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Review: The Soul of Care by Arthur Kleinman

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

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

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

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

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

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


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

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

 

 

 

Book Review: Susan Lanzoni’s Empathy: A History connects the dots between the many meanings of empathy

Short review: two thumbs up. Superb. Definitive. Well written and engaging. Innovative and even ground-breaking. Connects the dots between the different aspects and dimensions of empathy. Sets a new standard in empathy studies. The longer – much longer – review follows. Note also that since this is not a softball review, several criticisms, incompletenesses, and limitations are called out.

Susan Lanzoni’s comprehensive history of the concept of empathy – the concept, not the mere word – breaks new ground in our understanding of the distinction.  She

Cover art: Empathy: A History by Susan Lanzoni - showing the full spectrum of aspects of empathy from projection to receptivity in interpersonal relations

Cover art: Empathy: A History by Susan Lanzoni – showing the full spectrum of aspects of empathy from projection to receptivity in interpersonal relations

explores empathy’s significance for diverse aspects of our humanity, extending from art and advertising to race relations and talk therapy: Empathy: A History. New Haven: Yale University Press, 392 pp., $30 (US).

Just to be clear: Lanzoni’s is not a “how to” or self-help book; which does not mean that one cannot expand one’s empathy by engaging with empathy’s deep structure in this multi-dimensional, historical encounter. One can. However, the reader will not find explicit tips and techniques in applying empathy.

Lanzoni engages with empathy and: (1) natural beauty and art (2) the 19th century psychological laboratories of Wilhelm Wundt (1832–1920), Edward Bradford Titchener (1867–1927), and their rivals (3) theatre and modern dance (4) mental illness such as psychosis and schizophrenia (5) social work and psychotherapy (6) measurement using psychometric questionnaires (7) popular culture including advertising and the media (8) race relations (9) neuroscience.

Lanzoni begins by quoting the work of Ted Cohen (1939–2014) on metaphor in Thinking of Others: On the Talent for Metaphor(2009). Formulating a metaphor and imagining oneself in another person’s position point to a common twofold root, an art [Kunst] hidden in the depths of the human soul, whose true operations we can divine from nature and lay unveiled before our eyes only with difficulty, but whose depths we are unlikely to be able ever adequately to plumb. Lanzoni’s implies the art in question is precisely empathy and the translation it makes possible. Thus, we always honor the late Ted Cohen, whose predictably cutting, caustic and cynical wit, however, masked a deep and abiding empathy.

The narrative proper begins with Violet Paget (Vernon Lee (1856–1935)), who, with her partner and muse Clementina (Kit) Anstruther-Thomson, engaged in introspective personal journaling to detect and report the physiological effects of art and beauty on the human organism. Paget’s research crosses paths with that of Munich psychologist Theodor Lipps (1851–1914). Lanzoni reports that Lee and Lipps may have met in person in Rome at the Fifth International Congress of Psychology in 1905 (where both were on the program).

At the risk of over-simplification, Paget, Lipps, and Karl Groos (1861–1946) form a triumvirate of empathy innovators, who turn to motor mimicry, inner imitation, sympathetic muscular memory, and aspects of physiological resonance to account for the stimulating effects of artistic and natural beauty on human experience. Their analysis is the flip side of the implicit panpsychism, personification, anthropomorphism by which beautiful nature is animated with human expressions of the emotional life – for example, angrystorms in the ocean, melancholymists in the valley, a joyfulsunrise, a fearfuldarkness.

This remarkable feature of human experience: that we attribute emotions (and even intentions) to natural objects – angry storms, cheerful sunsets, and melancholy clouds. Magical, primitive thinking? An adaptive reflex? This review does not require that anyone, including Lanzoni, have solved this problem. However, some contemporary thinkers have speculated that it is a cognitive design defect of human nature to attribute intentionality (including emotional propositional contents) to otherness – whether human or physical – as an adaptive mechanism arising in the context of biological evolution.

 Theodor Lipps is the one who puts Einfühlung on the map between 1883 and 1914 (his death), and those who are contemporaries must explain how they differ from his position.

 Lipps’ position on empathy was already multidimensional, extending Einfühlung from the projection of feelings into objects to the perception of other people’s expressions of animate life. Lanzoni’s reading of Lipps is much more charitable than mine, and I find Lipps at loose ends and philosophically naïve as he tries to account for the first person’s access to the experiences of the second person by “an original innate association between the visual image and the kinesthetic image (1903: 116). Lipps thinks he has demolished the philosopher’s problem of other minds but unwittingly recreates it in his own terms (e.g., Agosta 2014: 62 – 63).

 Lanzoni engagingly (but briefly) references the critique of Lipps’ theory of projective empathy by the phenomenologists Edith Stein (1891–1942), Max Scheler (1874–1928), Edmund Husserl (1859–1938), Maurice Merleu-Ponty (1908–1961), and Martin Buber (1878–1965) (p. 37).

 Lanzoni notes Sigmund Freud’s (1856–1939) debt to Lipps based on transference as a kind of projection. For Lipps, psychological processes were performed, with few exceptions, beneath the threshold of consciousness, which is another factor that made Lipps’ positions attractive to Freud.

 Any thinker or author who used the term “Einfühlung” would inevitably also conjure up the image of Theodor Lipps, which limited the thinkers ability to use it without extensive argument or the risk of being mistaken as a follower of Lipps. This point is key: in his own time Lipps had in itself branded himself as the “go to guy” for all matters empathic. More on the significance of this dilemma below.)

 By the way, Lanzoni does not italicize the word “Einfühlung” unless it is used in a specifically German context. “Einfühlung” is now an English word!

 Johann Herder (1744–1803) also gets honorable mention at this point (p. 32) as a philosopher in the Romantic tradition. Herder is noteworthy as a proponent of empathy as a verb – sichhereinfühlen– to feel one’s way into. Herder was a fellow traveler of Goethe and actually “on staff” as the chief Lutheran prelate at Weimar, innovating in the historical development of language in a proto-evolutionary (and metaphysical) context. This points to an entire undeveloped paradigm of empathy not developed by Lanzoni. For example, for Herder empathy was required to feel one’s way into the world of Homer in order to produce an accurate translation of Homer’s Iliad.

 This paradigm of empathy as translation is arguably at the same level of generality as empathy as projection, but remained undeveloped until the rise of hermeneutics along a separate trajectory. And since Lanzoni seemingly unquestioningly accepts Rudolf Makkreel’s dismissal of the relevance of Einfühlung for Wilhelm Dilthey (granted he has little use for the word), this approach is not further explored.

 Yet the modern innovators of interpersonal empathy such as Carl Rogers (1902–1987) might be read as leap-frogging back to the original sense of entering the other’s world in order to translate it into the first person, subject’s own terms. Such Herderlike usages also fits well with what Gordon Allport (1897–1967) and Kenneth Clark (1903–1983) were doing in arraying empathy against racism and prejudice in expanding the boundaries of community by empathically translating between them (see Chapter Nine).

 An entire possible alternate history of empathy, as yet unwritten, opens up at this point – empathy as translation between subjects. (Granted that Rogers probably never heard of Herder, at least not in the context of empathy, so this is a conceptual nuance; but Rogers probably never heard of Lipps either.)

 As is by now well known, in part thanks to Lanzoni’s work, the word “empathy” itself comes into English thanks to Edward Bradford Titchener, the founder of a Wundtian style psychology lab at Cornell University (and translator of Wundt). However, what is less well known is the back-and-forth about the meaning of Einfühlung as explored in detail by Lanzoni.

I was impressed by the work of James Mark Baldwin (1861–1934), who contribution to empathy as semblance was interrupted and obscured as he had to leave town in a hurry – apparently for Paris – after being arrested in a raid on a Baltimore house of prostitution. Baldwin was innovating with empathy in terms of semblance – the “as if” of child’s play and the play of the artist.

 Lanzoni quotes in detail the devaluing remarks about “empathy” made by James and Alix Strachey, the translators of Freud, who call it a “vile word” (p. 67). Though Freud used variations of “Einfühlung” some 22 times in 24 volumes, the word is often paraphrased or mistranslated by the Stracheys, using synonyms such as “sympathetic understanding.”

