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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

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

People want to know: Can empathy be taught? People complain and authentically struggle: I just don’t get it—or have it. In spite of the substantial affirmative evidence already cited, the debate continues.

The short answer is: Yes, empathy can be taught.

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

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

The one minute empathy training is: most people are naturally empathic. Remove the obstacles to empathy and empathy comes forth.

Remove the resistances to empathy and empathy expands.  

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

What happens is that people unwittingly have been taught to suppress their empathy. People have been taught to conform, follow instructions, and do as they are told. We are taught in first grade to sit in our seats and raise our hands to be called on and speak. And there is nothing wrong with that. It is good and useful at the time. No one is saying, “Leap up and run around yelling” (unless it is summer vacation!). But compliance and conformity are trending; and arguably the pendulum has swung too far from the empathy required for communities to work effectively for everyone, not just the elite and privileged at the top of the food chain.

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

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

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

Studying the Humanities and literature, art and music, rhetoric and languages, opens up areas of the brain that map directly to empathy and powerfully activate empathy. Read a novel. Publish a blog post. Go to the art museum. Participate in theatre. These too are empathy lessons, fieldwork, and training in empathic receptivity.

Reduce or eliminate the need for having the right answer all the time. Dialing down narcissism, egocentrism, entitlement (in the narrow sense), and dialing up questioning, motivating relatedness, encouraging self-expression, inspiring inquiry and contribution, developing character, and, well, expanding empathy.

Yes, empathy can be taught, but it does not look like informational education. It looks like shifting the person’s relatedness to self and others, developing the capacity for empathy, accessing the grain of empathy that has survived the education to conformity. Anything that gets a person in touch with her or his humanness counts as training in empathy.

(Note: Putting the “one minute” into the “one minute training” so that readers would not have to work too hard was hard work. I did the work of reviewing over a hundred publications on empathy training, the two dozen most significant of which are listed here: For evidence-based research on empathy training see the Bibliography and start with this list.  

[1] Angera et al. 2006; Antoni et al. 2011; Brunero et al. 2010; Chiu et al. 2011; Coke et al. 1978; Davis et al. 1996; Decety et al. 2012; Del Canale et al. 2012; Golan et al. 2006; Gordon 2005; Hadwin et al. 1997; Halpern 2001; Hojat et al. 2009; Hojat et al. 2011; Levine 2012; Ozcan et al. 2012; PBS 2013; Pace et al. 2009; Pecukonis 1990; Riess 2013; Riess, Kelley et al. 2014; Riess, Kelley et al. 2012; Therrien 1975; Zaki and Cikara 2015 (Note – this required more than one minute!)

For those interested in more than one-minute of training: You do not have to buy the book, Empathy Lessons, to get the research, but if you would like more detail see especially Chapters Four and Six in Empathy Lessons (click here to get EMPATHY Lessons from Amazon). Also of interest: A Rumor of Empathy

Remove the resistance to empathy and empathy grows, develops, and blossoms. In every instance of resistance to empathy, the empathy training consists in identifying, reducing, or eliminating, the resistance to empathy. When the resistance is reduced, empathy has space to develop, and it does so spontaneously as well as through providing explicit practices, tactics, strategies, and training .

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Review: The Soul of Care by Arthur Kleinman

When I say, reading Arthur Kleinman’s books changes one’s listening, I do not mean changes one’s listening the way reading Lacan or being hit on the head with a rolled up newspaper changes one’s listening. What I mean is, reading Kleinman expands one’s humanity, empathy, and capacity for engaged caring.

 This is likewise the case with The Soul of Care: The Moral Education of a Husband and a Doctor (due out September 17, 2019 from Viking), the most important memoire by a psychiatrist since Carl Gustav Jung’s Memories, Dreams and Reflections (1962) [though with a different source and trajectory], an unsolicited prepublication copy of which showed up in my snail mail. It is a real page-turner.

 Arthur Kleinman, MD, trained as a psychiatrist, is an innovator in medical anthropology, a discipline of which he is the virtual founder. He and his late wife Joan, also an academic, spent considerable time and effort doing cross cultural (anthropological) research in China on traditional medicine, modern medicine, and the connecting points (and divergences) thereof. Of particular interest were survivor of Mao’s Cultural Revolution, who suffered from the symptoms of “neurasthenia,” a disorder whose explicit diagnosis has declined in the west – including fatigue, dizziness, anxiety, demoralization, and hard to diagnose pain(s).

 In the course of their time in China, Kleinman (Arthur) gets a combination of exhaustion and dysentery, which reaches life disabling and even life threatening, stages. Joan is the very soul of caring – nursing him back to health.

