiological representations interconnection with the excitatory force of hot memories. Ordinary, random events become triggers of this network.

The trauma LIVEs. It takes on a life of its own as the fear network. PTSD survivors learn to avoid triggers that act as activators of hot memories. The client isolates. He or she has difficulties with the cold context of autobiographical memory. A negative cascade of experiences is mobilized as symptoms suck the life out of the individual, leaving him or her as an emotional zombie. “Shut down” replaces intrusive thoughts and hyper-arousal with passive avoidance and disassociation.

The effectiveness of NET consists in reestablishing the connections between hot and cold memories, the hot traumatic events and the cold, everyday occurrences that situate them in place and time. In a context of acceptance and toleration (i.e., non-judgment and empathy), the client is supported in reliving the details of what happened by putting them into words without losing the connection to the here and now. If one can say what happened, the emotion is called forth and reintegrated into the context of the person’s life. The trauma starts to shrink.

The imagined exposure to the traumatic event is maintained long enough for the affect, especially the fear, to be called forth and allowed to begin to fade in intensity. The narrative is essential. Absent words, retraumatization – invoking the trauma in an uncontrolled way – is the risk to the client. Even if time is running short, the session must not end until the client (with the help of the therapist (as appropriate)) has found some words to describe what happened. (If the trauma involves organized or domestic violence, the testimony may be recorded or documented for forensic purposes.) 

Two of the strengths of NET are the low drop out rate and the scalability due to building a network of lay therapists. Lay therapists?

The World Health Organization endorses this approach for those communities with limited resources (Jordans, Tol 2012). Given the limited resources of third world countries or even many communities in the USA due to the monopoly-like rents being collected by healthcare insurance providers, NET embraces “task shifting.” “Task shifting” consists in training lay therapists to perform the intervention.

Regarding the training and use of lay therapists to deliver NET, it is scalable, affordable, and workable. It is also controversial. In the State of Illinois (USA) one needs a license to cut hair. However, so far as I know, one does not need a license to have a structured conversation for possibility with another human being about what they had to survive. No doubt the graduates of PsyD programs may have an opinion about that; but personally having taught in two PsyD programs, I know the dedication, commitment, and hard work of the students and teachers; and I also know that one cannot take a course entitled (or with the content of) “empathy lessons” or with “empathy training” in any of these programs. I know because I proposed to do so, but it simply did not get approval due to other priorities. 

NET offers significant potential not only to treat PTSD survivors of violence and trauma. Anxiety and panic disorders, depression, eating and substance abuse disorders, borderline personality disorder (BPD), all report intrusive memories filled with upsetting content but lacking cold memory context.

One final thought. Those suffering from PTSD are suffering from reminiscences –  disorganized, toxic memories. The astute reader may recall this is what Freud said, in slogan-like sound byte, about hysteria (Breuer, Freud 1893). Each memory has to be transformed into words, into a narrative. Each memory has to be expressed in speech so that the body no longer has to function as the corporeal narrator in flashbacks, startle response, panic attacks, intrusive ideas, emotional numbing and overstimulation. Narrative exposure therapy gives new meaning to the phrase “the talking cure,” and it is one. How shall I put it delicately? My “French” fails me: The more things change, the more they stay the same.

 REFERENCES

Breuer, Josef and Freud, Sigmund. (1893). Studies on Hysteria. Translated from the German and edited by James Strachey. (The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. II.) Hogarth Press, London 1955.

Hijazi, A. M., Lumley, M. A., Ziadni, M. S., Haddad, L., Rapport, L. J., & Arnetz, B. B. (2014).Brief narrative exposure therapy for posttraumatic stress in Iraqi refugees: A preliminary randomized clinical trial. Journal of Traumatic Stress, 27(3), 314–322. https://doi.org/10.1002/jts.21922

Jordans, M. J., & Tol, W. A. (2012). Mental health in humanitarian settings: Shifting focus to care systems. International Health, 5(1), 9–10.

Kohut, Heinz. (1959). Introspection, empathy, and psychoanalysis. Journal of the American Psychoanalytic Association7. (July 1959): 459–407.

Morath, J., Gola, H., Sommershof, A., Hamuni, G., Kolassa, S., Catani, C., … Elbert, T. (2014).

The effect of trauma-focused therapy on the altered T cell distribution in individuals with PTSD: Evidence from a randomized controlled trial. Journal of Psychiatric Research, 54, 1–10. https://doi.org/10.1016/j.jpsychires.2014.03.016

Neuner, F., Onyut, P. L., Ertl, V., Odenwald, M., Schauer, E., & Elbert, T. (2008). Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 76(4), 686–694. https://doi.org/10.1037/0022-006X.76.4.686

Neuner, Frank, Elbert, Thomas, Schauer, Maggie. (2011).Narrative Exposure Therapy: A Short-Term Treatment for Traumatic Stress Disorders, 2ndEdition, Göttingen, Germany: Hofgrefe Verlag.

Neuner, Frank, Elbert, Thomas, Schauer, Maggie. (2018).Narrative Exposure Therapy (NET) as a Treatment for Traumatized Refugees and Post-conflict Populations: Theory, Research and Clinical Practice. 10.1007/978-3-319-97046-2_9.

Zang, Y., Hunt, N., & Cox, T. (2013). A randomised controlled pilot study: The effectiveness of narrative exposure therapy with adult survivors of the Sichuan earthquake. BMC Psychiatry13(1), 41. https://doi.org/10.1186/1471-244X-13-41

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

Empaths don’t get enough empathy: Review of Orloff’s Empath’s Survival Guide

Empaths don’t get enough empathy.

An empath is a person who is naturally endowed with an overabundance of empathy. As I understand the term, a “natural empath” (my term, not Orloff’s) is an individual who is empathsSurvivalGuideCOVEROrloffnaturally endowed from birth or genetically “loaded” with a deep and extensive empathy, a hypersensitivity to the experiences of others.

This gift of empathy shows up as a mixed blessing, since the natural empath experiences the pains and sufferings of the world more intensely and deeply than do other individuals. Less charitable people redescribe the “natural empath” as someone who is “irritable” or “overly sensitive.”

Granted, the natural empath brings a deep sensitivity to the experience of human suffering and joy, the natural empath also lives through the nuances and delicate details of the experiences intensely. Too intensely?

Granted that the empath seems to be protesting, at least sometimes, that her empathy is working overtime and causing suffering—a breakdown—a book such as Judith Orloff’s The Empathy’s Survival Guide is a timely antidote. [1]

Such empaths seem to be challenged—lack skill—in tuning down their empathy. Indeed they often do not think of the possibility of such skillful tuning. They do not acknowledge such a possibility. There is nothing wrong, but there seems to be something missing. Hence, the need for Orloff’s guidance. Granted, individuals are born a certain way, and that, no doubt, can represent a challenge, but being born a certain way does not mean one always has to stay that way.

Meanwhile, the empath is experiencing a breakdown in empathic receptivity (my term, not Orloff’s). According to Orloff, instead of a well-rounded, mature, developed empathy, the empathy of the natural empath breaks down into emotional contagion (at least on a bad day). The suffering of the other person floods her or his empathy; indeed the suffering of the world inundates the individual.  But that is not all, and the dominoes start falling.

Orloff gets into the details. Overwhelmed and under stress, the natural empath engages in defensive gestures that ultimately are self-defeating. These include isolating oneself, turning to alcohol or street drugs in an attempt to self-medicate, enacting other addictive behaviors (over-eating, restricting., sexual acting out), and so on. Furthermore, the chronic social stress experienced by the natural empath is a source of inflammatory disorders such as autoimmune diseases, allergies, clinical anxiety, depression, and so on, to which we are all susceptible, but the empath especially so. The result is a form of emotional burnout, compassion fatigue, empathic distress, emotional contagion, not empathy.  

The empath is just being what she or he calls “empathic”; but it is not working for the individual in question. Why not? Orloff explains that due to natural endowment and/or adverse childhood experiences, the empath lacksexperiential filters and sensory inhibition. The glass is both half empty and half full. The empath is endowed with intuitive abilities that may be exceptional. However, the trouble is that the empath’s empathy lacks inhibition. He is too open to the pain and suffering of the world. Heck, even a succession of sunny days can become burdensome, though in a different way.

In contrast to the natural empath, most people are too inhibited, including being inhibited as regards their empathy. Most of us are not sufficiently in touch with our feelings and experiences in relationships.

Not so, the natural empath. The natural empath endures too much “in touchness” with feelings and experiences of the pain and suffering of others. In this one respect, empathy, the natural empath is too uninhibited. In this one particular area of openness to the suffering and pain of other people, the natural empath may usefully increase her inhibition. Consider the example of Dr Brecht in Thomas Mann’s celebrated novel Buddenbrooks, a dentist who deeply experiences the pain of his dental patients, so that he has to sit down, exhausted by the suffering of his patient, and wipe his brow after each procedure. Dentistry – perhaps not the best choice of profession for a natural empath.

A sound scientific basis exists for this a predicament. (We will shortly get to the scientifically debatable aspects of Orloff’s work.) People who are “natural empaths” have an acute sensitivity to in-bound sensations and perceptions. The function of what physiologists call “lateral inhibition” of sensory perception seems to be “lazy” and under-performing in these people. Lateral inhibition enables the nervous system to filter out the distracting background noise and intensify the relevant, salient sensations in the environment.[i]

That does not mean the natural empath should become hard-hearted or unkind, though paradoxically that is sometimes the sad result of burnout, compassion fatigue, or empathic distress. In order to overcome the breakdown of empathy, what does one actually doin order to expand or contract one’s empathic receptivity?

Orloff’s work is rich in tips and techniques for the struggling empath. Many of her best tips can be summarized in one phrase. Set firm limits and boundaries. The empathy lesson for such individuals consists in: Practice methods of “down regulating” one’s empathy.  State a request; and use humor (p. 122). Remember that “No” is a complete sentence (p. 222). “Don’t try to fix others” (p.  230).  

In a different category of tips and techniques are a long list of self-soothing, distress tolerance, and emotional regulation skills. Since this is self-help book, expect to encounter numerous recommendations about proper nutrition, regular exercise, sleep hygiene, and so on. All good recommendations, every one, but not specific to empathy as such. More problematic is the writing heavily weighted in the direction of “new age” interventions such as burning incense, holding healing gems, telepathic communication with plants and animals, and Epsom salt baths.

I hasten to add that I am a big advocate of Epsom salt soaking, especially in the form of sensory deprivation, though it tends to expand openness and sensitivity. More on the other “new age” interventions shortly. Empathy works to create a space of acceptance and toleration, so if the practice in question helps one regulate one’s emotions, do it.

The empath definitely can feel like he needs a survival guide – and Orloff’s work is a good place to start for the magical thinking free spirit. However, from the perspective of a rigorous and critical empathy, some real problems and issues are going to get in the way of a serious appropriation of this book, outside the confines of a weekend retreat on telepathy and intuitive energy healing.