 It is amazing how much empathy or lack thereof turns on a mistranslation. My take on it? Basically Freud did not use the word Einfühlung more often because he was not someone who could abide being a footnote to Lipps (who, as noted, virtually owned the distinction Einfühlungin German). There are other technical reasons Freud chose not to comment more extensively on empathy, including his dismissal of the philosophical uses of introspection as a function of the conscience (superego), whereas introspection and empathy are “joined at the hip” in a therapeutic context (see also Agosta 2014: 66 – 82).

 I hasten to add that Freud did say in his “Recommendations for Physicians Beginning Psychoanalytic Treatment” (1913) that if the would-be analysts start in any other way than with empathy, they are headed for trouble. But once again the reader has no idea of Freud’s true position, because “empathy” is mistranslated as “sympathetic understanding.” However, these observations are less critical to Lanzoni’s point, which is otherwise unexceptionally on target.

 Meanwhile, Titchener has numerous ideas (that we would today consider highly unconventional) about how images accompany word meanings, but his translation of “Einfühlung” as “empathy” sticks. In an otherwise comprehensive engagement (Lanzoni really does seem to have read everything!), she does not mention how empathy subsequently becomes embroiled in the disappearance of introspection controversy (behaviorists regard it as illusory) and ultimately is “taken down” by the behaviorists in their attack on all things relating to subjective consciousness and inwardness. However, all this lies ahead in the B.F. Skinnerian 1950s through 1980s, and the Chapter ends with Einfühlung being an intertwining of projection, aesthetic appreciation, and Baldwin’s “semblance.”

 But how does one get from a empathy that projects human emotions and mindedness onto objects in art and nature and an empathy as human understanding of another, second person who contains an emotional life and mind of his or her own distinct from that of the first person?

 Lanzoni skillfully navigates the challenge of engaging how the projective aesthetic empathy of Lipps et al get transformed, translated, and reconciled, with the interpersonal receptive empathy of talk therapy and personal counseling.

 One missing link comes in modern dance. The missing link is identified as to “live in the mind of the artist who designed it [the object]” (p. 97). At this moment in the text, the intentionality of the artist looms large. In effect, the regression (my word, not Lanzoni’s word) is back from the intentionality built into the artistic artifact or performance towards human subjectivity. Now intentionality is available to build a bridge between a projective empathy of the object and a receptive intersubjective empathy of the human subject.

 Both projective empathy and receptive empathy are ways (admittedly divergent) of dealing with and transforming otherness– the otherness of the object and the otherness of the human subject. This is why aesthetic empathy and interpersonal empathy belong to the same concept and are not merely the same homonymous word for different underlying concepts.

 Another missing link occurs in “Personality as Art.” Lanzoni gathers together the contributions of Herbert Langfeld (1879–1958), Wilhelm Worringer (1881–1965), Carl Gustav Jung (1875–1961), who expand the boundaries of aesthetic, projective empathy in the direction of the understanding of human beings. The study of the artistic self-expressions of psychotics incarcerated in mental asylums also deserves mention here as opening up the exchange between aesthetic projective empathy and interpersonal receptive empathy.

 Nowhere does any one (including Lanzoni) say, “Relate to the human being with the respect and interpretive finesse with which one relates to a work of art,” but that is the basic subtext here. In our own time, the late Richard Wollheim, a notorious free spirit, sometimes took such a position about art and its objects.

 The engagement with empathy as human understanding picks up speed. Whenever a breakdown occurs the possibility of a breakthrough also arises. Such is the case with schizophrenia. In apparently separate but overlapping and near simultaneous innovations, E. E. Southard (1876–1920), Roy G. Hoskins , Louis Stack Sullivan (1892–1949), Karl Jaspers (1883–1969), and C. G. Jung identified schizophrenia as a challenge to or a disorder of empathy. In short, it is hard to empathize – Jaspers maintained it was impossible – with people who were disordered in such a way that they displayed the cluster of symptoms we now group as schizophrenia including perceptual distortions, incoherent speech patterns, disordered thinking, lack of reality testing, bizarre ideas, emotional flatness, intermittent acute anxiety or paranoia, lack of motivation, lack of responsiveness, burn out, and (occasionally) lack of personal hygiene.

 Southard designed an “empathic index” (p. 101) guiding the psychiatrist through a series of questions such as: How far can you read or feel yourself into the patient? Thus the first, admittedly over-simplified, version of the schizophrenia test: Can you imagine experiencing what the patient reports he or she is experiencing? If not, then that counts as evidence they are on the equivalent of what we would today call the “schizophrenic spectrum.”

 We finally arrive at our present day folk definition of empathy: the ability to step into and walk in another person’s shoes and then to step back into one’s own shoes again, and, in so doing, to “feel along with, to understand, and to insinuate one’s self into the feelings of another person” (p. 124).  

 Lanzoni asserts: “[T]he psycho-therapeutic rendering of empathy traded self-projection for its opposite: one now had to bracket the self’s findings and judgments in order to more fully occupy the position of another” (p. 125). Thus, a coincidence of opposites in which the two extremes are perhaps counter-intuitively closer to one another than either point is to the middle.

 With Chapter Five on “Empathy in Social Work and Psychotherapy,” Lanzoni makes yet another decisive contribution to empathy scholarship.

 Carl Rogers famously puts empathy on the map in the 1950s, 60s, and beyond, as the foundation for psychotherapeutic action. Though it is an oversimplification, in client-centered Rogerian therapy, one gives the client a good listening – one gives the client empathy – and the client gets better.

 Lanzoni connects the empathy dots. They lead back into the empathy archives. They lead back from Carl Rogers to D. Elizabeth Davis, a student of Jessie Taft (1892 – 1960), a nurse and social worker, who, in turn, was strongly influenced in her conception of relational therapy by G. H. Mead’s (1863–1931) social behaviorism and Otto Rank (1884–1939). Rank belonged to Freud’s inner circle along with Ernest Jones (1879–1958), Karl Abraham (1877–1925), and Sándor Ferenczi (1873–1933).

 Not a medical man or even a scientist, Otto Rank met Freud in 1905 when he presented Freud with his innovative work on the artist as inspired by Freud’s theories. Something clicked between them. In 1905 Freud was less isolated, but still hungry for recognition and fellow travelers. Think: father son transference.

 Rank eventually completed a PhD dissertation at the University of Vienna on literature (the Lohingrin Saga), in part thanks to the financial generosity of Freud. Freud paid him to be the recording secretary of the Psychoanalytic Association. The literary dimension is of the essence, and, in our own time, we have a renewed appreciation that studying literary fiction expands one’s empathy.  This too  strengthens the case for the overlap of the aesthetic and interpersonal dimensions of empathy.

 As was often the case with Freud and his “sons” – Jung, Ferenczi, Adler – the seemingly inevitable “falling out” between Rank and the Freudian establishment was especially bitter. Ultimately Louis Stack Sullivan made the parliamentary motion to expel Rank from the American Psychoanalytic Association. With friends like these … Rank formed his own separate Association and continued to innovate and earn Greenbacks.

 Carl Rogers learns of Rank’s work through one of his colleagues, who is being analyzed by Rank, now residing in the States. Rogers invites Rank to speak at a three-day seminar (circa 1936), lecturing to forty-five social workers and educators. Rogers later notes that it was in this context “that I first got the notion of responding almost entirely to the feeling being expressed” (p. 144). Voila! Mark the historical moment: Client-centered therapy is conceived.

 Mine is a bare bones outline of how Lanzoni connects the dots. The dynamics and the personalities, which Lanzoni richly narrates, make for fascinating story telling in themselves. Fast forward to the 1930s as Jessie Taft, a nurse and social worker separately innovating in empathic relatedness, is translating Rank’s Will Therapyfrom the German. There is still research to be done to follow the threads into Rank’s work, whose literary skills in mining myth and fiction are used in elaborating an approach to the emotions that transgresses the relatively narrow definition of Freudian libido (desire).

 Though Lanzoni does not get so far, I do not believe that Rank had the specific distinction of Einfühlung, but worked with the communication and understanding of the emotions in such a way as to produce psychological transformation. Rank uses the word “love” in the way of an empathy-like “unconditional positive regard.”

 By the time Rogers is fully engaged with Einfühlung, “empathy” does notmean agreement with the other or mere mirroring. The therapy client may usefully be self-expressed about the emotions with which he or she is struggling. These emotions, in turn, are thereby brought to the surface, acknowledged, worked through, and able to be transformed. The therapist helps the client to metabolize the emotional congestion and gives back to the client the client’s own experience in a form that the client recognizes, hypothetically opening up a reorganization of psychic structure.