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

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


This provides one of the paradigms for Arthur when Joan eventually gets early onset Alzheimer’s and he decides to take care of her at home.

 The Soul of Care is the memoir of Kleinman’s life’s work (to date) and what happens when he decides to practice what he preaches and takes on the task of carrying for his increasingly ill wife, Joan.

 Kleinman does not use the word “empathy” much, but it lives in his work, and in this case, the man is living in an empathy desert and that includes the health care system that is relating to him as pain instead of a whole person. Kleinman’s listening, which creates a context for human relatedness, succeeds in moving the dial back a few notches, though no way exists of undoing the now fused spine.

 I have frequently had my mind blown by the power and precision of Kleinman’s writings. For example (and now we are in The Soul of Care), another patient has intractable pain relating to her diabetes, yet the diabetes is under control. The numbers from the blood work and related tests show that the diabetes should not  be producing such results. Something is not adding up. Is the patient faking? Is there some disorder that has been overlooked?

 This fellow, Kleinman, sits down and has a conversation with someone with intractable pain. He is genuinely curious about the patient. He is interested. He nails it. He brings along a medical student on a home healthcare visit. The above-cited patient is a diabetic, and is eligible for Meals on Wheels, transportation to the hospital, alternative housing (p. 206). The medical team (notice: there is a team!) had no idea, because no one asked.

 Time-after-time, Kleinman shows up and asks a few questions – it all comes tumbling out – in many cases out-and-out trauma; in other cases, subclinical post traumatic stress disorder; in most cases, life circumstances, stress, inaccurate or incomplete diagnoses being transformed into bodily symptoms.

Continuing the above example, the patient is a single working mother; poor; working the grave yard shift while simultaneously cooking, cleaning, getting her kid (who is doing quite well, thanks) to school, and managing everything else well enough – everything except her pain. The patient is not faking – the pain is authentic, but diabetic neuropathy is not the cause. The cause is a work life imbalance of virtually unimaginable proportions (once again, “work-life balance” is my summary description, not Kleinman’s). The patient is running flat out, and is eligible for food stamps and other support available within the system. But no one on the team even bothered to have the conversation, even bothered to ask.

 What is happening is that a medical issue does indeed exist. But the human being is more than an insulin pump. If medicine wants to be a caring profession not a bureaucratic profit center, then the doctor may useful make inquiry as to what the patient thinks is going wrong (and right) in her life. What is happening is that the emotions, affects, cognition, personal spirit, are elaborating what is in effect the anatomical or organic lesion and defect.

 One can appreciate that individual practitioners may well feel they are like the “Lone Ranger,” single-handedly arrayed against human suffering. One will do what one can, writing the prescription at the end of the session for something, anything, to at least get the placebo affect as a positive expectation itself sets off a cascade of neurotransmitters. Kleinman appreciates how devilishly tricky it is both to address the biological system and the suffering human being present in the space

 Yet Kleinman is uncompromising – and with good reason. Time-after-time, simple inquiries as to what are the facts of the person’s life circumstances point powerfully in the direction of human interventions that shift the person out of suffering and stuckness and into action. Putting the pain in context enables the person(s) to improve their own health through life style adjustments.

 After all, is this not the age of the informed, engaged, proactive health care consumer? Many medical doctors pay lip service to such engagement, yet are not prepared to answer questions or, just as importantly, help the patient formulate the half-formed questions they are struggling to express. Do the job, do it completely, and do it the way it was meant to be done on behalf of the patient and suffering humanity.

 

Pain is one of those things that sometimes one can’t live with, but one certainly can’t live without. The reflex that causes one’s hand to jerk off of a hot casserole dish is not yet pain. The reflex precedes the experience of pain by a couple of seconds.

 The reflex does not go through the brain; the experience of pain does. To become pain, the sensory information in the nerves has to go through the brain. In short, pain is important to tell the person about damage to his or her body that requires attention. Pain powerfully focuses one’s attention on getting actionable results in addressing the problem. But pain can cause a member or organ to become hyper-cathected – a tight loop that creates pain in anticipating pain to avoid pain. By focusing on the pain, attention can expand pain, grow pain, and become a habitual pattern of pain stimulation to the organism. Focus one’s attention elsewhere? Easier said than done, though alternative interventions such as meditation, hypnosis, and self-soothing stress reduction activities (which Kleinman does not much discuss) aim to do just that.

