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Online therapy now. This is the time.

If ever there was a time for online (tele/cyber) talk therapy, this is it.

In case you were trekking through Tibet or living in a cave with Buddhist monks, allow me to clarify why. Key term: social distancing.

It is not that anyone who is sick or symptomatic would knowingly go to an in-person

Cover art: Theory and Practice of Online Therapy, eds., Weinberg and Rolnick

Cover art: Theory and Practice of Online Therapy, eds., Weinberg and Rolnick

therapy session anyway, nor does one have to avoid mass transit or public taxis or garage attendants (who may park one’s auto while coughing on the steering wheel). Reasonable accommodation works well. Yet just because you have a germ phobia or are getting clinically paranoid does not mean you cannot get physically ill!

Therefore, keep calm – and carry on – I mean: wash your hands!

Okay, this is not funny. The lesson? Psychotherapy 101 teaches us that the most fearsome thing is – the unknown.

You know how in the vintage black and white monster movies, once you actually see the guy dressed up as Swamp Thing, it is a lot less scary? The creature may still be disgusting, but it is no longer nearly as scary? The scary part is when the heroine is innocently combing her hair and the swamp thing (which is “off camera” and the audience cannot yet see) is silently sneaking up behind her.

You know that scenario? Well, that’s what we’ve got here with the World Health’s Declaration of a pandemic. I will not further comment on the details as numerous resources are available from WHO and the Center for Disease Controls, frequently updated as we learn more and more about what to do or not do.

Just as many businesses, schools, colleges, universities are working remotely – that is, online – for example, delivering a webcast online, clients and therapist may leverage the convenience and social distancing of online therapy for their therapy sessions. One can also apply the lessons of social distancing in an in-person office setting, but it has to be a reasonably large office (which I do have) about the distance of two sneezes across. However, that is not what I am talking about here. What am I talking about? Download a video telecommunication application (function) such as Zoom (this is just an example, not a product endorsement), which reportedly uses encryption. Then review the instructions or call the Help Desk (which I am not operating for purpose of this post).

I cut to the chase. Here are two lessons learned since I originally published this post about online (cyber) therapy in September 13, 2019.

First, an online session presents new opportunities for the equivalent of slips of the tongue. There was one individual with whom the occurrence of the word “mother” was inevitably followed by the Internet connection freezing up, requiring a restart. You can’t make this stuff up. After I called it out, he stopped messing with the volume controls, which seemed to have occasioned pressing the wrong button. Therefore, in an empathic space of acceptance and toleration, the therapist may reasonably provide understanding, accommodation, and some extra time to reinforce and support relatedness.

Next, I can see many psychiatrists, psychologists, and clinical social workers with contracts with insurance companies getting stressed because insurers generally resist paying [will not pay] for tele-consultation (or will do so only (say) in Alaska where there is no other provider within 200 miles).

That is definitely an issue; and it will not be solved here. It may require an act of Congress to curb expanding monopoly rents on the part of insurers during a national crisis, and I would be in favor of such action. It is true (as far as I know) that one cannot take someone’s blood pressure over Skype, though I would not rule out some innovator coming up with an attachment that connects to the computer’s USB. In any case, I am not holding my breath, and I am continuing to expand my online empathy consulting practice, since – how shall I put it delicately? –  my relationship with insurers is actually more than a distance of two sneezes across and, in many cases, breaks down in that an empathy deficiency is not [properly speaking] a medical diagnosis.

Update: March 17, 2020: This just in from The Washington Post: “Medicare expands telemedicine to allow seniors to get virtual care at home” [https://www.washingtonpost.com/world/2020/03/17/coronavirus-latest-news/#link-FAF2A2J73BDH3FH6GUHMGM5OSE] This is progress – and it is about time!

Meanwhile –

Meanwhile –

The following was published on September 13, 2019 and is repeated here as highly relevant to our current wellness challenges.

The genie is out of the bottle. The day that the first therapist invited his one-on-one client (who had an urgent need for a conversation but an inability to get to the office) to put down the phone and dial into Skype, the genie escaped from the bottle.