 Lanzoni also gives a “shout out” to Heinz Kohut, MD (1913–1981), but just barely. Kohut was the innovator who puts empathy on the map in psychoanalysis (then the dominant paradigm in psychiatry) starting in 1959 with his celebrated article “Introspection, empathy, and Psychoanalysis.”

 Kohut was very circumspect about his sources relating to empathy and regarding those who inspired him in his work on empathy. Chronically under-appreciated (and sometimes even under attack) by the prevailing orthodoxy of Freudian ego psychology, Kohut’s footnotes about empathy as such are few and far between. Surely knowing the fate of Adler, Jung, Ferenczi, and Rank, not even to mention Jeffrey Masson, Kohut pushed back against the unfriendly accusation that Kohut’s emerging Self Psychology was distinct from Freudian psychoanalysis, even as Self Psychology seemed increasingly to be so.

 It is likely Kohut was influenced by Sándor Ferenczi and Michael Balint (Lunbeck 2011). Speaking personally, I have never seen a shred of evidence that Kohut read Rank, who was by that time devalued as yet another notorious “bad boy” and psychoanalytic heretic. Of course, that does not mean that Kohut did not do so – and it is also possible that I just need to get out more. Kohut and Rogers seemed to have inhabited parallel but wholly distinct universes.

 My take? And not necessarily Lanzoni’s: Kohut was sui generis– and wherever he first got the word “empathy” itself (Kohut, though a Austrian, German-speaking refugee, was by 1959 writing in English), his definition of empathy as “vicarious introspection” is a wholly original contribution.

 One problem is that as soon as one engages Kohut’s The Analysis of the Self(1971), arguably a work of incomparable genius, discovering as it does new forms of transference, relations to the other, and possibilities for humanization, the reader is hit by a tidal wave of terms such as “cathexis,” “archaic object,” and “repressed infantile libidinal urges.” These make the reading a hard slog for most civilians.

 The force of historical empathy is strong with Lanzoni as she engages “Popular Empathy.” She describes how in the post World War II world “empathy” breaks out of its narrow academic context into the American cultural milieu at large.

For example, the then-popular radio (and eventually TV) personality Arthur Godfrey was featured on the February 1950 cover of Time magazine, asserting “He has empathy” (p. 208). The notorious quiz show scandals of the late 1950s were apparently a function of mis-guided empathy, giving contestants answers to build audience empathy for the contestants. Advertisers “got it”: help the audience empathize with the brand and the person using the brand – give the customer empathy, they buy the product. Even if it was never quite so simple, the Boston Globe(July 3, 1964) quotes the Harvard Business Review:  Empathy is “the ability feel as the other fellow feels – without becoming sympathetic” (p. 210).

 Meanwhile, Carl Rogers has an existential encounter with Martin Buber (celebrated author of I and Thou) at the University of Michigan (1956). Rogers is profiled in Timemagazine in 1957 as practicing a psychotherapy that uses empathy in contrast with the then-prevailing paradigm of psychoanalysis, which uses – what? Insert the caricature of an authoritarian analysis of the Oedipus complex.

 In an eye-opening Chapter on “Empathy, Race, and Politics,” Lanzoni documents the role of empathy in the movement for civil rights in the 1950s and 1960s in America. Both Kenneth B. Clark and Gordon Allport provided examples of (social) psychologists who were committed to social justice. They were committed to overcoming the one dimensional, trivial and convenient issues of academic research (still ongoing) instead engaging with urgent social realities such as prejudice, racism, poverty, and inequality.

 According to Lanzoni, Allport drew on the tradition of Einfühlung to describe empathy as a means of grasping the human personality holistically, thus breaking down the barrier between aesthetic and interpersonal empathy. Clark used empathy as the basis for arguing for equality under the law: “to see in one man all men; and in all men the self” (p. 217). Sounds like empathy to me.

 In 1944 Allport taught an eight-hour course to Boston police officers to tune down racial tensions. Allport encountered and faced what he called an “abusive torrent of released hostility.” In response Allport deployed the technique of nondirective or “unemotional listening,” learned from Carl Rogers. Once again, sounds like empathy. By the end of the session, the officers reportedly became bored by their own complaints. One who had “at first railed against the Jews tried in later remarks to make amends.” But empathy remained a two-edged sword, capable of eliciting searing anger when others thought they had not been given the dignity they deserved as well as dialing down narcissistic rage once it had been called forth (pp. 220 – 221).

Clark was so impressed by psychoanalyst Alfred Adler’s (1870–1937) power dynamics in the context of society that he shifted his major from neurophysiology to psychology. In 1946, Clark and his wife, Mamie Clark (PhD, Columbia) established the Northside treatment Center in Harlem to expand education, counseling, and psychological service for youth in Harlem.

 In July 1953 Clark wrote to Allport, asking help in preparing a document for the upcoming Supreme Court deliberations on desegregation in the Brown v. Board of Education case. Allport responded quickly. The rest, as they say, is history.

 Gunnar Myrdal (author of the celebrated American Dilemma, demonstrating that the history of the US isthe history of race relations (1944)) said of Clark’s work, especially Dark Ghetto(1965): a demand for “human empathy and even compassion of the part of as many as possible of those who can read, think, and feel in free prosperous white America” (p. 241). Just so.

 Instead of becoming ever more cynical and resigned in the face of prejudice that seemed baked into the neo-liberal, market-oriented vision of American society, Clark calls forth empathy. Clark’s calls for empathy became more insistent. What happens when Clark and empathy speak truth to power? Empathic reason? Rational empathy? One can only wish that Clark had lived to see the people of this great country elect Barak Obama as President of these United States. We do not know if this was an anomalous moment, a beacon in the current fog of fake everything, or a kind of liberal purgatory – one step forward, one step backward – to call forth further struggle. From the perspective of Q2 2019 as I write this review, such events seem like a dream. Breakdowns are hard but inevitably point the way to the next breakthrough.

 Lanzoni demonstrates that society’s interest in empathy had continuously been at the level of at least a steady simmer in the popular and social justice communities in the 1950s through 1970s even as professional psychology was lost and wandering through the wasteland of Skinnerian behaviorism.

 That which really brings the conversation about empathy to a rolling boil in the final chapter is the discovery of mirror neurons in the macaque monkeys by the group of brain scientists in Parma, Italy including V. Gallese,, L. Gadiga, L. Gogassi, and G. Rizzolatti.

 Mirror neurons are neurons are activated both when a subject takes an action and similarly when the subject watches another subject doing the same thing. For example, the set  of neurons in the premotor cortex of the monkey is activated when it drinks from a cup. Okay, fine. The astonishing finding is that these same neurons are activated when the monkey watches another monkey (or any one) drink from the cup. Could this be the underlying basis of the motor mimicry, inner imitation, felt resonance, with which thinkers such as Violet Paget, Theodor Lipps, and Karl Groos remarked? Could this be the neural infrastructure for Kohut’s vicarious engaged, or Roger’s felt sense of participating in the other’s experience? The infrastructure for Mark Davis or Alvin Goldman on perspective taking and simulation?

  The battle is joined.

 Lanzoni covers the explosion of theories, studies, and amazing results that have occurred since the identification of alleged mirror neurons. Bottom up, affective empathy is combined with top down, cognitive empathy to complete the picture of empathic relatedness.

 The author of Emotional Intelligence, Daniel Goleman, weighs in with a follow up on Social Intelligence– that is, empathy.  Victorio Gallese’s shared manifold hypothesis makes the case for a multi-person virtual manifold of experience that can be vicariously sensed by each partner in empathic resonance. Jean Decety’s seminal architectural definition of empathy paves the way for social neuroscience and functional magnetic imaging research (fMRI) that visualizes other people’s pain. Marco Iacoboni Mirroring Peopleargues that we have no need to use inference to understand other people. We use mirror neurons. Disorders of empathy are identified: Simon Baron-Cohen’s breakthrough work on Mindblindness(1995) identifies possible interventions for autism spectrum disorders.

 On a less positive note, the colonization by neural science of the humanities and social sciences has proceeded apace with neuroaesthetics, neurolaw, neurohistory, neurophilosophy, neuropsychoanalysis, neurozoology,and so on,  drawing provocative but, in many cases, highly questionable conclusions from what areas of people’s brains “light up” as they lay back in the fMRI apparatus and are shown diverse pictures or videos of people’s fingers being painfully impacted by blunt force.