 Kleinman is himself something of a survivor: a son who never met his biological father, a grade school student who bore two utterly separate family names once his mother remarried, from two opposed sub-ethnic factions, one in public school, the other in religious school; a scion of a mysterious past about which his Victorian family was silent or whispered inarticulately, so that he had the extra developmental task of figuring out by himself, yet not announcing to others, lest they be hurt what identified me, which therefore could not be authorized (or denied).  (See Writing at the Margin (p. 2).

 I learned a lot about empathy from Kleinman, though he rarely uses the word. Nor would I consider Kleinman an advocate of empathy understood in the narrow sense of a psychological mechanism. Rather in a medical world (Kleinman is a psychiatric), in which diagnostic categories are mapped to psychopharm interventions, Kleinman is an articulate advocate for sitting down and talking to the individual about what is going on in the person’s life. What is working and what is not working? While it takes extra time upfront, such a conversation for possibility makes a profound difference in actually getting an accurate diagnosis as opposed to a good enough, makeshift band-aide.

 Kleinman several times quotes the celebrated founder of sociology Max Weber in his studies on bureaucracy. As institutions become larger and more complex, rules and roles independent of individual charisma and personal genius are needed to scale up to deliver services to more people. Nothing wrong with that as such – serving more people with high quality medical care is everyone’s aspiration. Yet when I have a disorder whose cause or course are unclear, like most people, I want the brilliant diagnostician, the TV doctor from central casting whether Ben Casey or House or whoever is trending, not a functionary.

 For those interested in additional diagnostic pyrotechnics or just plain background, The Illness Narratives, the essentials of which are recapitulated in The Soul of Care, is the place to look for expanded and amazing narratives. It too is a real page turner.

Kleinman’s The Illness Narratives: Suffering, Healing, and the Human Condition (Basic Books 1989) distinguishes incisively between the person’s experience of illness and the doctor’s concept of the disease as part of a biological system. To be sure, substantial overlap often exists between these two, but not always. What then opens up and becomes possible is an entire method and approach to healing that puts biological reduction in its proper place.

 For example: When chest pain can be reduced to a treatable acute lobar pneumonia, the biological reduction[ism] is a success. When chest pain is reduced to chronic coronary artery disease for which calcium blockers and nitroglycerine are prescribed, while the patient’s fear, the family’s frustration, the job conflict, the sexual impotence, and the financial crisis go undiagnosed and unaddressed, it is much less of a success (The Illness Narratives, p. 6).

 The Illness Narratives expanded my appreciation of how a physical injury can take on a life of its own. The injury is real enough and it becomes a grain of sand around which a misshaped black pearl is elaborated (my metaphor, not Kleinman’s). The physical issue is elaborated by the emotions, as unresolved personal issues in a person’s life seem to be magnetically drawn towards making meaning out of pain and suffering. 

 Another example, in The Illness Narrativesa self made assistant police captain, performing good work, helping a neighbor, throws out his back. The pain gets habituated. He just can’t shake it off – month after month. It is affecting his job performance. He needs even more down time, sick time. He starts to feel that people do not believe him – he is really suffering.

 To demonstrate to others and to himself how serious the matter is – and in the hope of finding relief for his pain – he agrees to surgery. However, if one is in pain, surgery can be a deal with the devil (so be sure to read the fine print), because, at least in the short term, surgery is a cause of acute pain.

 Several years – and surgeries – later, the person – now a picture of pain – walks into Dr Kleinman’s office. The patient is the walking embodiment of pain. His every more seems painful. A conversation reveals a life narrative not for the faint of heart. He was not quite abandoned as a child, but basically he had to raise himself. He would have starved as a kid of tender age if he had not learned how to scramble some eggs; his head barely reaching high enough to assess the progress of the food in the frying pain.

 Culminating in his latest contribution, The Soul of Care, Kleinman’s career has spanned the Corporation Transformation of American Medicineas identified by Paul Starr (1984) during which the medical doctor has gone from being a sovereign authority, whose word was virtually the law, to being a functionary in a corporation optimized for capitation and revenue generation, all the while paying marketing firms to communicate how caring everyone really is.

 In order to preserve the integrity of his commitment amidst the corporate transformation of American medicine, Kleinman innovates, inventing his own field of study, medical anthropology. It has legs. It works. A journal is founder. High quality articles are published. Institutions, funders, and financial support are forthcoming. He teaches it at Mass General – we pause to honor the storied name – and at Harvard – another pause. With all this pausing, we are never going to get through this review. Yet the broader lessons for healthcare as a whole of medical anthropology do not break out of its own resonant, transformational niche.