There are more things on heaven and earth than are dreamt of in our philosophies – and Orloff points at many of them. How shall I put it delicately?, Orloff’s discussion proceeds as if subtle communications are undisputed medico-scientific-therapeutic facts not compelling puzzles that should alert us to a depth of our emotions and thoughts that may usefully be plumbed in a rigorous and critical empathy.

For example, in 1779 the Viennese physician Anton Mesmer published a treatise on animal magnetism, describing a subtle physical “magnetic” fluid – analogous to but different than Newtonian gravity – that permeates the universe, connecting, men, the earth, and the heavens. The imbalance of this hypothesized fluid in the body is responsible for such emotional disorders as hysteria and obsessive-compulsive behavior. Mesmer conducted “magnetic banquets” that provided the nobles and aristocracy with substantial relief from their physical and psychosomatic symptoms. 

At about the same time, one of Mesmer’s students, Viscount Jacques Maxime de Castenet de Puységur, differentiated “magnetic sleep,” which we would today call “hypnotic suggestion” and seemed to offer relief, not to the nobles, but to soldiers, workers, and peasants. The word “hypnosis” does not occur in the text, but I speculate that many of Orloff’s tips and techniques are forms of self-hypnosis. Might be worth a try.

Animal magnetism, psychic energy, libido, the energetic Chi practiced in Tai Chi, the instincts or vasanasliberated in Yogi, the mystical heat generated by the Shaman, emotional contagion, and so on, are not grounded in any conventional scientific theory or practice. So such energy work is not exactly an objective fact, and yet it is not a fiction.  

Speaking in the first person plural, since Orloff has diagnosed herself as an empath, she writes: “Since everything is made of subtle energy, including emotions and physical sensation, we energetically internalize the feelings, pain, and various physical sensations of others [….] [and] are even able to connect with animals, nature, and their inner guides” (p. 6).

Any one who owns a dog or cat knows from experience that we communicate with animals – exchanging feelings and experiences. But what Orloff has in mind is much more specific and goes well beyond provocative metaphors to questionable material instantiation.

Orloff is captured by the materialist fallacy and forgets that factual reality itself is permeated with fictions and fantasies. Ignoring the power of fiction, she wants to make a compelling linguistic locution such as “psychic energy” into a fact, thereby losing its power to enable us to describe and transform feelings and behavior. As demonstrated by many of Orloff’s imaginative and ”out there” statements, an idea does not need physical or factual reality to be effective – it just has to be expressed in a performative language.

There is a fancy name for Orloff’s main fallacy – reification – making into a thing that which is otherwise an abstraction. The idea of psychic energy is a compelling one, and it does have many applications in describing the mental status, awareness, or ability to be present in a conversation, of a person in a would-be empathic relationship. But it is the name of a problem and a deep issue, not a physical reality.

For example, neurology assures us that the brain – and indeed the body – gives off an electro-magnetic field. But this is a blunt instrument enabling us to tell whether an individual is conscious or in a coma, aware of his surrounding or experiencing an epileptic seizure. Orloff does not say that perhaps someday the granularity and specificity will improve. This is not a “some day” survival guide. No, she is claiming to have that skill now in her practice and workshops – and perhaps you can get it, too, if you work with her and follow her guidance .

Ironically, Orloff’s empathy is off. Empath’s are also naturally endowed with intuition, and Orloff consistently confuses intuition and empathy. Intuition and empathy are closely related, but they are inverselyrelated. More intuition often occasions less empathy, and vice versa. Intuition is the ability to make inferences, educated guesses, based on nuanced clues that are often barely over the threshold of perception. It is the kind of thing at which Sherlock Holmes excelled, and he was a notoriously hard case.

In contrast, empathy is the ability to take a vicarious experience, based on sustained listening to another person, and process it further cognitively, resulting in an empathic response. The properly empathic empath uses his empathic receptivity as to who the other person is as a possibility. The empath takes a walk in the other’s shoes with the other’s foot size, giving back and responding to the other individual her experience in a form of language such that the other person recognizes it as her own. As the empath learns to set firm boundaries and limits, her intuition is transformed into sustainable, usable empathy in the full sense from which both she and the community benefit.

Ours is a world in which pain and suffering are abundant. This does not make the would-be empath cold-hearted or the object of moral condemnation. Indeed such people might be more willing to engage in helping behaviors such as volunteering or donating money based on cognitive appreciation of the other person’s predicament rather than the experience of vicarious suffering. It means that the natural empath should practice taking distance from his own feeling in such a way that he gets a sample or trace of the other person’s feeling without being overwhelmed.

Expressed positively, if distance (or inhibition) were a medical drug, the natural empath may usefully increase the dosage. Take more of it. However, this is at best an imperfect analogy. Recall that inhibition is what enables the average person to get results in a world that the individual subsequently experiences as causing boredom precisely because inhibition is doing such a good job of down regulating the wave of stimulations that potentially wash over the person; and likewise the natural empath, hypothetically lacking such a filter, needs to down-regulate her empathy through self-distraction and abstraction to sustain emotional equilibrium rather than over-stimulation. The natural empath is an important and engaging case, and he may actually increase his good deeds in a particular situation by contracting his empathic receptivity, one particular part of empathy.

Note that Orloff considers herself an empath. She shares childhood experiences that indicate this was so as long as she can remember. I consider myself to be one of those “neuro typical” individuals, who used simply to be called “normal” (except that we no longer know what is “normal’). I hasten to add that I have expanded my empathic capabilities through extensive practice and training discussed elsewhere.[2]

Being an empath is surely a mixed blessing – as is this book. If one can expand one’s empathy, one can also contract it. The power of the empath – and the ordinary person – consists in doing both in their proper time and place. That is an important point from the perspective of a rigorous and critical empathy, about which Orloff may usefully be more explicit. Empathy in all its forms works to create a space of acceptance and toleration, so I acknowledge Orloff’s commitment to empathy.

REFERENCES

[1]Judith Orloff, MD, 2018, The Empathy’s Survival Guide: Life Strategies forSensitive People. Boulder, CO: Sounds True, Inc.; 263pp, $17.95.

[2]Lou Agosta, (2018), Empathy Lessons. Chicago: Two Pairs Press.

[i]Georg von Bekesy. (1975). Sensory Inhibition. Princeton, NJ: Princeton University Press. Von Bekesy was awarded the Nobel Prize for his work in physiology and medicine.

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

 

Top Ten Trends in Empathy Lessons for 2019

Empaths can’t seem to get enough empathy – get some here!

10. Empathy versus bullying: in mud wrestling with a pig, everyone gets dirty – and the pig likes it. 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. It means listening carefully, and responding accordingly.

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. By all means, try to be friends: “Courtesy don’t cost ya nothin’.” Make an extra effort – and go the extra mile. But do not surrender one’s integrity or basic human values. However, taking a walk in the other person’s shoes applies to the enemy too. It is called “Red Team” – think like the other side. Are they angry? Fearful? Sad? Enthusiastic? Empathy gives one access to what is going on “over there.”

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 empathy is no longer empathy; it is empathy in the form of a breakdown of empathy. The “empathic” response to an attack is to “neutralize” the attack and be empathic with the survivors. You knew that, right? Empathy consists in restoring the boundaries and integrity to the situation.

9. There is enough empathy to go around. Granted, it does not seem that way. It seems that the world is experiencing a scarcity of empathy – and no one is saying the world is a sufficiently empathic place. Consider an analogy. You know how we can feed everyone on the planet? Thanks to agribusiness, “miracle” seeds, and green revolution, enough food is produced so that people do not have to go hungry? Yet people are starving. They are starving in Yemen, Africa, Asia – they are starving in Chicago, too.

Why? Politics in the pejorative sense of the word: bad behavior on the part of people, aggression, withholding, and violence. The food is badly distributed. Now apply the same idea to empathy.

There is enough empathy to go around – but it is badly distributed due to bad behavior and politics in the pejorative sense. Drive out the aggression, bullying, shaming, integrity outages, and so on, and empathy naturally comes forth. People are naturally empathic, and the empathy expands if one gives them space to let it expand.

8. Empathy is not an “on off” switch. Empathy is [like] a dimmer, a tuner. Dial it up or dial it down. We tend to think of empathy as an “on off” switch. Turn it on for friends, the home team, the in crowd; turn it off for opponents, the competition, the outsiders. However, empathy is a dial or tuner – turn it up or down gradually depending on the situation.

The surgeon has to turn his empathy way down in order to operate on the human body as a biological system; but the surgeon never forgets that the operation is occurring so that the patient can return to his or her family and friends as a whole human being. This “dialing up” or “dialing down” does not come naturally (whereas “on” or “off” seems to be the common reaction). That is why training and practice are needed.

If I can cross the street to avoid the homeless person and thereby regulate my empathy downward; and I can also cross the street in the other direction and buy Streetwise or give her a shrink-wrapped snack bar.

Approaching empathy as a tuner or dial that expands or contracts one’s openness to the experiences of the other person (rather than an “on-off” switch), shows the way to avoiding being overwhelmed by the other’s difficult experience and the accompanying burn out, “compassion fatigue,” or empathic distress. Dial down the exposure. Take a sample and a vicarious experience. Put one’s toe or ankle in the water rather than jump in up to one’s neck.

7. The poet Robert Frost wrote: Good fences make good neighbors. There is a gate in the fence [a fence, not a wall] and over the gate is the word “empathy.” Empathy is all about boundaries. Empathy is all about moving across the boundary between self and other.

The boundary is not a wall, but a semi-permeable membrane that allows communication of feelings, thoughts, intentions, and so on. As noted above, the poet Robert Frost asserts that good fences make good neighbors. But fences are not walls. Fences have gates in them. Over the gate is inscribed the word “empathy,” which invites visits across the boundary. In the business world, the gate is sometimes called a “service level agreement (SLA).”

6. Empathy reduces conflict, aggression, and rage. Getting a good listening calms, soothes, and de-escalates. Getting a good listening de-escalates, period. When a person does not get the dignity, respect, or empathy to which he feels he is entitled, then he becomes angry. Lack of empathy and dignity violations expand anger and rage.

In particular, overcoming resistance to empathy, expanding empathy, is on the critical path to eliminating or at least reducing organizational conflicts and dysfunctional behaviors. When staff, executives, stake-holders, and so on, expand their empathy for one another and for customers, they are able to deescalate confrontations and negativity; they avoid provocative and devaluing language; and they are able to head off dignity violations, all of which reduce the conflicts that literally suck the life out of organizations.

When employees appreciate the possibilities of empathy, they even try to replace office politics with professional behavior. Staff get more done because they can concentrate on doing their jobs, working smarter, and serving customers and coworkers rather than struggling with departmental politics.

In addition, expanding empathy—overcoming resistance to empathy—is on the critical path to building teams. Empathy is the foundation of community, and the team is nothing if not a community. In empathy, people practice giving acknowledgment and recognition for their contribution to the success of the team and the organization. Being inclusive does not always come naturally or easily to us humans, territorial creatures that we are. We oscillate between closeness and distance like a pendulum.