 Lanzoni reports on the neuro-hype that accompanies the discovery of mirror neurons in monkeys: “Cells That Read Minds.” Hmmm. The backlash is predictable if not inevitable. Greg Hickok’s The Myth of Mirror Neuronsraises disturbing questions about voodoo correlations in fMRI research. Other than a single report from 2010 of human mirror neurons allegedly identified in epileptic patients undergoing surgery, there is no evidence of the existence of human mirror neurons.

 Lanzoni is an equal opportunity debunker: The fMRI research, while engaging and provocative, provides evidence of diverse brain functions that include thousands of neurons, not individual ones, whose blood oxygenation level data (BOLD) is captured by the fMRI. Correlation is not causation. The brain lights up! Believe me, if I doesn’t you are in trouble.

 Still, the neuro-everything trend has traction (and its merits). Even if human mirror neurons do not exist, it is highly probable that some neurological system is available that enables us humans – and perhaps us mammals – to resonate together at the level of the animate expressions of life.

 If there is a myth, it is that we are unrelated. On the contrary, we humans are all related – biologically, socially, personally. You know that coworker or boss you can’t stand? You are related. You know that politician you regard with contempt? You are related. You know that in-law or neighbor who gets your goat? You are related – intimately related, because we all share the same cognitive, affective, and neural mechanisms – and defects – designed in from when we were that band of hominids fighting off large predators and hostile neighbors in the environment of evolutionary origin.

 Since this is not a softball review, as noted, I call out the limitations and incompletenesses of Lanzoni’s impressive contribution. One of the challenges is that the history of the concept empathy is not limited to the word “empathy” or Einfühlung. Indeed prior to Lanzoni’s work, some entirely reasonable individuals had concluded that Lipps projective empathy and Roger’s interpersonal empathy were entirely distinct concepts. We now know that they belong together in a kind of coincidences of opposites because empathic animation of the work of art or beautiful nature and empathic receptivity to other human beings are related, but diverse, ways of engaging with otherness. 

 First incompleteness: Prior to Titchener’s invention of the word “empathy” as a translation of the German “Einfühlung” the main word in English was “sympathy.” Now it is a common place today to say that “sympathy” means a reactive emotion such as pity in contrast with “empathy” that captures a vicarious experience of the other’s experience or takes a sample or trace affect of the other’s experience. And that remains true today. David Hume (1711–1776) and Adam Smith (1723–1790) get barely a shout out.

 However, if one goes back as recently as David Hume’s Treatise of Human Nature(1731) one can find at least four different senses of sympathy – emotional contagion, the power of suggestion, a vicarious experience such as one has in the theatre, the conjoining of an idea and impression of another’s expression of emotion with the idea of the other [which starts sounding like our notion of interpersonal empathy].

 In addition, if one looks at Hume’s aesthetic writings, one finds the distinction of a delicacy of sympathy and of taste. If your delicacy of sympathy and taste is more refined than mine, then you may experience a fine-grained impression that is more granular than mine. For example, you perceive sadness behind a person’s outburst of temper whereas I only perceive the obvious anger. Your delicacy of sympathy and taste is superior to mine. In our own modern language, you empathy is more discriminating.

 A second incompleteness is in the treatment of the phenomenologist’s – Edith Stein (1891–1942), Max Scheler (1874–1928), Edmund Husserl (1859–1938), Maurice Merleu-Ponty (1908–1961), who receive honorable mention in a cursory nod to their diverse engagements with Einfühlung. For example, in a footnote, Scheler’s eight distinctions of sympathy and empathy are called out in a footnote (p. 360n40): Miteinanderfühlung[reciprocal feeling], Gefühlsansteckung[infectious feeling], Einsfühlung[feeling at one], Nachfühlung[vicarious feeling], Mitgefühl[compassion], Menschenliebe[love of mankind], akosmischtishe Person- und Gottesliebe[acosmic love of persons and God], und Einfühlung[empathy]. Well and good.

 Leaving aside purely practical considerations of editorial constraints on word count and that the phenomenological material may have been covered elsewhere [e.g., see Agosta 2014, especially Chapters 4 – 6]: the reason that the additional phenomenological chapter was not provided is a breakdown in an otherwise astute historical empathy. 

 In particular, today hardly anyone has heard of Theodor Lipps (granted that Lanzoni’s work is changing that). However, in his own day Lipps was famous – celebrated as the proponent of a theory of Einfühlungthat provided the substructure for aesthetics and grasping the expressions of animate life of other people. It was as if Lipps was an Antonio Salieri to would-be Mozarts such as Freud or Husserl (once again, except for the play (and movie) Amadeus). Using modern terms, it was as if in his own day Lipps was branded in the marketing sense as “the empathy guy.”

 Between roughly 1886 and 1914 (the date of Lipps’ death) no philosopher, psychologist, or psychoanalyst could use the word “Einfühlung” without being regarded as a follower – or at least a fellow traveller – of Lipps.

 In the case of the phenomenologist, the result is a sustained attack on Lipps. Edith Stein quotes Max Scheler against Lipps’ theory of “projective empathy.” Her contribution becomes a candidate deep structure of Husserl’s 5thCartesian Meditation. Husserl attempts to overcome the accusation of solipsism [there is nothing in the universe except my own consciousness] without using empathy as a mere psychological mechanism. Yet Husserl dismisses empathy, using a Kantian idiom, and “kicks it upstairs”: “The theory of experiencing someone else, the theory of so-called ‘empathy,’ belongs in the first story above our ‘transcendental aesthetics’ ” (1929/31: 146[173]). “Transcendental aesthetics” is a form of receptivity – such as receptivity to another subject. But then Husserl has to reinvent empathy in other terms calling it “pairing” and “analogical apperception.”

 One thing is certain: in Husserl’s Nachlass(posthumous writings) he makes extensive use of Einfühlungin building an account of intersubjectivity. Empathy is the window into the sphere of ownness of the other individual subject. Empathy is what gives us access to the Other, with a capital “O.” Empathy enacts a “communalization” with the other. Key term: communalization (Vergemeinschaftung).

 In his published writings Husserl was exceedingly circumspect in his use of the term “Einfühlung,” virtually abandoning it between Ideas(1913) and the Cartesian Meditations(1929/31).  But in Husserl’s work behind the scenes empathy was moving from the periphery to the center of his account of intersubjectivity. The Nachlassvolumes corresponding the Cartesian Meditations contain hundreds of references to Einfühlung, in which it is doing the work of forming a community of subjects. The anxiety of influence? The influence of Lipps? Quite likely.

 I would not blame anyone – including Lanzoni – for not wanting to try to disentangle this complex of distinctions and influences of empathy in the context of phenomenology. It is not for the faint of heart.

 As of this date (Q2 2019), Lipps is not translated from the German so far as I know. There is a reason for that – Lipps falls through the crack between Immanuel Kant and Wilhelm Wundt. If ever there were someone of historical interest, it is Lipps.

 Lipps provides an elaborate rewrite of rational psychology using a quasi-Kantian idiom without any of the empirical aspects of Wundt. Still, Lipps enjoyed considerable celebrity in his own time. So far as I know, no one has commented on the fact that Lipps in effect substitutes the term “Einfühlung” for “taste” in his aesthetics. Those wishing to engage further may usefully see Agosta 2014: “From a Rumor of Empathy to a Scandal of Empathy in Lipps in A Rumor of Empathy: Rewriting Empathy in the Context of Philosophy: pp. 53 – 65: DOI: 10.1057/978113746534.0007.)

 A third incompleteness is the role of empathy in psychoanalysis proper, which was perhaps a wilderness too desolate to reward proper scholarly engagement. Lanzoni notes: “There were also handful of psychoanalysts, trained, not surprisingly, in Vienna, who ventured to explain empathy to a popular audience. Analyst and writer Theodor Reik published Listening with the Third Ear in 1948 [….] Empathy worked like wireless telegraphy to allow one to tune in to the inchoate messages of another’s unconscious” (p. 208). Empathy as receptivity andbroadcast of messages. However, Reik was not a medical doctor, and the American Psychoanalytic Association declined to validate his credentials, leaving him as yet another voice crying in the wilderness.