 Kleinman is definitely not living in a cave. He spends seven continuous years doing cross cultural research in China with his wife Joan, who becomes fluent in Chinese and provides important auxiliary functions in team building, networking, and having a life. (I shall follow the convention of calling “Arthur” by “Kleinman” and “Joan Kleinman” by “Joan” for simplicity.)

 Therefore when Kleinman’s own world is brought low as the love of his life and his professional partner, his wife of thirty years, Joan, is stricken with early onset Alzheimer’s, he find himself wrestling not only with the disease but with the medical bureaucracy and the fact that his innovations in medical education have definitely notbeen widely adopted.

 First he learns how to perform household chores. He learns how to pay the bills. He takes over bathing Joan and preparing meals. He marshals support from his gown up children, who have kids of tender age of their own and are running flat out – all the while continuing teaching and research (albeit with a certain amount of flex time provided by his  long-term employers – pause again to honor them – for whom Kleinman is a celebrity academic).

 He gets a home helper, who is indeed an essential part of the support system. With 20-20 hindsight, he second guesses his own agreement, requested by Joan, that she be allowed to decline (and die) at home. He has an important late insight, realizing that Joan is no longer the person who entered into that agreement, the dementia having robbed her of [essential aspects of] her identity. Nor is he the same person, who he was after the ongoing ten year long struggle. Between Joan’s agitation, loss of identity, intermittent fear or psychosis, and incontinence (wandering was less of an issue, because the patient became blind), all bets – and prior agreements – are problematic.

 The couple consult many specialists. The neurological resident Kleinman and his wife visit is interested in talking with them again – in six months – and in following the irreversible course of the disease, not in engaging with the human impact and cost for the wife and husband.

 Confidentiality is important; but it becomes yet another obstacle as the well-intentioned neurology resident insists on addressing Joan, even though her expressed wishes are that Arthur be included in all the decisions. Queue up the living will and health care power of attorney. All well and good. But the problem is that the patient does not want to have a legal conversation, she wants to have one about caring. Noticeably absent is guidance as to caring. Key term: caring.

Kleinman matriculates in the college of hard knocks. As caring – and empathic – has he already is, it is all used up by the progressive dementia. He gets a home helper since, though relatively well off, he must keep working to pay the mounting bills – and for his own sanity. Towards the end of the middle stage of the disease, he actually takes her with him to Shanghai, China, in order to fulfill academic obligations and complete a stalled  project in cross cultural health care.

The reader cannot help but wonder, “What is this guy thinking?” as he takes Joan, by then an easily agitated person developing Capgras (“imposter”) syndrome, through airport security to Shanghai. Somehow he pulls it off. The quality of care in China and the support for the family is truly inspiring, especially given how eager his Chinese colleagues are to be supportive with both traditional and modern medicine (and given that no one really has the answer regarding Alzheimer’s).

 Without using the word “empathy,” Kleinman was already operating at an advanced level in relating to others in a caring way. He is the Other whose listening brought relatedness to suffering individual in one case after another. Now he faces new, life-defining challenge.

 A recurring theme becomes how his ten years of care giving becomes a descent to the hell of irreversible dementia without the prospect of rebirth. As near as I can figure, his is a journey of the hero, with ample commitment and tragic struggle, but without heroism.

 Even given his training as a psychiatrist and anthropologist, a well-connected professorial network with high quality, [relatively] responsive support, he is brought low, isolated, at the brink of emotional despair. But how could it be otherwise? He is losing his wife to a disease that robs a person of her identity (i.e., dignity), but she is still physically present and intermittently coherent. Even so he struggles to get straight answers from the medical professionals about the course of the disease, about the trade-offs between home care and assisted living.

 The back story is that at some point early on in their relationship Joan decided that her life project was to take care of him (Arthur), the family, the kids, even supporting his research – they published academic papers together – while also mastering the Chinese language and immersing herself in that culture. She got good at it – very good indeed.

 Kleinman decides that he wants to return the favor. Of course, it is not as simple as that. Kleinman talks about his own guilt and what he had to survive coming up. The point is that this man Arthur Kleinman is already the soul of caring; but he takes his caring to a new level through the refiner’s fire of caring for Joan.

It is a heart-warming and inspiring narrative – the ultimate illness narrative (also the title of Kleinman’s most impactful work prior to this one) – but also a harrowing one. Not for the faint of heart. Apparently at some point, [many] advanced Alzheimer’s patients stop eating. A morphine drip and lip moistening are the palliative measures recommended.