5. Empathy is a method of data gathering – sampling – about the experiences of the other person. Hold this point. Simply stated, empathic receptivity is a technique of data collection about the experiences of other people. This is not mental telepathy. Human beings are receptive to one another, open to one another experientially, but with some conditions and qualifications. You have to listen to the other person and talk with him or her. You have to interact with the person. The one individual gets a sample of the experience of the other person. The one individual gets a trace of the other individual’s experience (like in data sampling) without merging with the other.

Through its four phases, empathy is a method of gathering data about the experience of the person as the other person experiences his or her experience. This data (starting with vicarious experience) is processed further by empathic understanding of possibilities and empathic interpretation of perspectives in order to give back to the other person his or her own experience by means of empathic responsiveness in language or gesture in such a way that the other person recognizes the experience as the person’s own.

4. Empathy is distinct from compassion or even rational compassion. If you are experiencing compassion fatigue, maybe you are being too compassionate. I hasten to add this does not mean be hard-hearted, cold, mean-spirited, or indifferent. It means in the face of overwhelming suffering, tune down one’s empathic receptivity in order not to be emotionally neutralized. Tune up one’s cognitive empathy in order to understand what is going on and what are the options for making a positive difference in the face of the challenge at hand.

Engaging with the issues and sufferings with which people are struggling can leave the would-be empathizer (“empath”) vulnerable 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. Maybe one is being too compassionate instead of practicing empathy. In empathy, the listener gets a vicarious experience of the other’s issue or problem, including their suffering, so the listener suffers vicariously, but without being flooded and overwhelmed by the other’s experience.

The world needs \ more compassion and expanded empathy; but in managing compassion fatigue one may usefully turn down one’s compassion and turn up one’s empathy. The power of well-practiced empathy is that it enables one to sample the experience of the other, including their suffering (which is the problematic experience), without being inundated by it. Instead of diving in head first, one puts one’s toe in the waters of the other person’s experiences. To extend the metaphor, one needs to get the entire ankle in the water to gauge its temperature accurately, but that is still a lot different than being up to one’s neck in it.

The bottom line? Empathy is distinct from compassion. 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.

3. Empathy lessons are available every moment of every day: They are available in every encounter with another person, every anticipated encounter, and every encounter that has just occurred. Whether struggling to survive and attempting just to get through the day or flourishing, consider the other person as one’s empathy trainer.

The other person trains one in empathy by being uncommunicative, difficult, shut down, fearful, angry, enraged, outraged (lots of rage), sad, high spirited, too withholding, too generous, disequilibrated, perfectly centered, stuck up, arrogant, passive aggressive, aggressively helpless, annoyingly right, “obviously” wrong, or otherwise struggling with something that is hard to express. Sometimes the message is loud and clear. Thus, the baby trains the parent in empathy with loud exclamations; the customer sometimes does exactly the same thing to the businessperson; the patient, the doctor; the consultant, the client, and so on. The empathy lesson is to listen with renewed receptivity, understanding, and responsiveness to your kids, customers, clients, neighbors, and fellow human beings.

Every human encounter is a potential empathy lesson in picking up on the affect of the other person; in processing what is possible for the other person in spite of the stuckness or difficulty; in taking a walk in the other’s shoes when one really is without a clue as to what is going on; in taking what one has gotten by way of a vicarious experience and giving it back to the other person in a way that the other person recognizes it as his own.

The baby, the student, the patient, the customer, the neighbor, are the ones who bring empathy into existence for the parent, the teacher, the business person, in turn. The former provide an opening, a “set up,” a clearing, for the possibility of empathy on the part of the latter.

If we needed to multiple the number of empathy lessons available in every moment, then we would make these tips into equations: cynicism down, empathy up; shame down, empathy up; egocentrism down, empathy up; opinions and meaning making down, empathy up; narcissism down, empathy up; stress down, empathy up, and so on.
One can also reverse these empathy lessons: cynicism up, empathy down, and so on. In addition, numerous things are positively correlated with empathy: Acknowledgment up, empathy up; humor up, empathy up; self-esteem up, empathy up; random acts of kindness up, empathy up; a gracious and generous listening up, empathy up.

If you work in an environment laced with cynicism, the opportunities for empathy are constantly present, albeit in a privative mode. Get in touch with your empathy, which is powerful in such a context, and express a positive possibility. Your life, your job, your relations, will never be the same.

2. Empathy expands its claim to be a key leadership competency. Empathic leadership is never more visible than when it is lacking. Empathic leaders provide governance from contribution, commitment, and communication, not fear, chaos, or bullying. Empathic leaders follow the money, but do not follow it off a cliff. Empathic leaders make integrity the foundation of workability. They respect boundaries, speak and act with integrity, and honor their word. Here “integrity” means “workability,” not moral judgments. So, for example, a square bicycle wheel lacks integrity. It does not work. Empathic leaders find the best person for the job, get the person’s input on what it’s gonna take, create a set up for success, let the person do the job, and follow up periodically.

1. Natural empaths get expanded empathy. 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.

Over-intellectualizing (often considered a defense mechanism) is also a proven method of inhibiting empathic receptivity. Compartmentalization, rationalization, and displacement are all methods of putting distance between oneself and another’s feelings. Though usually considered defenses against feelings, in the case of the Natural Empath, such defenses are just what are needed to get through a tough spot of over-stimulation or emotional flooding in the face of the difficult experiences of other persons.

Ours is a world in which pain and suffering are abundant. This does not make the would-be empath cold-hearted or the object of moral condemnation. Indeed such people might be more willing to engage in helping behaviors such as volunteering or donating money based on cognitive appreciation of the other person’s predicament rather than the experience of vicarious suffering. It means that the Natural Empath should practice taking distance from his own feeling in such a way that he gets a sample or trace of the other person’s feeling without being overwhelmed.

Expressed positively, if inhibition (or distance) were a medicine, the Natural Empath may usefully increase the dosage. Take more of it. But this is at best an imperfect analogy. Remember, inhibition is what enables the average person to be effective in a world that the person subsequently experiences as boring and dull precisely because inhibition is doing its job of down regulating the tidal wave of stimulations that potentially wash over the person; and likewise the Natural Empath, hypothetically lacking such a filter, needs to down-regulate her empathy through self-distraction and abstraction to sustain emotional equilibrium rather than over-stimulation.

This is surely a mixed blessing. The Natural Empath is a special case, and he may actually increase his good deeds in a particular situation by contracting his empathic receptivity, one particular part of empathy. If one can expand one’s empathy, one can also contract it.

The way out of this apparent impasse is to consider that the Natural Empath does indeed get empathic receptivity right in empathic openness to the other’s distress, but then the person’s empathy misfires. Whether the misfiring in question is over-identification, resulting in empathic distress, depends on the description and redescription. Standing on the sidelines and saying “Try harder!” is easy to do. Where is the training the person needs when they need it?

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 empathy 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.

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

 

Review: The Empathy Effect by Helen Riess

The force of empathy is strong with Helen Riess, MD, and her team.

In The Empathy Effect: 7 Neuroscience-based Keys for Transforming the Way We Live, Love, Work, and Connect Across Differences(with Liz Neporent, Forward by Alan AldaTheEmpathyEffectRiessMD.jpg (Sounds True publishing, 234pp, $22.95)) Riess lays out a program for training medical doctors (and the rest of us) to expand our empathy.

The most important point that Dr Riess makes in the concise opening three chapters is that empathy is learnable. Empathy can be taught. The empathic capabilities of the human being can be expanded by practice and training. This is the set up for the introduction and promotion of the proprietary empathy training program, “E.M.P.A.T.H.Y.”®, offered by the for profit enterprise, Empathetics, of which Riess is the CEO. The training based on intellectual property developed at Massachusetts General Hospital and Harvard University. More on that shortly.

The work contains many personal reflections amid a fully buzz-word compliant narrative on the psychology and neuroscience of empathy. Dr Riess lets slip that she was in second grade when the 1963 Community Mental Health Act set in train consequences, some planned, most unintentional, that resulted in the emptying out of the Psychiatric Institutions (“Asylums”) that served for the long-term incarceration of those diagnosed with severe mental disorders.

This means that Dr Riess was young enough to have benefited from the innovations in empathy of Carl Rogers, PhD, and Heinz Kohut, MD, who, prior to the second psychopharmacological revolution, were responsible for putting the term “empathy” on the treatment intervention map of humanistic and self psychology.

Though not explicitly discussed by Riess, for practical purposes, the “second psychopharmacological revolution” is dated from Peter Kramer’s Listening to Prozac(1993). It took the legs out from under virtually every form of talk therapy then in the market, including Cognitive Behavioral Therapy (CBT, however, has demonstrated staying power for many reasons, not the least of which is that insurers are willing to reimburse for a dozen (or so) sessions).

Riess is conversant with Paul Ekman’s innovative research in coding (and decoding) the micro-expressions of the human face, an emotional “hot spot,” to discern what a person is “really” experiencing and feeling. Though Ekman does not use the term “empathy,” his approach to micro-expressions implies a definition of empathy distinct from that of Riess’ proprietary approach, which, in turn, aligns with David Hume’s “delicacy of sympathy and taste” (1741). If one person literally perceives a micro-expression of which another is unaware, then the one person’s “delicacy of empathy” (my term, not Hume’s) is more expansive that the other’s.

Thus, Dr Riess calls out the contributions of Rogers and Kohut such as “unconditional positive regard” and “vicarious introspection,” respectively. She appreciates the deep history of empathy (“Einfühlung”) in German aesthetics, in which empathy emerged from the projection of human feelings onto beautiful nature and art, something we humans seem to be cognitively designed to be unable to stop doing.

Riess appreciates that the distinction “empathy” is significantly different than “compassion,” “sympathy,” or “projection,” and she helps the reader distinguish among them. She “gets it” that empathy, like so many phenomena, is on a spectrum and that some people are naturally endowed with less of the capacity (think: disorders of empathy such as autism or at another extreme psychopathy) and some people have more of it (think: the natural empathy, who is acutely sensitive). Riess understands that empathy can misfire or breakdown: empathy faces obstacles and roadblocks, which, paraphrasing now, extend from sentimentalism, spoiling, codependence, projection, all the way to burnout, compassion fatigue, and empathic distress.

In every case, practice and training can expand the empathic competence of the individual and the empathic response in the face of the challenges of unempathic people and circumstances. Riess refers to turning “the dial on … emotional empathy” (p. 19), which is why training is needed. Thus, empathy is more like a dial or tuner – turn it up or down – rather than an “on-off,” all-or-nothing switch.

This brings the discussion round to the details of Riess and Empathetics, Inc.’s innovative, proprietary empathy training. She begins by citing research that demonstrates medical doctors are often trying to deliver one message and their patient’s are getting another one or nothing at all. The antidote? “E.M.P.A.T.H.Y.”®!