 Lanzoni gives Kohut another “shout out,” noting that empathy was an observational act that led the analyst to a scientific appraisal of the other person rather than one of the “sentimentalizing perversions of psychotherapy” (p. 207). Of course, Kohut moved steadily in the direction of asserting that empathy itself could be curative, though, in contrast to Rogers, mainly in a process of optimal breakdown, being ruptured and restored. Empathy breaks down, the attuned therapist acknowledges and cleans up the misunderstanding, empathy is restored, psychic (personality) structure is shifted and strengthened – thenthe patient gets better.

 A fourth incompleteness is the missing paradigm of empathy as translation between different individuals and the worlds in which the individuals inhabit. Once again, this is not a criticism of Lanzoni, but simply to note that, substantial though Lanzoni’s contribution is, there is more work still to be done.

 Herder was working on a complex interpretive problem of empathy, creating an entire world in all its contingencies and details in order adequately to translate a text from attic Greek into German or understand a work of art in its ancient context. Herder’s project envisions no trivial translation, and, if anything, is an application of empathy broader and bolder than what is being proposed here or in any reconstruction of Kant. According to Herder, in order to deliver an adequate translation, the translator must think and feel himself into – empathize into [sichhineinfühlen] – the world of the author or historical figure. The translator is transformed into a Hebrew, e.g., Moses, among Hebrews, a poet among bards, in order to “feel with” and “feel around” the world of the text (e.g., Herder as cited in Sauder 2009: 319):

 Feeling is the first, the most profound, and almost the only sense of mankind; the source of most of our concepts and sensations; the true, and the first, organ of the soul for gathering representations from outside it . . . . The soul feels itself into the world [sichhineinfühlen] (1768/69: VIII: 104 (Studien und Entwürfe zur Plastik)) (cited in Morton 2006: 147-148).

 Thinking from the point of view of everyone else is not to be confused with empathy in the Romantic idea of empathy where empathy is a truncated caricature of itself and summarily dismissed as merger, projection, or mystical pan-psychism. Nor is it clear that Herder, always the sophisticated student of hermeneutics, ever envisioned such a caricature of empathy. In any case, empathy is not restricted to the limitations of a Romantic misunderstanding of empathy as merger. Empathy as creating a context within which a translation – an empathic response – can occur stands on its own as an undeveloped paradigm (see also Agosta 2014: 36–37 (from which this text is quoted)).

 Among the many strengths of Lanzoni’s book is her engagement with the many women researchers and scholars who contributed to the history of empathy: Violet Paget (Vernon Lee), who was there are the beginning with the physiological, mirroring effect of empathy in inner imitation; Edith Stein, research assistant (along with Martin Heidegger) to Edmund Husserl and her dissertation The Problem of Empathy(1917), which was influenced by and, in turn, informed Husserl’s ambivalence about making Einfühlungthe foundation of intersubjectivity (community); Jessie Taft, who developed an entire model of psychotherapy, relational therapy, combining element of G. H. Mead’s social behaviorism and Otto Rank’s psychoanalytically informed approach to the emotions, which, in turn, decisively influenced Carl Rogers. All this and more does Lanzoni truly deliver.

 References and Further Reading

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

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

Sigmund Freud. (1913). “Further recommendations: On beginning the treatment.” Standard Edition, Volume 12: 121-144.

Victorio Gallese. (2001). “The shared manifold hypothesis: embodied simulation and its role in empathy and social cognition.” In Empathy and Mental Illness, T. Farrow and P. Woodruff (eds.), Cambridge, UK: Cambridge University Press, 2007: 448-472.

Edmund Husserl. (1905/20). Zur Phänomenologie der Intersubjectivität: Texte aus dem Nachlass: Erster Teil: 1905-1920,I. Kern (ed.). HusserlianaXIII. The Hague: Martinus Nijhoff, 1973.

 ______________. (1913). Ideas: General Introduction to Pure Phenomenology, tr. W. R. Boyce Gibson. New York: Collier Books, 1972.

 _____________. (1918). Ideas Pertaining to a Pure Phenomenological Philosophy: Second Book, tr. R. Rojcewicz and A. Schuwer. Dordrecht: Kluwer Academic Publishers, 1989.

 ______________. (1921/28).  Zur Phänomenologie der Intersubjectivität: Texte aus dem Nachlass: Zweiter Teil: 1921-1928I. Kern (ed.). HusserlianaXIV. The Hague: Martinus Nijhoff, 1973.

 ______________. (1929/31). Cartesian Meditations, tr. D. Cairns. Hague: Nijhoff, 1970.

 _____________. (1929/35).Zur Phänomenologie der Intersubjectivität: Texte aus dem Nachlass: Dritter Teil: 1929-1935, I. Kern (ed.). HusserlianaXV. The Hague: Martinus Nijhoff, 1973. 

 Marco Iacoboni. (2007). “Existential empathy: the intimacy of self and other.” In Empathy and Mental Illness, Tom Farrow and Peter Woodruff (eds.), Cambridge, UK: Cambridge University Press, 2007: 310-21.

L. Jackson, A. N. Meltzoff, and J. Decety. (2005). “How do we perceive the pain of others? A window into the neural processes involved in empathy,” Neuroimage24 (2005): 771-779.

G. Jung. (1921). Psychological Types, tr. R. F. C. Hull. Princeton: Princeton University Press, 1971.

Susan Lanzoni. (2012). “Empathy in translation: Movement and image in the psychology laboratory,” Science in Context, vol. 25, 03 (September 2012): 301-327.

Vernon Lee [Violet Paget]. (1912). Beauty and Ugliness and Other Studies in Psychological Aesthetics. New York: John Lane, Co.

 Theodor Lipps. (1883). Grundtatsachen des Seelenlebens. Bonn: Verlag des Max Cohen und Sohns.

 _____________. (1897). “Der Begriff der Unbewussten in der Psychologie.” In Dritter internationaler Congress für Psychologie in München vom 4. bis 7 August 1896. München Verlag von J.F. Lehmann, 1897: 146-163.

 _____________. (1909). Leitfaden der Psychologie. Leipzig: Wilhelm Engelman Verlag.

 _____________. (1903). Aesthetik. Volume I. Hamburg: Leopold Voss.

 Lou Agosta. (2014). “From a Rumor of Empathy to a Scandal of Empathy in Lipps in A Rumor of Empathy: Rewriting Empathy in the Context of Philosophy: pp. 53 – 65: DOI: 10.1057/978113746534.0007.

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

Elizabeth Lunbeck. (2011). “Empathy as a Psychoanalytic Mode of Observation: Between Sentiment and Science,” in Histories of Scientific Observation, ed. Lorraine Daston and E. Lunbeck. Chicago: University of Chicago Press.

George H. Mead. (1922). “A Behavioristic account of the significant symbol,” Journal of Philosophy, 19 (1922): 157-63.

 Michael Morton. (2006). ‪Herder and the Poetics of Thought: Unity and Diversity in On Diligence in Several Learned Languages. London and University Park: Penn State University Press.

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

Three books on empathy reviewed: The good, the bad, and the ugly

The first empathy book reviewed here is very good indeed. William Miller’s Listening Well: The Art of Empathic Understanding  (Wipf and Stock, 114pp, ListeningWellEmpathicUnderstandingCoverArt($18US)) is a short book. Admirably concise. My short review is that, as I am author of three academic and one “how to” book(s) on empathy, this is the book that I wish I had written.

Listening Well contains the distilled wisdom of Miller’s several decades of practicing listening as the royal road to expanding empathy. Listening Well is a “how to” book, but the author is adamant that such a skill lives and flourishes in the context of a commitment to being empathic. (I hasten to add that, though Miller’s is the book I wish I had written, my own publications on empathy are significant contributions, and I shamelessly urge the reader to get them on the short list, too.)

Being with the other person without judgments, labels, categories, diagnoses, evaluations, and so on, is what empathy is about most authentically. It is not that such assessments do not occur. They do, but they almost always get in the way. Listening Well is way too short to be a textbook, but I can see it as being useful in a workshop, seminar, or as exercises in a class.

In case you are unaware of William Miller’s background, he is the innovator behind Motivational Interviewing. Listening well – the practice, not just the title of the book – is at the heart of this approach. In turn, the practice of listening well is based on empathic understanding. Miller is explicit in invoking the work of Carl Rogers (1902 – 1987) Rogers was one of the founders of humanistic psychology, and Rogers’s person-centered psychotherapy provides the foundation for this results-oriented intervention.