If you need a good cry, you will get one by the time Kleinman realizes there is no way to take care of Joan at home even with a full time assistant. The end is not

Joan Kleinman (Obituary Photo)

Joan Kleinman (Obituary Photo)


quick, but given the morphine drip, neither is it painful. What it is is impossible to put into word. The image of suffering of Shakespeare’s Lear, blind and wandering in a storm of agitated emotions towards the edge of the cliff, looms large. It’s her; it’s him; it’s both, though he ends up being a survivor. What is painful is the loss – the loss of humanity of the Alzheimer’s patient.

 When Kleinman uses the word “moral” – it occurs in the subtitle of The Soul of Care as well as in the subtitle of his What Really Matters(Oxford 2007) – of course, he is referring to value judgments, candidate categorical imperatives, and assessment of ethically right and wrong behavior and character. At times, I doubt that the word “moral” adds to the discussion, since it is mainly about preserving one’s sanity in the face of the disintegration of the skills needed for the activities of daily living.

“Humanity” and “morality” overlap extensively and I doubt it makes sense to ask which came first. Yet they are not identical. There is a conflictual aspect to our humanity that morality attempts in vain to capture and make right by judging. Lear, blind and stumbling towards the edge of the precipice, is also wandering at the edge of morality, though arguably he never stops being a struggling human being. Neither does Kleinman.

Nor at any time does Kleinman become a moral relativist, though he is keenly in touch with the fuzzy, grey areas. The problem is that the space of human action and engagement becomes so thick with judgments and evaluations that one can hardly think, much less take action in the face of urgent emergencies.

Most of the tough (and narratively engaging) cases involve fraught decisions where fundamentally good people actually perform bad actions. In some cases the consequences of the action escape from the agent – as when the soldier follows the sergeant’s orders and blows up the car supposedly containing the suicide bomber, but it is actually a family of five on the way to deliver a baby. That is moral trauma. But in other cases individuals actually, intentionally commit war crimes (e.g., Winthrop Cohen in Kleinman’s What Really Matters) and spend the remainder of their lives twisted in knots over what happened, what does it mean, and how to go on.

Taking matters up a level, one such looming moral trauma is the ongoing corporate transformation of American medicine.

Kleinman channels some of his well-founded anger into targeting the systematic breakdowns of the American Healthcare system in the face of revenue incentives, corporate metrics, and devaluing caring. His jeremiad – I mean, argument – may usefully be made required reading – not only for doctors but especially for administrations and managers – in medical schools and systems. It is often the administrators who are taking advantage of the medical professional’s empathy in demanding more patients per period with no compromise of quality or attention to the demands of addressing human suffering in its physical as well as emotional and spiritual aspects.

Kleinman throws down the gauntlet, demonstrating just how far main stream, neoliberal, bio-political health care has diverged from his humanistic vision: “The problem, as some suggest, is not that we fail to quantify these experiences [of caring], but that they cannot be quantified, because they are essential human interaction, the soul of what health care is” (p. 238).

Many long term advantages exist in reducing spending upfront by life style changes in nutrition, exercise, stress management – and avoiding expensive medical technologies and interventions once the damage is done. A compelling quantitative case can be made that an ounce of prevention is worth a pound of cure.

Nevertheless the fact remains: quality health care is expensive. Though I am just a citizen, the Siemens Magnetic Resonance Imagining (MRI) device that took a picture of the torn cartilage in my knee looks to be almost as large and as complex, though in totally different ways, as the lunar excursion module (LEM) that landed two men on the moon in 1969. It turns out to be Rocket Science, so why should it be less expensive? Imaging, genomics, proteomics, personal medicine, personalized treatment using the most advanced technologies are quite simply expensive.

What is a lot less expensive – though by no means totally without cost – is sitting down and having a conversation for possibility with another human being – about her pain, disorder, and her life. And this conversation is one of the sources of quality healthcare and human flourishing, or at least pain management. This provides a powerful picture, too.

Read an excerpt from the book, quoted in Time Magazine: https://time.com/5680723/doctor-wifes-alzheimers/

A rumor of empathy is no rumor in The Soul of Care and Kleinman’s works. Empathy LIVES in Kleinman’s contribution. Kleinman does not emphasize this point about the power of ordinary language, though it is near enough to the surface of his text, but rather calls out the moral imperative: we must think deeply and with integrity about the kind of society and community we want to be. The extreme wealth being generated by innovations in technology make possible maximizing acts of humanity that advance community well-being. Whether that happens to the USA, as a healthcare nation is an existential choice of the highest order on the part of the individual and the community.

Lou Agosta, PhD and the Chicago Empathy Project

 

 

 

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