It turns out there is a “secret sauce,” a proprietary application of biofeedback technology. I have a report that if you, as a hospital or medical group practice, actually pay the $50K [I am making this number up] to train your medical doctors en masseat Mass General, then patented biofeedback metrics are used to judge the arousal of the subject and, hence, the effectiveness of the empathy induction. Though I am not sure, it sounds like they put the  little Velcro-cuff on one of your fingers to measure the galvanic skin response.

While galvanic skin response is a blunt instrument and does not distinguish between emotions such as fear, anger, sadness, high spirits, much less subtle states such as envy or indignation, it does provide a measure of physiological stimulus and arousal. Useful. Might be worth a try.

This add something to that old joke that when a therapist meets a new patient, there are two anxious people in the room; and it is the therapist’s job to be the least anxious. It adds something, but what? Still, it might be worth a try, especially given the emotional numbness of the survivors of the boot camp approach to medical school and the sleep deprivation regime of medical residency.

Meanwhile, the technology is wrappered in a conversational training that aims at expanding the empathic capabilities of the trainee. There are seven “keys” to empathy which, of course, occur simultaneously, but have to be presented in sequence for purposes of exposition.

The empathy training works on: (1) Eye contact: the eyes are the window to the soul. Look the other person in the eye to expand connectedness, but do not stare without blinking, which communicates aggression. Riess does not mention, but might usefully have done so, that Simon Baron-Cohen[1]calls out lack of eye contact as one of the indicators of a person being on the autistic spectrum.

Training in making eye contact to expand empathy leads naturally to including: (2) Facial expressions as a whole: the human face is an emotional “hot spot,” and while humans can fake many facial expression, there are some micro-expressions that are disclosive of an emotional depth that cannot be faked.

Here the decisive innovations and work of Paul Ekman and his team are critical path. Ekman spent some seven years mapping all the muscles of the face and their contribution to the expressions of emotions. The bottom line? People can consciously control many of these muscles – but not all of them. The muscle around the eyes participate in an authentic smile, and when they do not do so, the smile is perceived as off – as fake.

Riess says: “You don’t have to be an expert to pick up on the minute micro-expressions described by Ekman and others.” Actually you do. Significant practice and training is required, and even then one may know that the other person is not being entirely straight with you, but the micro expression does notprovide any insight into the underlying motive(s). Is the motive sinister or is the person suffering from shame, guilt, or post trauma upset? One has to have a conversation. The “M” is for “facial expression” – okay, actually “muscles” or “micro expressions” in the face.

The face, in turn, leads to: (3) Body language as a whole. Amy Cuddy’s “power pose” does not increase testosterone in the saliva, but significant anecdotal evidence indicates it does expand a person’s self-confidence. In short, look at how a person is standing or sitting and attend to one’s own posture. It can reveal a lot about how one is feeling.  “P” is for “body language,” or, to be exact “posture.”

Riess acknowledges the distinction between cognitive and affective empathy – top down and bottom up empathic understanding and receptivity. A future version of this training might incorporate “perspective taking” or “point of view,” in the place of the “P,” the folk definition of empathy, which is otherwise missing from the list of keys.  I make no representation as to how such a gesture would require adjustment or amendment to the intellectual property or whether it is even possible to claim as one’s own property something that is arguably the proper possession of all of humanity. One thinks of Kohut’s notion of empathy as oxygen for the soul. Who owns the oxygen? Presumably, humanity, not Harvard.

Next (4) empathy is all about “affect” and the communication of affect. People are not born knowing the names of their emotions. We have formal training in kindergarten in naming colors and numbers. It is not too late to practice experiencing one’s emotional experience and naming it.

In a separate section, Riess calls out the disorder of “alexithymia,” inability or extreme difficulty in naming and articulating feelings. This is different than “over intellectualization,” but sometimes not by much. This is an occupational hazard of anyone who spends years in graduate or medical training, but other people are seemly hardened against experiencing their feelings due to disposition or adverse life experiences.

(5) The “tone” of voice is richly communicative. If is a person is telling what should be a sad story of loss, injury, or set back, yet the person sounds happy, then something is going on beneath the surface that warrants further inquiry. The pace, rhythm, pitch, delivery, and prosody of a statement make a big difference in its reception and processing. Not to be overlooked: “A surgeon’s voice peppered with dominance and delivered with a lower register of concern was predictive of a malpractice claims history” (p. 54). But if one is only undertaking this training to stay out of legal trouble, that is itself an indication of trouble.

(6) Listening to the whole person is the point at which the training has to go beyond the tips and techniques that have dominated this list. This one is easier said than done and may require a deep engagement with spiritual disciplines of mindfulness, Tai Chi, or a couple of years of one’s own therapy in order to be available to the other person. “H” is for listening to the whole person – and hearinghim or her – presumably within the fifteen minute encounter that is budgeted for the initial medical inquiry.

(7) Empathy without responsiveness is like a tree that falls in the forest without anyone being there. It does not make a difference. Regarding empathic responsiveness, I would have appreciated an example of giving the other person’s experience back to her in a form of words that demonstrate that one “got it” without the exchange being so explicitly compassionate.

Recognition, acknowledgement, and alignment are ways of responding that do not require agreement or altruistic intervention. Yes, of course, it is helpful to be appreciated in one’s struggle and effort, and that is different than having someone jump in and actively provide compassionate support.

By all means, if someone is bleeding, apply a tourniquet while awaiting emergency services. But here one has actually to “dial down” one’s empathy in order to be effective. The point is that both empathy and compassion are often in short supply in the world and the world needs both more compassion and expanded empathy. However, empathy and compassion are distinct.

I may have misread Dr Riess if she wants to build into the human capacity for empathy, a compassionate response – whether her own proprietary version or empathy writ large. I offer this caveat because the vast majority of the examples of empathic response she gives are instances of pro-social helping, altruism, charity, or other aspects of being a Good Samaritan.

Once again, the world needs more Good Samaritans. The world needs both more compassion and expanded empathy; but the two are distinct. The exceptions in the text to examples of compassion are largely those of being over-whelmed or nearly over-whelmed by trauma and counting one’s breaths in order to stay centered in the face of hospital emergency room style dismemberment.

The irony of this book, which promotes linking empathy to its underlying neuroscience, is that the empathy is strong but the neuroscience, weak. Since this is not a “softball review,” a few examples will make this clear.

For example: “Scientists can see the electrical impulses spread through the brain using fMRI (functional magnetic resonance imaging) brain scanning technology” (p. 28). False.

The fMRI makes visible the blood oxygenation level data (BOLD) of between five thousand and fifty thousand neurons in its unit of measure, the voxel (depending on the variable size of the neuronal cells). The inference is: when the neurons get active, because the person is having an experience such as thinking a thought or attending to an event, then the neurons require more blood-rich oxygen to do their job.

In no way, does the fMRI monitor individual neurons or even a small number of them. The fMRI is a powerful tool for imaging soft tissue disorders, but it does not provide visibility down to the level of granularity of anything like individual neurons.

Perhaps Riess was thinking of the EEG: The spread of “electrical impulses through the brain” can indeed be monitored by an electro encephalogram (EEG), a fundamental tool for evaluating disorders of consciousness such as epilepsy and sleep disturbances, but even with an EEG the overall, high level activity of the brain is what is being monitored not individual or even small numbers of neurons.

A similar slip occurs early on: “Scientists first viewed the brains of their subjects in a brain scanner as the subjects had their fingers stuck by needle to determine the precise neurons involved in pain perception” (p. 17). Here “precise” would mean between five thousand and fifty thousand neurons, which is not my definition of “precise”. The level of granularity of the fMRI is an order of magnitude off from that required to “see” an individual neuron. Thus, fMRIs do not see or monitor mirror neurons (if they exist). Period. Once again, the fMRI does provide evidence that the parts of the brain that are busy processing experience receive enhanced blood oxygenation level data (BOLD), and that is the data captured by the fMRI.

Another problem item: “Mirror neurons are specialized brain cells in specific areas of the brain called the premotor cortex, known as the F5 area…” (p. 18). The problem is that the F5 area is part of the brain of the macaque monkey.  There is no F5 area in the human brain. Thus, the battle is joined, whether mirror neurons even exist in human beings.

The neurohype around mirror neurons is well represented; but what about the alternative point of view that such an entity as a mirror neuron does not even exist in humans and that the neurological infrastructure has a different configuration and explanation?[2]

How do we advance from synchronization and mirroring (Riess’ big idea of “shared mind intelligence”) to understanding of another person or the person’s mindedness? There are several questions of representation and functional analysis between which scientists and researchers are still working to “connect the dots.”  Riess represents this all as a “done deal” with the answer being “mirror neurons,” but she is oversold and fails to connect the dots.

Mirror neurons are one hypothetical explanation for such a phenomenon as “low level (empathic) affective resonance” in human beings. However, so are reflex-like mechanisms such as associations of actions, impressions, and ideas—known to the British empirical philosopher David Hume (1711–1776) as “habits” or “customary conjunctions.”

Macaque monkeys (the original subjects in the research done by Rizzolati, Gallese, and others (1996)) have a community and social order for which mirror neurons are sufficient to provide monkey interaction in the monkey community; buthuman behavior, action, and emotion involve more complex meanings, which human mirror neurons (if they exist) do notexplain—do not explain by means of language, social institutions, cultural practices, or tradition—because meaning is more than matching. As a mere mechanism of matching, mirror neurons struggle to explain the meaning created and deployed in minded actions and emotions.[3]

In humans and the human species, the macaque mirroring mechanism has been elaborated in evolutionary time into expanded behavioral, emotional, and cognitive capabilities useful for interrelating in significantly more complex human communities. Once prehistoric humans acquired language and used it to expand group solidarity in building communities with tools, art, stories, religious practices, social rituals, and the description of regularities in behavior of the stars and other human beings, diverse pathways opened up for creating and communicating meanings, emotions, projects, and thoughts between individuals.

The neurohype continues as the author moves from the neurologically misleading and false to the superficial. Using the example of addiction to alcohol: “New findings in Neuroscientific studies have redefined addiction from a condition of flawed character to a model of biology and disease. We now know that the brains of people who become addicted are different from those who do not” (p. 174). The brains of people who study French are different than those who do not, so we are on thin ice here in terms of a compelling analogy or contribution.

The good news? If a person has a disease such as pneumonia, modern medicine can cure him even if he is in a coma. That is not the case with the “disease” of addiction. In contrast, overcoming addiction requires the participation of heart and mind – and conscious commitment. The choice between a “moral flaw” and “neuroscience” is a false one once any physical dependency on the abused substance has been attenuated.

Riess recommends the empathic practice of perspective taking is key to shifting out of addictive stuckness – and gives a “shout out” to the program at the Hazelden Betty Ford Foundation; and, no doubt, getting a good listening is highly beneficial to any person, including addicts. However, the contribution of empathy is unwittingly weakened by making it seem like empathy is the answer to overcoming the conflict between the nucleus accumbens, a pleasure center in the brain, and the frontal lobe responsible for decision making.