Cris Beam is a would-be “bad girl,” who has written a very good book. In a world of constrained, limited empathy, the empathic person is a non-conformist. Beam is one of those, too, and succeeds in sustaining a nuanced skepticism about the alternatingIFeelYouCoverArt hype and over-valuation of empathy over against those who summarily dismiss it. Most ambivalently, she calls out the corporate infatuation with empathy. I paraphrase the corporate approach: Take a walk in the other person’s shoes in order to sell them another pair.

In Beam’s book I Feel You: The Surprising Power of Extreme Empathy (Houghton Mifflin, 251 pp. ($26 US$)), Cris Beam makes empathy present. She brings forth empathy her engagement with difficult cases that challenge our empathy, including her own conflicts. In the process of struggling with, against, and for empathy, she succeeds in bringing forth empathy and making empathy present for the reader. From an empathic point of view, I can think of no higher praise.

It gets personal. Beam reports that she is a survivor of a floridly psychotic mother and a father who, at least temporarily (and probably to save himself), abandoned Cris to her fate with that woman. As a teenager, Beam escapes to her father and his second marriage only to be rejected when she “comes out” as a lesbian some years later. Fast forward to Beam’s own second marriage [both to women].

Beam’s partner announces that the partner (at that time a “she”) is committed to transitioning to becoming a man. Beam decides to support her (becoming him) and sticks with it through the top surgery, administering the testosterone shots. The partner tells Beam: “I will love you always [regardless of my gender].” Beam decides to believe the partner. (See what I mean? You can’t make this stuff up.)

 Nor is this a softball review, and I decisively disagree with Beam when she says that empathy is “mutual vulnerability” and approvingly quotes André Keet: “there are no neat boundaries between victim, perpetrators, beneficiaries, and bystanders …” (p. 191). While such a statement is descriptively accurate, once the father walks, leaving the psychotic mother and child behind, the commitment of empathy is to respect boundaries and (re)establish them when the boundaries have broken down or been violated.

Empathy is all about boundaries, and Beam, like so many of us, has her share of struggles with them. No easy answers here. But one final thought as my personal response to Beam’s thought provoking and inspiring work on empathy. We may usefully consider the poet Robert Frost: “Good fences make good neighbors.” I add: There is a gate in the fence, and over the gate is written the word “Empathy.”

The third empathy book, The Routledge Handbook of the Philosophy of Empathy (Routledge, 410pp, $245 US$), has a truly ugly hardcover price of $151 even after the Amazon discount as publishers continue to respond to economic pressures by

Cover Art: The Routledge Handbook of the Philosophy of Empathy

Cover Art: The Routledge Handbook of the Philosophy of Empathy

squeezing the life out of traditional print books that one can hold in one’s hand. The recommendation? Have the library order a copy (the paperback is $54.95, a better price, but nothing to write home about).

I have read, reviewed, and sometimes struggled, not only with the tangled history of empathy from David Hume to mindreading to mirror neurons, but with all thirty-three articles as a would-be empathic contribution for those who come after me. In many cases, I resonated empathically with the article. Bringing a rigorous and critical empathy to the article based on my life and experiences, sometimes the article “clicked,” i.e., worked for me. In other cases, I had to activate “top down” empathy, trying to create a context for a conversation, in which all I can otherwise see is an effort to maximize the number of stipulations that can be made to dance on the head of a pin—the pin being “empathy” (seems like about two dozen).

In every case, I try to be charitable; but in some cases the “empathy meter” goes in the direction of “tough love.” In one or two cases, I acknowledge my empathy breaks down completely in the face of academic over-intellectualization—an obvious occupational hazard in philosophy, but one that needs to be firmly contained in an engagement with a critical and rigorous empathy—and I simply recommend hitting the delete button—or a rewrite from scratch.

A “Handbook” promises to be a comprehensive engagement with the issues. So it is with deep regret, that I call out the fundamental incompletenesses. Nothing on education. Philosophers are not educators? Socrates was not a teacher? Mary Gordon’s program The Roots of Empathy (also the name of her book) includes bringing a baby into the grammar school classroom. Too developmental? Too psychological? The Philosophical Baby (Gopnik et al 2009)?

Also missing is the alternative point of view. The neurohype around mirror neurons is well represented; but what about the alternative point of view that such an entity as a mirror neuron does not even exist in humans and that the neurological infrastructure has a different configuration.[1]

The evolutionary context of empathy is considered; but missed are the role of the human mother-child matrix in the development of affective empathy, the empathizing effect of female sexual selection on male aggression, and the development of perspective taking in group selection in empathy as a “cheater detection system” and “empathic cruelty.” Empathy and morals are well represented; but little about social justice, overcoming prejudice, building bridges between disparate individuals and communities, or the tough related issues.

I am just getting warmed up here. Other incompletenesses are more fundamental—methodological. Empathy is not just the object of the inquiry, but it also needs to be the subject of the inquiry. We get our humanity from the other individual—and the other’s artistic expressions and social contributions.

This is subtle; so let me give an example. Expand your empathy: go to the art museum. Deepen your empathy: attend the symphony. Broaden your empathy: study a foreign culture or indigenous community. Stretch your empathy: read literary fiction. The engagement with aesthetics expands, trains, and develops our empathy; likewise, with the engagement with the other person. How does that work? The contributors seem not to have considered the possibility.

Instead empathy is on the defensive in too many places in the Handbook under review. Empathy is not represented as something of value that needs no apology and is worthy—along with (say) compassion and motherhood—of active promotion and expansion as a benefit to the community. Strangely enough, the breakdowns, failures, and misfirings of empathy—emotional contagion, conformity, projection, and communications lost in translation—are mistaken for empathy itself as if empathy could not misfire or go astray.

Nevertheless, bright spots appear. As Shoemaker points out in his article, the solution to a so-called parochial empathy that is limited to the “in group” is empathy itself – expanded empathy. Expand the boundaries of the community to be inclusive of those previously excluded. No doubt, easier said than done, but that is not a limitation of empathy itself, but of our need for expanded training and practice of empathy.  

The battle is joined. Dan Zahavi, an otherwise impeccable and astute phenomenologist, enters into apologetic worrying about the conundrum: Can we really ever appreciate, understand, empathize with another person’s experience without having had a similar experience [or words to that effect]? Zahavi makes good use of Max Scheler to show that we can. With the exception of Jenefer Robinson (on “Empathy in music”), what is not called out (or even hinted at) is that the encounter with the other person, art, music, and literature enhances and expands our empathy.

 In a world of limited empathy, the empathic person is a nonconformist. I wish I could write this Handbook is overflowing with nonconformists. Happily there are some and they produce several excellent articles—Zahavi, Gallagher, Ickes, Denham, Debes, Hollan, and John (Eileen); but it is otherwise filled with over-intellectualization, stipulations, neurohype, inaccurate phenomenological descriptions (mostly by the neuro-philosophers, not the phenomenologists), and tortured conceptual distinctions lacking in empathy. Seven out of thirty-three is a modest harvest.

One expects a Handbook on empathy would make empathy present for the reader. In the long, dreary march through 397 pages, thirty-three articles, I thirsted for it. Eileen John comes closest to doing so, and she is able to marshal the resources of empathy in the context of literature to help her get over what is admittedly a high bar. The scandal of this Handbook is that amid so many conceptual distinctions relating to empathy, empathy itself—empathy as a presence in the encounter with the reader—goes missing except in this one out of thirty-three articles.

What I am saying is that, with a few exceptions, largely concentrated in the contributions of Heidi Maibom and issues with her editing, there is nothing wrong with this Handbook; but there are so many things missing it is hard to know where to start with them. The practice of empathy is the source out of which emerge the ten thousand empathic distinctions in this Handbook. Key term: practice. Thinking and writing informed by the practice of empathy is the ultimate missing link.

Reviewing each of the thirty-three articles in the Handbook requires a book length treatment in itself. Therefore, I have provided one entitled A Critical Review of a Philosophy of Empathy (Two Pairs Press, 162pp. $10US (Amazon)), in which extensive background on the issues is also engaged. In short, this is a book about the book, and is the complete book review. Each of the articles is reviewed in detail with a seven separate and substantial sections orienting the reader to the issues, pro and con, engaged under core problems, history, understanding (mindreading), morals, aesthetics, and cultural issues, all relating to empathy. The recommendation? Check out the review, priced to cover printing plus a latte and biscotti for the reviewer, prior to engaging with the Handbook. You may get 80% of the value in the review; and you will not be bored.

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

REFERENCES

Complete, expanded Review of William Miller’s Listening Well: The Art of Empathic Understanding: Review-of-William-Miller-Listening-Well

Complete, expanded Review of Cris Beam’s I Feel You: The Surprising Power of Extreme EmpathyReview-of-Cris-Beam-I-Feel-You-Extreme-Empathy

Completed, expanded Review of Lou Agosta’s A Critical Review of a Philosophy of EmpathyAbout-Lou-Agosta-A Critical-Review-of-a-Philosophy-of-Empathy

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

REVIEW: Surviving the Borderline Mother

I am catching up on my reading. Christine Ann Lawson’s Understanding the Borderline Mother is a classic in its field, with a whopping 396 Amazon reviews (Q1 2019), enjoying a rating of 4.7 out of 5.0. Impressive. (See the bottom of this review for bibliographic information on the book [1].)

Numerous readers have remarked that this book opened their eyes to what they had to survive growing up. These survivors were not bad,

Review: Understanding the Borderline Mother by Christine Lawson

Review: Understanding the Borderline Mother by Christine Lawson

crazy, or broken in the way they were led to believe by what was fundamentally an invalidating child-rearing environment. The vignettes and analyses in Lawson’s book provided them with a transformational “Ah ha!” moment. For many survivors this was a tad like Saul becoming Saint Paul on the road to Damascus – a bolt of lightening out of the blue. They then could begin the hard work of incremental change needed to restore the self-soothing, emotional regulation, and distress tolerance capabilities needed to feel like whole persons again – or for the first time ever.

So up front and considering this is not a “soft ball” review, I acknowledge the importance of Lawson’s contribution and recognize that her work made a profound difference for many survivors. It is especially important to keep that in mind, given that I express significant reservations and criticisms.

The technical details? The borderline personality disorder (BPD) gets precisely defined as a psychiatric entity in 1980, entering the third version of the Diagnostic and Statistical Manual (DSM-III). However, long before that signal event “borderline” was understood to be a person whose personality structure (or lack thereof) is characterized by a compensatory but problematic defensive structure that guards against a psychotic breakdown.

Here “psychotic” means “out of touch with everyday reality.” The implication was that such borderline individuals were at risk of completing losing contact with the world of everyday life, decompensating into a full-blown psychotic breakdown. In particular, if the borderline person were treated with psychoanalytic methods, itself encouraging a mild form of regression back to the childhood fixations, whether real or imagined, the risk was of causing the borderline treatment to “go off the rails” into explicit mental illness. In a different, allegedly humorous context, the description “borderline” has come to mean that the patient is hard to work with, difficult, or simply “the therapist doesn’t like the patient.” 

A bit more background will be useful. Innovations in treating personality disorders by Heinz Kohut, MD, including new forms of transference such as self-object transference, made narcissistic personality disorders (NPD), arguably on a continuum with borderline personality in a pre-1980 sense, accessible to psychoanalytic methods. (See footnote [2] below.) However, NPD remains distinct from BPD. The treatment of NPD is relevant here since the children of BPD parents do not necessarily acquire BPD themselves, but sometimes suffer from a pervasive narcissistic vulnerability.

In contrast with Kohut’s deficit model of the narcissistic self, Otto Kernberg, MD, developed a formulation that posited actual defects in the structure of the borderline personality – aspects that were not merely missing but broken. The resulting borderline behaviors need to be confronted and rooted out by a kind of “tough love” on the part of the therapist.

Meanwhile, Marsha Linehan, PhD, a self-styled radical behaviorist, is the innovator who created a treatment approach called “Dialectical Behavioral Therapy” (DBT) that often is effective in treating BPD while other approaches have been [are] less successful. No short description of Linehan’s program is available, but a suitable over-simplification may be useful: DBT combines cognitive behavioral therapy (CBT) within a framework that emphasizes mindfulness, empathic listening, and validation of the grain of truth in even the BPD person’s most perplexing distortions to restore the BPD individual’s capabilities for emotional regulation, distress tolerance, self-soothing, interpersonal skills, and self-esteem. DBT is not for the faint of heart and requires an entire team, including both one-on-one counseling and extensive work in groups. It is different than boot camp, but sometimes not by much. Substantial evidence-based, peer-reviewed publications support the effectiveness and validity of the approach.[3]

Lawson, gets matters right with her use of Marsha Linehan, Heinz Kohut, Otto Kernberg, and Ernest Wolf, even when these innovators are not specifically addressing borderline personality disorder (DPB). As noted, Kohut and Wolf have done a deep dive on narcissistic personality disorders. In comparison to BPD, though related, neither the symptoms nor the treatments options are the same. This points to the hazards of broad-brush stroke labeling segments of suffering humanity, albeit with the worthy end of expanding our empathy and understanding for the survivors.

Lawson gets the Diagnostic and Statistical Manual(DSM) criteria right in terms of the BPD person’s fear of abandonment [“I hate you – don’t leave me!”], volatility of relationships, volatility of emotions, volatility of self-image, self-injurious (para suicidal) behavior, impulsivity and acting out, and physiological symptoms. People have different ways of expressing their suffering and the suffering of the BPD person can be intense, so engaging with them is not for the faint of heart.

One strong point. Lawson’s is perceptive in the use of Christina Crawford’s searing memoire, Mommy Dearest, about Christina’s Academy Award winning movie star mother, Joan Crawford (1905 – 1977). This paints a convincing picture of growing up with and surviving the BPD mother (in this case, Joan Crawford). Once again, such material is not for the faint of heart. It turns out that many Hollywood movie starts are good actors both in front of the camera on stage and off of it. “Acting” is different than “faking,” but to a child of tender age the distinction is not always clear. “All the world is a stage,” but when one is a child of tender age, one cannot simply walk out of the show if one does not like it or is being traumatized by it. The lives of the rich and famous are as susceptible to mental and emotional disorders as anyone.

The criticism? To generalize from the example of the tortured genius of Joan Crawford to the run-of-the-mill perpetrations, self-deceptions and manipulations of the standard, working class BPD mother is to go from the sublime to the ridiculous or at least to tear a passion to tatters. It makes for bad theatre, but then again so does real life. I would have liked to hear more about how Christina and her brother dealt with the worst of the perpetrations and escaped the disorder themselves, even if it did leave them with a pervasive narcissistic vulnerability.

Christina describes an invalidating environment, one of the principle causes of BPD. Yet she retained powers of self-expression and freedom that allowed her to overcome [some of] the worst consequences of her environment. This is not to say she did not suffer. She did. What made a difference? What enabled her to compensate – acquiring the distress tolerance, emotional regulation, and self-soothing skills in which mother was so dramatically lacking? Strange to say, maybe Christina got these life saving skills from the nuns at the religious boarding school where she was sent. No doubt the matter is more complex.

Thus, the help promised in the subtitle “Helping her children transcend the intense, unpredictable, and volatile relationship” is mostly targeted at the grown ups who have survived childhood with a BPD mother. It is not clear what such help would look like for a child of tender age other than to turn to the other parent, relative, or mentor-like friend of the family for the mirroring and recognition needed to acquire skills in emotional regulation, distress tolerance, and self-soothing. In some cases cited by Lawson, the abuses rises to a level at which intervention by the state (Children and Family Services) would be appropriate, though such is sometimes like going from the frying pan into the fire.

For example, Lawson’s examples of the mother who drowned her two children, strapped into their car seats in her SUV (Susan Smith (1994)), and the mother who shot her three children at close range (Diane Downs (1983)). These examples result in the reader feeling vicariously traumatized. I am not saying these are not horrific examples of criminality, insanity, or both. They are. I am saying these examples in the book are symptomatic of Lawson’s rhetorically “over the top” approach. 

DBP is properly distinguished from manic depression (Bipolar I), post partum depression that reaches psychotic proportions, psychopathy, or paranoid schizophrenia. My concern is that Lawson gathers wide-ranging and provocative examples of trauma, deceptions, perpetrations, manipulations, lies, dangerous half-truths, and total nonsense – and attributes them to BPD. BPD is characterized by boundary issues – and violations – and so are the distinctions in this book. 