This brings us to the mereological fallacy, which is pervasive in Riess as indeed in many works of this kind. The mereological fallacy attributes the function of the whole to the part (and vice versa). Brains are a part of a person; and neurons are a part of the brain. Brains are all about neurons; and, in so far as neurons are a necessary condition for the functioning of the embodied person, persons are neurons “all the way down.” But the neurons then start generating phenomena such as consciousness, meaning, language, intentions, joint intentionality, personality, community, and culture.

Thus, social neuroscience is born. Yet brains do notthink; people think. Brains do not express emotions; people express emotions. Brains do not intend this-or-that; people intend this-or-that. Brains do not become addicts; people become addicted. Brains do not empathize; people empathize. The mereological fallacy is a growth industry in social neuroscience. My brain made me do it? Hmmm. Human choice and commitment suggests your brain was definitely participating, but it is far from the whole narrative. The task is to avoid or contain the mereological fallacy, even while allowing social neuroscience to make its contributions in the areas of its strengths. This has not happened in this text.

Another problem? The number of variables changing simultaneously for a person lying still in a fMRI (functional magnetic resonance imaging) machine is large, very large. What worries me is that in an attempt to capture a response in the brain to interesting events experienced by the subject, the researchers, including Helen Riess, have created a brain in a vat. The vat is the fMRI.[4]

What then do brains do when viewed in an fMRI? They “light up.” They discharge neuro-correlates of consciousness (NCCs) in patterns of activation, as indicated in the form of blood oxygenation level data. The empathy circuit “lights up” when people lie back and view “empathy cues,” “empathy triggers,” or “empathy inducers.” We enjoy punishing cheaters—when apprehended and subjected to sanctions, the nucleus accumbens—a pleasure center of the brain—“lights up.” It gets busy. Empathic cruelty? Of course, there are many things that cause the nucleus accumbensto light up, implying the hazards of backwards inference. If it doesn’t light up, you are dead, or in serious neural trouble.

Nevertheless, in spite of weakness in the main selling point promoted in the subtitle and that of which the author is most proud – neuroscience – the force of empathy is strong in this text. If one can survive the neurohype of Part I, the reader is rewarded in Part II – presumably the nucleus accumbens is lighting up like a Christmas tree at this point (but so what?) – with applications of empathy to early child development, education, the hazards of social networking, art and literature as ways of expanding empathy, leadership and politics (and the lack of empathy in them), tough issues in mental illness, criminality, sexual identity, and so on, as well as the benefits of empathy for self-soothing, distress tolerance, and emotional regulation.

Now take matters up several levels from neurotransmitters to two human beings interacting in a conversation in a would-be community. Though Riess does not explicitly say it, the solution to the limited empathy of parochial, biased in-group thinking and behavior is straight-forward: expanded empathy. The person on the street thinks of empathy as an “on off” switch. “On” for the in-group. “Off” for everyone else – the “out group.”

However, practice and training enable a person to relate to empathy as a dial or tuner that can be adjusted to the situation. If I am experiencing empathic distress, dial empathy down. If I just do not “get” the other person, dial the empathy up. This does not come naturally to most people – so, once again, the case is made for practice and training, including Riess’ particular solution.

As a critical reader, I would have appreciated a statement that many ways are available to learn and practice empathy. Every mother, parent, teacher, business person with customers, doctor with patients, therapist with clients practices empathy on a good day and already knows a lot about what works and what doesn’t. Thus I imagine Riess saying: “While you, dear reader, do not need a psychiatrist to tell you about empathy [whose training regime since the early 1990s has overwhelmingly consisted in psychopharmacology], nevertheless let me tell you about the advantages of my proprietary way offered by my company Empathetics.” Perhaps Dr Riess thought such a statement was implied, and I can appreciate that point of view, but I still would have welcomed the clarification that it is not the only empathy game in town.

I hasten to add that, to her great and unconditional credit, Riess is decisively in action against the appalling scandal that empathy peaks in the third year of medical school (Hojat 2009; see also Halpern 2000) and that since the 1990s psychiatric training has overwhelming emphasized psychopharmacology. Meanwhile, the rate of the disabled mentally ill has doubled between 1987 and 2007 and is now six times the rate as in 1955.[5]Hmmm.

In the final ten pages of her work, Dr Riess calls out the “cytokine theory of depression” (and related mental disorders). I assert that she ought to have begun the book with it.

The cytokine theory of depression (see Maes 1995, 1999) is the approach that emerged in the mid 1990s – about the same time that Prozac was disrupting mourning and melancholy paradigms of mental illness with its serotonin chemaical imbalance theory of depression – that emphasizes the role of chronic social stress (divorce, finances, business travel, bullying bosses, misbehaving teenagers, and so on) in kindling long-term inflammation of major organ systems resulting in “sickness behavior.”

Such sickness behavior looks a lot like major depression yet, at least initially, it lacks the melancholic, negative self-talk.  Riess highlights treatment options – and life style adjustments – such as mindfulness, yoga, Tai Chi, exercise, diet, alone and in combination, that emphasize stress reduction, self soothing, emotional regulation, and empathy for oneself.

Naturally, the brain participates in all these activities, but reducing stress and expanding distress tolerance through empathy is also a function of the adrenal-hormonal system. It’s just that neurology has the buzz this season, not endocrinology or psychotherapy. Never was it truer that empathy guides us in engaging with and treating the human being as a whole – not a mere amygdala hijack or frontal lobe disinhibition. So the stress reduction paradigm, which is at right angles to and arguably does not contradict the neurotransmitter imbalance paradigm, was pushed to the margins and hardly heard of again until recently (e.g., Segerstron and Miller 2004).

Perhaps after the boot-camp of medical school, the rigors of residency, and the corporate transformation of American medicine (relying as it does on “hitting the numbers”), empathy is at such a low water mark in the medical doctor’s consciousness that “tips and techniques” are the best we can do. Indeed the “H” stands for “listening to the whole person and hearingthe individual,” so the intention is present.

Yet using empathy to “dial down” stress, aggression, and narcissistic injuries,  does not map in any obvious way to “E.M.P.A.T.H.Y.”®, which becomes a pair of golden hand-cuffs for the trainer. The ultimate irony is that the only obstacle in the way of expanding empathy – the distinction, not the propriety gimmick – is precisely “E.M.P.A.T.H.Y.”®.

References

Agosta, Lou. (2018). Empathy Lessons. Chicago: Two Pairs Press.

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

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

Hojat, Mohammadreza, M. J. Vergate, K. Maxwell, G. Brainard, S.K. Herrine, and G. A. Isenberg. (2009). The devil is in the third year: A longitudinal study of erosion of empathy in medical school, Academic Medicine84 (9): 1182–1191.

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

Hume, David. (1741). Of the delicacy of taste and passion in Of the Standard of Taste and Other Essays, Indianapolis: Bobbs-Merrill: 1965.

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

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

_______. (1999). Major depression and activation of the inflammatory response system, Advances in Experimental Medicine and Biology461: 25–46.

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

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

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

Rizzolatti, G., L. Fadiga, V. Gallese, and L. Fogassi. 1996. Premotor cortex and the recognition of motor actions, Cognitive Brain Research 3: 131–41.

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

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

FOOTNOTES

[1]Simon Baron-Cohen. (1995). Mindblindness. Cambridge, MA: MIT Press.

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

[3]The following paragraphs are adapted from the section “Your brain on empathy” in Lou Agosta 2018: 171–172.

[4]Presumably this is notwhat the late Hilary Putnam meant when he wrote his prescient article of the same name, since the fMRI had not yet been invented, but who knows for sure? See Hilary Putnam. (1981). Brains in a vat, in Hilary Putnam. (1981). Reason, Truth and History. Cambridge: Cambridge University Press: 1–21.

[5]Robert Whitaker, (2010), The Anatomy of an Epidemic. New York: Broadway Paperbacks (Random House), 2010: p. 7.

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

Top 10 (and more) Empathy Lessons for Life, the book

This book contains some thirty (30) empathy lessons for life. A key empathy lesson that explicitly addresses empathy training: remove the resistance to empathy—obstaclesCover art from EMPATHY LESSONS - two pears leaning in to listen by Alex Zonis such as cynicism, shame, guilt, aggression, narcissism, devaluing language, and so on—and empathy spontaneously shows up, comes forth, develops, and grows.

Most people are naturally empathic. This is the training in a nutshell. (To order the book click here: Empathy Lessons.) Read on for more details –

The empathy lessons in this book include how—

to perform a readiness assessment and establish a set up for success in cleaning up inauthenticities that block empathy so that empathy can expand and flourish (perhaps the most challenging part of this work);

empathy is not an “on–off” switch but a tuner (dial or dimmer) that expands or contracts in accessing the vicarious experience of the other person;

empathy breaks down in emotional contagion, empathic distress, “compassion fatigue” (in quotes because it is really about compassion, not empathy), burnout, conformity, projection, devaluing language, and, most significantly, how to overcome these break downs of empathy through multi-dimensional empathy;

empathy works as a method of data gathering in relating to the other person, providing a vicarious experience of the other person without being overwhelmed by the experience;

introspection, vicarious experience, listening to one’s own “voice over” and radical acceptance of one’s own experiences are the royal road to empathic receptivity;

empathic understanding overcomes conformity and creates possibilities of shifting out of stuckness into contribution, transformation, and leadership, including possibilities of engaging and attaining satisfying and flourishing relationships;

empathic interpretation is the folk definition of empathy, walking in another’s shoes, adding “top down” empathy to “bottom up,” empathic receptivity;

empathic responsiveness drives out anger and rage, acting as a soothing balm to suffering and emotional upset, deescalating conflict and aggression;

scientific, peer-reviewed, evidence-based research confirms that empathy (and a set of related interventions) reduce inflammation and stress, the five forms of stress, and connecting the dots between empathy, the reduction of inflammation, and stress reduction;

relationships get “weaponized” in bullying and, coming from empathy, how to overcome bullying, reestablishing boundaries: recommendations that promote empathy in students, teachers, administrators, and stop bullying (including cyber bullying);

“corporate empathy” is not a contradiction in terms, “CEO” now means “chief empathy officer,” and empathy is applied as the ultimate “capitalist tool”;

empathy is the “secret sauce” in sexual satisfaction within an authentic relationship, featuring the desire of desire, the “good parts,” and intimate engagements that are sustainable and last.

These empathy lessons put you back in touch with your empathy. Most people have quite a lot of empathy but are out of touch with it. Empathy lessons—not merely the formal title of this book, the actual practices—provide applications to tough cases. The applications give back to you your power in engaging and overcoming life’s social stresses and the need to expand well-being in the face of emotional upset, handling dynamic relationships, meeting business challenges in the corporate jungle and empathy desert, overcoming bullies and bullying, and applying and practicing empathy in sex and romance.