In short, BPD mother is straight out of Grimm’s fairy tales – now the waif, now the hermit, now the queen, now the wicked witch. Well and good. This is not a treatise on fairy tales; yet Lawson misses the point about the uses of enchantment. To the child who is being weaned, the loving (not BPD!) mother who is temporarily withholding the breast in favor of a Sippy-cup, this standard mother suddenly seems  like the devouring witch. She is now and will be the loving caretaker again once the crisis of weaning has passed, but with an enriched personality that includes both positive and negative aspects instead of the splitting and extremes of early childhood. In short, there is nothing wrong – but something is missing – empathy.

For example, Lawson does a nice job marshaling a nightmare and candidate BPD mother from the ancient Greeks, Euripides’ Medea. When Medea’s faithless husband, Jason, proposes to leave Medea for another woman, the gates of chaos are opened. In revenge, Media kills her children and the other woman. This is perhaps the literary origin of the expression “hell hath no fury like a woman scorned.” From another perspective, a common place exists that when people do not get the empathy or dignity that they feel they deserved, they become enraged. But this takes rage to new, heretofore unprecedented levels. Medea “acts out” her revenge with chilling effectiveness. Medea’s pending loss gets transformed into psychopathic, psychotic, criminally insane rage. Does anyone besides me think that to attribute such perpetrations to BPD would be overstating the case?

One of Lawson’s commitments is to expand the reader’s empathy for the child of a BPD mother. Of course, to the child it is not BPD. It is just behavior that leaves the child bewildered, confused, in semi-shock, or even traumatized. By definition, the diagnosis of BPD cannot be applied to anyone younger than adolescence. Personality disorders usually show up in puberty or adolescence.

The BPD person’s behavior is a study in invalidation, misuse, abuse, emotional disregulation, boundary issues, boundary violations, lack of empathy, lack of recognition, lack of mirroring, lack of response to the child as a whole person, and inconsistent, intermittent, low quality parenting. When the environment is sufficiently invalidating and the child lacks resilience or another sane adult model to help compensate, then the result can indeed be a perpetration of generational BPD.

Ultimately Lawson shocks, shifts, and shakes our complacency about BPD. She may even leave some vicariously traumatized by her narratives of child abuse and boundary issues. However, she fails to enhance our empathy with the BPD person by sensationalizing and “demonizing” the worst excesses of BPD.

I hasten to add that BPD can be described as lying a spectrum with demonic behavior. This is especially so if one is describing BPD from the perspective of the child of tender age. But, once again, that is the issue. The devouring witch of Hansel and Gretel is a representation of the standard mother who is withholding the breast from the child as the latter is being weaned. But the standard mother is usually not suffering from BPD.

The fairy tale narrative informs our empathy with the child. Within the story, the story teller inspires empathy with the children (Hansel and Gretel) such that it seems to them alternatively like a death sentence by starvation, leaving a hunger big enough to eat a house (which is how the children first encounter the gingerbread house). It is of course neither of these, but the narrative enables the grown up empathically to get inside the child’s experience.

The issue with Lawson’s book is that it does not distinguish between BPD, child abuse, and criminality. Yes, BPD mothers’ relationships with their children sometimes cross the boundary between “mere” BPD and even more severe forms of loss of reality testing, psychosis, and sheer insanity. However, BPD is distinct from narcissistic exploitation, manipulation, and criminality. It takes more than BPD to produce the kinds of horrific results that occur when a parent murders her child, but we only hear about BPD as if it were the only “cause.”

No one is endorsing using a child as a narcissistic extension of the parent’s defective grandiosity. The mental health consequences of the latter are severe, especially when occurring habitually. No one is endorsing everyday, run-of-the-mill bad parenting. There is not a lot of good news here. However, all these failings are different than child abuse and criminality.

Lawson rides the slippery slope from perpetrations and emotionally traumatizing behavior all the way down to dehumanization and homicide. Granted it may seem to the survivor of a BPD mother as if she or he were a Holocaust survivor – nor should anyone devalue the suffering of what anyone else had to survive, including the Holocaust – but a significant difference between the two still exists.

Lawson’s best guidance for surviving the BPD mother, whether as a child of tender age or a grown up survivor, may be summarized: set limits, deploy different ways of setting limits to inbound aggression, insist on respect for boundaries, drain the emotion out of emotionally fraught situations, deconstruct upsets, do not personalize accusations, call out “crazy making” behavior. These are all ways of managing manipulation, bullying, emotional perpetration, and so on.  All are easier said than done. 

The most critical remark I can think of? Lawson deploys the main psychological mechanism underlying BPD, splitting, resulting in a black and white representation of the BPD mother – only there is no white. In short, the BPD mother is literally described as a “witch” (as well as a queen, waif, and hermit). This satisfies the definition of “demonization,” both literally and metaphorically.

I am just getting warmed up here. Granted Lawson does not aspire to evidence-based peer-reviewed research. Her argument is narratively and rhetorically strong. However, how is Lawson’s argument that the BPD mother is the cause of the child’s suffering any different than that the “ice box” mother (usually attributed to Bruno Bettelheim (but the matter is debatable)) is the cause of childhood autism?

In both cases, as the mother enters the narrative – or the room – the audience expresses its negative opinion of the mother by breaking out in hisses and boos. Well and good. You have got to blame someone. Blame the mother?! Still, as usual, correlation is not causation; and the correlation is indeed compelling in the case of BPD in the ways that escape the “ice box” mother description.

Lawson documents that the BPD mother enacts a long list of behaviors that are manipulative, perpetrating, and out-and-out boundary violations. This is not disputed. Unacceptable. From the perspective of the child of tender age, the behaviors are particularly appalling.

What Lawson may usefully have acknowledged is people have different way of expressing their suffering. The BPD person’s dramatic, para suicidal behavior – cutting, substance abuse, acting out – inevitably gets our attention. That is the effect of the behavior – it gets our attention. But that is not the reason why the person misbehaves in this way.

The BPD person is trying to regulate her emotions, deal with the distress she is experiencing, or sooth herself. The person is trying to survive her life – survive the distress of the moment. That one can attain emotional equilibrium in an emotional emergency by carving up one’s upper arm with an Exacto knife is hard for the non mental health professional to get one’s head around. Indeed it is hard for anyone to get their head around it; but that is what needs to happen to understand the BPD person.

Lawson properly directs such empathy as is available in the conversation at what the children have to survive. I am not proposing at this late point that Lawson needs to have expanded her empathy for the BPD mother. Rhetorically and narratively that is not in the cards. However, this may be a moment to hate the sin and “love” – or at least provide treatment for – the sinner. That someone ends up in jail for child abuse does not mean that the perpetrator does not need treatment. She does – as does the child.

By the time the survivor of the BPD mother shows up at the door of Lawson’s clinic, it is too late for early intervention. It is too late for empathy lessons in child development. It is too late to teach parenting skills. It is too late. Period.

Still, I came away persuaded, identifying and devaluing the BPD mother as the cause of the survivor’s suffering, too – fully enrolled in Lawson’s project and interpretation. However, what did not happen was creating a space of validation, toleration and acceptance in order to engage the tough issues of recovery, transformation, change, and mourning one’s losses.

Borderline personality disorder remains stigmatized even today. Lawson’s account does nothing to remove the stigma, and, in several ways, reinforces it with devaluing labels such as “witch.” Once again, I hasten to add there is no excuse for bad behavior on the part of anyone, including BPD persons or those committed to treating them.

Truth and reconciliation commissions are in short supply in the political world; and, likewise, such is the case in the milieu of psychotherapeutic treatment. Rare is the instance in which a BPD mother says, “I did it – I was the perpetrator – no excuses – I was a shit. This is what happened [….]” And the survivor then gets to say whether or not she accepts that as the truth and can go forward on that basis. However, I would have appreciated Lawson’s at least calling out the value of such interventions in the context of community mental health – prior to referring the subjects and survivors to Dialectical Behavioral Therapy.

REFERENCES

[1] Christine Ann Lawson, (2004), Understanding the Borderline Mother: Helping Her Children Transcend the Intense, Unpredictable, and Volatile Relationship. New York: Rowan and Littlefield. 330 pp. $46.92 [“free” Audiobook with (Amazon) Audible Subscription].

[2] Heinz Kohut, (1971), The Analysis of the Self. New York: International Universities Press.

[3] Marsha M. Linehan, (1993), Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.

© 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