Our work together in this book is fully buzz word compliant including—

what is “mind reading”; how mind reading relates to empathy; the break down in empathy of “mind misreading”; and what is missing in mind reading, needed to bring it to fruition in empathic receptivity;

the ongoing debates about mirror neurons and the neurological basis of empathy (and an understandable explanation of their significance (and limits)); and the deeper truth that all human beings are related whether or not mirror neurons exist;

disorders of empathy such as Asperger’s and autism and (in a different context) the psychopathic person;

who or what is the “Natural Empath” and how this person, seemingly caught between nature and nurture, provides empathy lessons in abundance; and what happens when the Good Samaritan meets the Natural Empath;

social referencing and how we process the feelings of other people (and how that works);

evidence-based everything in which one would no more jump out of an airplane without a parachute or treat a bacterial infection without penicillin than engage with a human being without empathy (positively stated, start with empathy or one is headed for trouble);

and practical applications to tough, recalcitrant cases using literature, film, and story telling to teach empathy—deliver empathy lessons—and overcome the common breakdowns in the practice of empathy.

This work brings you step-by-step from what it takes to be present—fully present—with another human being, through the breakdowns and misfirings of empathic understanding to radical acceptance, which is profoundly different than mere agreement with someone’s opinion.

A bold statement of the obvious: I acknowledge that I am a proponent of empathy. Yet empathy has a dark side, too. Yes, compassion fatigue and burnout; but also Machiavellian and alienated empathy in business—appearing to be empathic while only being interested in closing the sale: walking in the other’s shoes to sell another pair to the other person. How to turn these risks, resistances, and breakdowns to advantage and even breakthroughs in satisfying and successful relationships in one’s personal life, career, business, and parenting, are canvassed in detail.

Every break down in empathy points the way to a potential breakthrough, if one knows how to listen, identify what’s missing, restore it, process, and respond.

In Chapter One, our empathy lessons introduce and clarify the multi-dimensional definition of empathy. The four dimensions of empathic receptivity, empathic understanding, empathic interpretation, and empathic responsiveness are defined, exemplified, clarified. These four aspects of the process of empathy are used throughout this work on empathy and applied to diverse examples, situations, cases, and stories.

In Chapter Two, our work uncovers the misfirings and failures of empathy including: empathy breakdowns in emotional contagion, burnout, empathic distress, “compassion fatigue,” conformity, projection such as egocentrism and narcissism, and devaluing talk that gets “lost in translation” in gossip, shaming, and bullying speech. The secret to expanding empathy is practicing overcoming these breakdowns.

In Chapter Three, the empathy lessons lead the reader from overcoming resistances to empathy to the breakthrough of empathy training and empathy as a method of data gathering that can be taught.

In Chapter Four, the data supporting evidence-based training in empathy is engaged and developed, as the Natural Empath meets the Good Samaritan, resulting in expanded control of the dial to tune empathy up and turn it down when one needs to do so.

In Chapter Five, empathy lessons directly engage the work of expanding the reader’s empathic receptivity in (1) the vicarious experience of the lives of others; (2) empathic understanding of possibilities of satisfaction in relatedness; (3) empathic interpretation in the folk definition of walking in the other person’s shoes to connect with difficult individuals you might not have been able to relate to previously; (4) empathic responsiveness that leaves one in the presence of fulfilling relationships with human beings without anything else added.

In the next four chapters, the multi-dimensional approach to empathy is applied to four challenging cases (each a chapter) including: stress reduction, featuring empathy as a spa treatment for the human soul, evidence-based medicine, and the contribution of empathy to emotional well-being (Chapter Six); what happens to people when relationships get “weaponized,” how empathy puts bullying in its place, including extensive recommendations for students, teachers, administrators on establishing boundaries (Chapter Seven); business in which empathy becomes a “capitalist tool” and ends up being good for business, too (Chapter Eight); sex and love and rock and roll in which “empathy is the new love”—what everyone really wants (Chapter Nine). This wide ranging, round-the-mountain romp through empathy lessons and the related recommendations are collected together in the final chapter on the top tips and techniques for expanding empathy (Chapter Ten).

As this intellectually rigorous but accessible and, I hope, intermittently humorous story of empathy unfolds, readers get empathy lessons on every page, pointing the way to success in expanding empathy in relationships, stress reduction, contribution to community, career, and romance. From time-to-time, I will pause for breath and remind the reader, like repeating a mantra, in order to drive the lesson down into the neurons through repetition: Empathy is oxygen for the soul. If you are short of breath due to life stress, get this book and expand your empathy through empathy lessons and applications. When all is said and done—when all the distinctions are deployed, arguments made, guidance provided, and recommendations completed—empathy means being in the presence of another human being.

A preface is the proper place for a personal reflection. Friends and colleagues have said to me, “Lou, nice work with the those other academic books on empathy you already published—great job!—but—how shall we put it delicately?—they are a tad too—too academic. What we really need now is something more readable, more accessible.”

Voila! This book aspires to address the everyday, educated reader, rather than the scholar or academic. I hasten to add that does not mean that I am sloppy about distinctions or intellectually lazy. However, I caution my academic friends, who are also inspired to engage with empathy, that, instead of using “journal speak,” I write casually and inspirationally. I use sentence fragments: “Likewise, with empathy.” I speak in the first person, which I have found effective in inducing empathy in the reader. I say “her or his.” Sometimes I even slip into using “they,” even though the subject is singular. So please do not say that I do not take risks. I try to be funny, but do not try too hard. I engage the reader personally.

What then is my guidance to you, dear reader? The reader can expect me (the author) to empower you to expand your empathy. I provide the distinctions needed to inquire into your own empathy in such a way that it develops, unfolds, grows, and expands. A simple yet powerful definition of empathy is developed and is then applied to opening up and resolving tough cases. This approach to empathy enables you to get in touch with your own empathic abilities through practicing a series of simple empathy lessons that, in turn, are engaging, confronting, humorous, and inspiring.

In the world of advice to the reader, the first five chapters are a sustained look at the definition, meaning, and explanation of how empathy works (and sometimes doesn’t work), delivering empathy lessons designed to make empathy present for the reader in the page-by-page progress of the work; the next four chapters are applications of empathy to four “tough cases”; and the final chapter is a summary in one place of tips and techniques encountered throughout the book with a modest amount of further analysis and explanation. This book was written as a coherent, integrated whole. Though modularly designed, the chapters were never separate papers, now cobbled together as an anthology. Nothing wrong with collections or anthologies as such; but this is not one of those.

The book’s approach to empathy gathers examples from life experience, story telling, literature, film, the author’s private empathy lessons, and his own biography and empathy consulting practice, to shift out of stuckness into expanded empathy. I provide examples of practices that have worked for me (and others) in expanding empathy in the real world. The anecdotes and vignettes are used with permission or are composites of experiences with identities changed to preserve anonymity. I am straight with you about practices that I believe work and practices that don’t work; what are the pitfalls and breakdowns; and how to avoid them or if they are unavoidable, how to reduce and manage them.

In exchange, I expect the reader, well, to read. I also ask the reader to examine and test her or his own feelings and experiences in the light of what is presented. Expect to be challenged. Expect to have your comfort zone stretched in a firm yet empathic way. The narrative loops back on itself so that distinctions relevant to empathy are introduced and sustained, while the context for applying, practicing, and mastering the distinctions is deepened and broadened. The narrative then cycles back at a higher level of engagement, forming an upward spiral (rather than a circle) so that the connections between aspects of empathy are strengthened. Ultimately, I strive to make empathy present, and, bring it forth in a conversation with the reader. The extent to which I succeed in actually doing so, the reader must judge. Okay, I’ve read enough. I want to order the book (click here to order Empathy Lessons).Hold on tight—the journey is about to begin.

Please note that Lou Agosta is available for individual or group empathy lessons, training, and conversation by appointment. Contact Lou at LouAgosta@gmail.com and mention this blog post.

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

Top Ten Empathy Lessons: Trends for the New Year 2018

Here are Empathy Lessons for the New Year ahead. You know what would really interest me? To hear from you (dear reader) what is your empathy lesson? Future73nbcroppedWhether inspired by this list or your own experience over the winter holiday or living into the future: what is your empathy lesson? (My contact data is at the bottom of this post. Let me hear form you.) Meanwhile, my top ten (10) trends in empathy lessons for the New Year 2018—this is a count down list (think: Letterman)—are as follows:

  1. Empathy deserts grow; empathy lessons struggle to get traction: Under late modern digital global capitalism, empathy is a means, not an end. Capitalism organizes empathy along with workers and production processes. Yet many workplaces are empathy deserts in spite of the appearance of mangers with published “open door” policies.[i] Key term: empathy desert.

One’s humanity withers in the desert. So if you find yourself feeling dehumanized by your job, maybe you work in one of those, regardless of the prevailing rhetoric.

Instead of the industrial supervisor shouting orders to his workers, who curse under their breath and conform, managers employ therapeutic strategies to create a convivial environment of trust, relatedness, sociality, loyalty, and care. Happy people sell. Happy people write more software code with fewer bugs. Happy people who happen to be medical doctors see more patients an hour for more hours. Happy people deliver projects on time, on budget. Value creation in the late capitalist economy is a function of the exchange of emotion and empathy.[ii]

Yet the boss is not necessarily a paragon of empathic understanding. On the contrary, it’s “by the numbers,” “get your numbers,” and if you don’t get your numbers, your days are numbered. And if you don’t have any numbers, that itself is a bad sign, and we will find some for you. Relations with coworkers and superiors can be Machiavellian—and conflict-laden. The guy who said, “We don’t need more data; we need expanded empathy” was counseled out. Truth be told, successful business requires data and empathy; and both have their uses.

Today empathy is trending. Everyone is “talking the talk” of empathy. What could be better than empathy? But “walking the walk” of empathy arouses resistances, which are a major point of engagement in a similarly titled chapter.

The empathy lesson? Coming from empathic understanding—identify upsets and breakdowns. Do so in the spirit of expanding relatedness and community. Identify the unfulfilled expectation, thwarted commitment, or undelivered communication. Restore what is missing, especially if it is empathy, to complete the expectation, commitment, or communication.

In other words, clean up your own act: if you owe something to another person—whether money, an overdue library book, a promised email response, or a borrowed lawn mower—arrange to pay it back. If you have lied, acknowledge the lack of integrity to the other person; and take action to repair the damage done. Asking forgiveness does not just mean the slate is wiped clean and the perpetrator is free to commit boundary violations again. It means the person asking forgiveness tells the truth about what he (or she) did. It means being prepared to deal with the cost and impact of one’s inauthenticities and integrity outages.

This creates a clearing for success with empathy by cleaning up inauthenticities: Take action assertively to repair disruptions in relatedness and communication by acknowledging your contribution to the disruption. A person cannot relate authentically—that is, empathically—to people while being inauthentic in other areas of his or her life. People have to compartmentalize in order to survive the day; but empathy is the one area where compartmentalization is least effective. The inauthenticity around empathy in one particular area tends insidiously to spread to other areas.

Challenging as it may be, creating a foundation of authenticity is actually the first step in recovering and expanding one’s empathy, one’s power in relation to empathy, and the authentic relatedness that empathy makes possible.

Absent such a foundation, a person is simply not ready to engage empathically. Even if readiness was established up front, it can be lost along the way. Go back to step one. Those who are unwilling to do so may drop off at this point. Empathy is simply too hard; but any other approach is built on sand. No matter how good the following recommendations may be, if one does not establish a foundation of authenticity for empathy, a clearing for success, one is putting buttercream frosting on a mud pie.

  1. Empathy, capitalist tool: “CEO” now means “Chief Empathy Officer”: You heard it here first, and not for the last time. One can already hear the push back. This conversation shows up like another responsibility with which the head of the organization is tasked. As if she did not already have enough alligators snapping at various parts of her anatomy, now “CEO” no longer means “Chief Executive Officer,” but “Chief Empathy Officer.”

The things that cause people to excel at getting business results (beating the competition, solving technical problems, dealing with legal issues) do not necessarily expand one’s empathy.

Never is empathy needed more in business than when it seems there is no time for it. Building a business, growing a market, innovating in products and services, are all about building teams, networks of people, and communities. Empathy is at the foundation of community. Therefore, empathy is the foundation of business. Though business leaders hate to be tasked with yet another job, empathy has to start at the top if it has any hope of percolating up from the bottom. “CEO” now means “chief empathy officer.”

When I ask executives what is the budget in the organization for empathy training and empathy consulting, they usually look at me with a blank stare or just say “zero.” However, when I ask what is the budget to reduce conflict, enhance teamwork, innovate and improve productivity, then they see possibility and make it a priority to obtain a budget.

At the risk of over-simplification, empathy training consists in surfacing the resistances to empathy, the pervasive fear and cynicism (and so on) in the organization that lurks just beneath the surface. Interpret the resistance: “It is perfectly understandable that you would be cynical, given what you have been through, but that is not who you (we) authentically are.”

  1. Empathy’s “dark side” strikes back: “Machiavellian empathy” emerges as a growing threat to empathic empathy. When those in the executive suite are surveyed, some 60% of executives believe that their organizations are empathic, whereas 24% of their employees agree.[iii] An empathy deficit?

Niccolò Machiavelli (1469–1527) was famous for saying that it would be best if the leader—the Prince, in his day—was loved, but it is essential that he be feared. Machiavelli never actually said that the ruling Prince must be perceived to be empathic, even as he ruthlessly wields power behind the scenes. But that is what he implied.

In the context of politics, Machiavellian empathy refers to business people and politicians who present themselves as being empathic while manipulating, spinning alternative facts, and double dealing behind the scenes. Machiavellian empathy shows up in business, too. If managers are not in touch with their empathic abilities, they are counseled to “fake it till you make it.” Most never “make it” and continue “faking it.”

Whether or not one authentically understands the experience of the other person is less relevant to the Machiavellian empath than scoring points on a check list of concerned behavior.

If the corporation were a machine, which is a well-worn but all-too-accurate metaphor, empathy would be the lubricant that keeps the various parts working together without overheating. The number of corporations that are “over heating” and “going up in flames,” with dramatic news hitting the global media, is one index of those experiencing the most severe empathy breakdowns.

The explicit symptom is predictably a revenue shortfall, but behind the headlines lurk dysfunctional relationships, cynicism, a culture of bullying and shaming, loss of authenticity, lack of leadership, and lack of empathy.

Even the cynical sales person understands the value of taking a walk in the customer’s shoes, if only to sell him another pair. The wise (and empathic) sales person understands that in any business that allows for product differentiation or distinctions in service level agreements, building a relationship with the customer is the royal road to solution selling.

Strictly speaking, Machiavellian empathy takes nothing away from empathy’s intrinsic benefits and uses. Even if one wants to present the appearance of being empathic for propaganda purposes while continuing to operate with dubious business practices the behind the scenes, reality has a way of catching up with appearances.

It is not entirely fair, but when a person with psychopathic tendencies—once again, wanton lack of respect for boundaries, cruelty to animals, and a willingness, even eagerness, to inflict pain on others—grows up in poverty, the person often runs afoul of the criminal justice system. The person ends up in prison.

In contrast, when such a person grows up in affluence and gets an education in business, the person often becomes a hard-charging, “type A personality,” and a successful executive. The person ends up in the corner office. When psychopaths go to work, or get elected to political office, the result is sometimes snakes in suits (the title of a book cited in the endnote).[iv] We observe, and not for the last time, that the things that create success in business, do not always expand our empathy.

Amazon said it was a wonderful place to work. Then the New York Times got some employees to comment on the record about “mean” behavior.[v] Uber was disrupting the disrupters and creating the Gig Economy, which supposedly set us free. Then the CEO, Travis Kapernick, got unwittingly interviewed on camera by a driver.[vi] Bullying is not just for high school kids anymore; it has always lived in the business world, too. Still, there is no guarantee that the Machiavellian empath will slip up and document his or her own inauthenticity; but it just might happen.

Is this then the ultimate cynical moment? Is this the reduction to absurdity of empathy? If empathy is about setting boundaries, where is the boundary? The limit to Machiavellian empathy is Lincoln’s famous saying, “You can’t fool all the people all the time.” Ask Travis Kapernick. Ask Bernie Madoff and Michael Milken.[vii]

  1. Empathic response is an act of imagination, not agreement: Positively expressed, empathic response means giving the other person back his experience in such a way that he recognizes his humanity in the experience. However, agreement is often what people want in expressing their unhappiness or describing the setbacks in life that they have experienced.

After giving an account of some dramatic encounter, the one person turns to the other with a significant pause in order for the other person to respond with a heartfelt, if not empathic, agreement and approval. One often turns to the other person to get validation that the experience conforms to one’s own preferred interpretation. One uses the spontaneous response of the other to guide how one really feels about what occurred. This does not rule out that one person is often looking in advance for a particular reaction and to “get a rise” out of the other.

The scenario is complex; and the “get a rise” is not necessarily what a gracious empathic understanding or receptivity is going to provide. “Tough love” shows the other what he does not necessarily want to confront. Sometimes so does “a rigorous and critical empathy,” specially when the latter is framed in a way that recognizes and respects the other’s struggle.

The bridge between the cynical present and an impossible-to-envision future is empathy. The empathic moment is the act of imaging a different world, a future world of expanded empathy, in which the community expands inclusively.

Different viewpoints are available with regard to one’s action, including the perspective of one’s adversaries. One forms an opinion by engaging the issue from different perspectives. One makes present to the mind the perspectives of those who are absent or even opposed. That is, one represents them. This process of representation adopts the points of view of those who have different standpoints.

Thus, empathy is closely related to what one can imagine about the other person in relationship to oneself. An empathy that does not include the other fails the definition of empathy. This especially applies when the other is at odds with oneself. It may seem like a dream; but the dream lives. The empathic response is an act of imagination.

  1. If you have “compassion fatigue,” maybe you are not empathic enough: It is no accident that the word “compassion” occurs in “compassion fatigue.” Could it be that people who are experiencing compassion fatigue, but claim to be in a break down of empathy, are actually in a break down of compassion?

If one is trying to be empathic, but one is experiencing compassion fatigue, maybe one is doing it wrong. Maybe one is practicing empathy “wrongly,” with inadequate skill, precision, completeness, or finesse; and one needs a tune up for one’s empathy.

One reason that empathy training programs have not worked or have had mixed results is that they train the participants in compassion, being nice, conflict resolution, baby and child care, and a number of worthy and related tasks. This is all excellent, and the use of empathic methods is making the world a better place in all these situations. So keep it up. There is nothing wrong with being nice and so on: do not be “unnice”! But paradoxically something is missing—empathy.

The empathy lesson “not more empathy, expanded empathy” indicates that if one subtracts empathy from compassion, then one gets sympathy, reaction, burnout, compassion fatigue, which end up giving empathy a bad name. Now I do not wish to give anyone a bad name, who is committed to empathy, compassion, or making a difference is overcoming human pain and suffering. On the contrary, I acknowledge and honor one and all. The battle is joined; we are all on the same side; but we want to deploy our limited resources wisely.

Expanding one’s empathy requires an engagement with one’s own inauthenticities around empathy.

Expanding one’s empathy requires engaging with one’s own resistance to empathy. Until we engage with our own resistance to empathy we will remain stuck in our blind spots, breakdowns, burnouts, and compassion fatigue. In order to expand one’s empathy, one needs to engage with applications of empathy in the tough cases—stress and well being, bullying, business, and gender and romance. Engaging with these implementations is essential to consolidating the mastery of one’s practice of empathy—practice, practice, practice.

  1. Empathy and humor are closely related, and converge even further: Both empathy and humor create and expand community. Both empathy and humor cross the boundary between self and other. However, empathy crosses the boundary between individuals with respect, recognition, appreciation, and acknowledgement, whereas humor does so with aggression, sexuality, or a testing of community standards.

Here “aggression” includes language that people would find insulting. Therefore, be careful. The aggression or sexuality in question is usually presented in such a way that it creates a tension by violating social standards, morals, or conventions to a degree that causes stress short of eliciting a counter-aggression against the teller of the joke.

Substituting humor for empathy can work in some situations, but in others it can create a breakdown in the would-be relationship. You know how the more objectionable the joke, the funnier it is?

The result is either the release of tension through laughter or a failed joke and a shameful, if not scandalous, situation on the part of the joker. Indeed when the violation of the social convention, moral, or standard is such that the target of the joke experiences a dignity violation, then the joke arouses anger or even rage, not laughter. The caution flag is out.

Ground zero of cynicism and humor is Scott Adam’s Dilbert cartoon. It is wickedly funny because it expresses more than a grain of truth about dysfunctional, anti-empathic organizations.

In one classic example, the pointy-haired boss says that the organization will assign job functions based on the Myers-Briggs Personality Test. For those readers who may not know, the MBPT is the famous test that distinguishes introversion and extroversion, thinking and feeling, and related categories. The boss continues: “For those of you who do not have a personality, one will be assigned by the human resources department.”[viii] I must say that I am deeply ashamed of myself; I can’t stop laughing.

In humor, stress and psychological tension are created by violating a standard—in this case against insulting the lack of personality of the corporate cog—and then the stress is released in laughter by the mechanism of the joke such as a pun, double meaning, or violation of expectations.

The more objectionable the joke is, the funnier it is. The put down, “If you do not have a personality, one will be assigned by HR” is indeed wickedly funny; but it is also deeply debunking of the corporate world (and shaming of the individual), in which people come to feel like a gear in an inhuman mechanism.

After a day at the office, people often feel as if their personality had been erased.

So a trace of empathy for the long suffering inhabitants of corporate cubicles does come to the surface after all. That is what Scott Adam’s Dilbert longs to express. It is a common place in the corporate world that people function as replaceable cogs in a well-oiled machine. Therefore, in this case, the cartoon is an example of how not to expand empathy. Cynicism and shame drive out empathy; and driving out cynicism and shame create a space into which empathy can expand spontaneously.

How then does one drive out cynicism, shame, denial, and so on? The short answer is by calling it out, acknowledging it, interpreting it, and offering an alternative point of view. Not “alternative facts,” which have come to mean “spin” and “deception”; but an alternative perspective. It is cynicism versus empathy.

Empathy is the foundation of community in a very deep way, for without empathy we would be unable to relate to other people. In being empathic with another person, one creates a community with the other person; likewise, with humor. Humor creates a community among the audience and joke teller as the tension is dispelled in the laughter. For more on creating community through jokes, I recommend Ted Cohen’s Jokes: Philosophical Thoughts on Joking Matters, which also contains some really funny jokes.[ix]

  1. Train and develop empathy by overcoming the obstacles to empathy: People want to know: Can empathy be taught? People complain and authentically struggle. People say, “I just don’t get it—or have it.” The short answer is: Yes, empathy can be taught.

What happens is that people are taught to suppress their empathy. People are taught to conform, follow instructions, do as they are told. We are taught in first grade to sit our seats and raise our hand 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, “Jump up and run around screaming” (unless it is recess!). But compliance and conformity are a growth industry 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 pyramid. The lesson? If a person can contract his or her empathy, the person can also expand it.

Now do not misunderstand this: people are born empathic, 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 math 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 that rule-making and the drum beat of compliance seem to be growing by leaps and bounds.

Teaching empathy consists in overcoming the obstacles to empathy that people have acquired. When the resistances are overcome, then empathy spontaneously develops, grows, comes forth, and expands. That is the training minus all the hard work.

The hard work? Remove obstacles to empathy such as dignity violations, devaluing language, gossip, shame, guilt, egocentrism, narcissism, lack of integrity, inauthenticity, hypocrisy, making excuses, finger pointing, jealousy, envy, put downs, being righteous, stress, burnout, compassion fatigue, cynicism, denial, competing to be the biggest victim, and injuries to self-esteem—and empathy spontaneously expands, comes forth, develops, blossoms. Yes, empathy can be taught.

  1. Health insurers promise empathy, do not deliver, and continue to collect monopoly rents. The empathy gap widens. Health insurers maintain a firm grip on the market for empathy-related “behavioral health” services without actually providing any. This is the only candidate trend from the last two years that I am repeating, since it is still accurate but a work in progress—and, unfortunately, picking up even more speed, going in the wrong direction. The Affordable Health Care Act (“Obamacare”)—reportedly to be terminated with extreme prejudice at any moment—promised to equalize benefits for medical benefits such as annual physical health checkup (including $800 worth of blood work) with mental health services such as psychotherapy. At the risk of being cynical, I don’t know if the reader has tried to collect lately or services rendered. The war stories, pretexts for nonpayment, and simple violations of their own rules—e.g., timely response—by insurers continue to mount. One feels a certain dissatisfaction with the lack of solutions. What to do about it? In spite of claims to the contrary, the recommendation from insurers seems to be: “But your majesty, the people have no mental health benefits. Then let them pay cash! And then let them eat cake.”

Future73nbcropped2. Empathy is the secret sauce in sexual satisfaction: Empathy is the new love. It is what people fundamentally desire – to be gotten for who they authentically are. When one person’s desire aims at the other person’s desire, then desire begets desire. The desire of the other’s desire is precisely the empathic moment. Sex goes better with empathy, providing access to the kind of kindling that transports the couple into a raging conflagration. The empathy lesson is that one takes off one’s inhibitions with one’s clothes, undressing one another.

While love is a many splendid thing, empathy is what is required to get off with another person. The “secret sauce” is when one partner gives permission to be turned on, and the other partner is inspired to accommodate. Then the Hollywood cinema cliché of sky rockets and fire works fits the moment. The recipe is about facilitating and sustaining such a state to create a peak experience . The secret sauce is empathy.

Desire unleashes a runaway process of desire between the partners that works something like the Dutch tulip craze of the 1630s, only in sexual favors. Like a speculative market bubble, desire becomes desirable because it is desired. But does such “irrational exuberance” in desire then threaten the entire relationship between the partners the way the housing bubble threatened the world economy? Certainly there are risks to the relationship in unleashing a sexual inferno. It requires a certain ego strength to let go and be vulnerable. In the case of sexuality versus economic bubbles, organism and ultimately pregnancy tend to moderate the runaway process. Meanwhile, the partners are willing to try to read the clues and do what the other wants the partner to do to the other person. A synchronization of desires occurs. The other can see through one to one’s desire. One can see through the other to the other’s desire. That’s the empathy lesson. This is starting to sound a lot like empathy.

And THE number one empathy lesson trending in 2018 (drum roll, please):

  1. Empathy is the ultimate anti-bullying antidote: Bullying is abroad in the land.       Bullying is all about violating the boundaries between the bully and the target—personal, physical, emotion; empathy is all about establishing and reestablishing boundaries between self and other. Empathy is the antithesis of bullying. Wherever empathy lives, bullying has no place. When you think about it for two seconds, so is parenting, teaching, and being a traffic cop—all about setting boundaries.

At least initially, establishing boundaries is not about having empathy for the bully; it is about being firm about damage control and containing the bullying. Ultimately the bully benefits even as the community is protected from his perpetrations; but more in the manner of a three year old child, who, having a tempter tantrum, benefits from being given a time-out in such a way that he cannot hurt himself or others.

Kids in middle school have usually developed some empathy for those on the “inside” of their peer group. The developmental milestone for them is to be expand their definition of “inside” and widen the circle of caring, making more of “them” into “us.” The many different kinds of bullies, bullying, and possible responses on the part of children, students, teachers, parents, and administrators will not be repeated here. Suffice to say: if it’s mean, intervene.

Empathy versus bullying is receiving much needed attention in middle and high schools; but it is also a significant factor in business and politics.

Bullying is not just for high school “bad boys” anymore. In politics, Mr. T. returns tit for tat in a verbal salvo against “Little Rocket Man [LRM].” LRM man remains true to his name and fires a real missile test across Japan in the direction of the central pacific. Under a future scenario that is not hard to envision, a miscalculation leads to a fail safe situation, which does not fail safely. A nuclear exchange escalates, resulting in burning cities that put enough particulate matter into the upper atmosphere to create a twenty-five year long “nuclear winter,” causing a species extinction. The human species ends; it was just a bad idea anyway. Come on, guys, we can do better than that. This is not an inevitable outcome.

However, a word of caution: it seems really to be the case that LRM would rather see the people of the North eat grass rather than give up the nuclear weapons. These people might have something to say about that at some point, or maybe not. But if shooting starts, head for the bomb shelter, it will be too late for empathy to make a difference, except perhaps much later on for the survivors, if there are any.

Meanwhile, the empathy lesson: empathy deescalates anger and rage: When people do not get the empathy to which they feel entitled, they start to suffocate emotionally. They thrash about emotionally. Then they get enraged. The response? De-escalate rage by acknowledging the break down—it seems you really have not been treated well—clean up the misunderstanding, and restore the empathic relatedness. Empathy does many things well. One of the best is that empathy deescalates anger and rage.

Without empathy, people lose the feeling being alive. They tend to “act out”—misbehave—in an attempt to regain the feeling of vitality that they have lost. Absent an empathic environment, people lose the feeling that life has meaning. When people lose the feeling of meaning, vitality, aliveness, dignity, things “go off the rails.” Sometime pain and suffering seem better than emptiness and meaninglessness, but not by much. People then can behave in self-defeating ways in a misguided attempt to awaken a sense of aliveness.

“Empathy is oxygen for the soul” is a metaphor. But a telling one. When people do not get empathy—and a short list of related things such as dignity, common courtesy, respect, fairness, humanity—they feel that they are suffocating—emotionally.

People act out in self-defeating ways in order to get back a sense of emotional stability, wholeness and well-being—and, of course, acting out in self-defeating way does not work. Things get even worse. One requires expanded empathy. Pause for breath, take a deep one, hold it in briefly while counting to four, exhale, listen, speak from possibility.

The empathy lesson? Set boundaries. Look for balance. Be responsible. Own it. Empathic parenting is about boundary setting. With older children, “first you do your homework, then you go to the mall (or play a computer game).” Just maybe there is a lesson here for international relations too. A good fence makes for good neighbors. But there is a gate in the fence. And over the gate is a sign that says “Empathy.”

NOTES / REFERENCES / CONTACT DATA / COPYRIGHT

[i] Roman Krznaric. (2104), quoted in Belinda Parmar.(2014). The Empathy Era: Woman, Business and the New Pathway to Profit, London: Lady Geek: 91. Parmar does not cite a page in Krznaric, and I have not been able to find it so far.

[ii] Tristam Vivian Adams. (2016). The Psychopath Factory: How Capitalism Organises Empathy. London: Repeater Books: 56–77.

[iii] William Gentry. (2016). Rewards multiply with workplace empathy, Businessolver: http:// www.washingtonpost.com/ sf/brandconnect/businessolver/ rewards-multiply-with-workplace-empathy/ [checked on 03/31/2017].

[iv] Ibid.

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

[vi] Alynia Selyuk. (2017). Uber CEO apologizes over video of dispute with Uber driver. National Public Radio (NPR) All Things Considered: http://www.npr.org/2017/03/01/5179 88142/uber-ceo-apologizes-over-video-of-dispute-with-driver [checked on July 2, 2017].

[vii] According to Forbes: Milken made his billions in leveraged buyouts in the 1980′s, only to be sent to prison in 1989. He pleaded guilty to securities fraud after the government agreed to drop criminal charges against his younger brother, Lowell, and then served 22 months. The one-time Drexel Burnham Lambert executive has charted an entirely different course ever since and is a well known philanthropist.: https://www.forbes.com/sites/luisakroll/2012/10/26/billionaires-and-former-billionaires-who-have-spent-time-behind-bars/#6b7b75 b32107. Meanwhile, more breaking news, as this article is being written, some 49 men stand accused of sexual misconduct in various workplaces extending from Harvey Weinstein’s Hollywood production company (from which he was fired) through venture capital firms to restaurant businesses: https://www.nytimes.com/ interactive/2017/11/10/us/men-accused-sexual-misconduct-weinstein.html?_r=0. The problem is that, while it is good that this abuse is finally coming out, it has been hidden in plain for years and years. See Harry Markopolis’ (2010) statement in a different context above, “no one would listen” [also the title of his book]. Where is Lord Acton when we need him? He is the one who said: “Power corrupts; and absolute power corrupts absolutely.”

[viii] Scott Adams. (1996). The Dilbert Principle. New York: Harper Business.

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

Contact data: LouAgosta@gmail.com

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