The reader will recall that in the 1001 Arabian Nights the Genie was very powerful but a trickster and nearly impossible to control. Making wishes is tricky, and if one is not careful, the sausages end up stuck to one’s nose and one must waste the last wish to get them off. In this case, the Genie is Internet technology such as Skype and Google Groups and the emerging conveniences, affordances, complexities, entanglements, and even resistances that it offers.

In the Arabian Nights, the hero, Aladdin, had to trick the Genie to getting back in the bottle by appealing to his narcissism. “You are not all powerful,” Aladdin said. “A large creature like you could not possibly fit in that small bottle!” The Genie’s wounded narcissism caused him to prove that he can indeed fit back in the bottle. Aladdin puts the stopper back on – trapped! However, in the case of the Internet and online communication tools, do not look to be able to turn back the clock.

But there is good news. The human face is an emotional hot spot. It is rich in micro-expressions many of which are available and visible even though the “real estate” on the screen in less rich in detail than an in-person experience. Indeed it is not even clear that the face as presented online is “less rich.” It is the only thing being displayed, and the viewer is led to concentrate on it in detail. But here the trade-off of bodily presence versus the imaginary comes into the foreground.

The criticism fails that the online conversation between persons lacks the reality of the in-person encounter. But this criticism fails, in a surprising way. The criticism fails not because the online media is so real. Rather the criticism fails because the in-person psychotherapy encounter is shot through-and-through with the imaginary, with symbolism, the imaginary and irreality. The “irreal” includes the symbolic, the imagined, the fictional, the part of reality which is distinct from the real but includes the past and the future and the imaginary, which are not really present yet influence reality.

In psychotherapy, the in-person encounter is precisely about the symbolic and the imagined – the transference. The basic definition of “transference” is that the person relives emotionally the relationship to objects (persons) from the past, persons who are not physically present in the room (or in the virtual space online).

What we are calling the “virtuality” of the technology media adds an additional dimension of irreality to the symbolic and imagined transference relationship. Yes, the media is the message (as Marshall McLuhan famously wrote), but with the arrival of online therapy the media is first and foremost the transference. The message now occurs with a strike-through, message.The online technology itself becomes a source and target of transference.

The one thing that immediately occurred to me: Psychotherapy invokes a virtual reality all of its own – even without cyber space. This is especially the case with dynamic psychotherapy that activates forms of transference in which one relates to the therapist “as if” in conversation with a past or future person or reality, the latter not physical present. Indeed, with the exception of being careful not to step in front of a bus while crossing the street on the way to therapy, we are usually over-confident that we know the reality of how our relationships work or what people mean by their communications. This is less the case with certain forms of narrowly focused behavioral therapies, which are nevertheless still more ambiguous than is commonly recognized. Never was it truer that meaning – and emotions such as fear – are generated in the mind of the beholder.

While virtual reality (VR) goggles as such are not a part of any online therapy group process, VR goggles are currently being used in individual psychotherapy with clients who are dealing with phobias and related individual issues.

[See www.psious.com– an engaging start up which is promoting the VR goggles for psychotherapists. The author (Lou Agosta) reports: I have no financial relationship with this company, and I wrote a blog post in 2016: “A Rumor of Empathy at Psious”: https://tinyurl.com/jyuxedq]

For example, it is much easier for someone with a fear of flying to put on a set of VR goggles in the therapist’s office and take a virtual trip to the airport, board an airplane (in VR), and be taxing down the run away (in VR), than it is to do this in the real world. The next step in a group process is to create an avatar that resembles one’s individual physical self, warts and all, and to join the other avatars in an online virtual reality group session. New possibilities are opened up by this form of therapy for dealing with all kinds of emotional and mental issues that are beyond the scope of this article.

Here the point is just to look at how virtual reality (“virtuality”) already lives in the in-person psychotherapy session even as it might have been conducted in 1905.  There is a strong sense in which the conversation between a client and a psychodynamic therapist already engages a virtual reality, even when the only “technology” being used is a conversation is English or other natural language.

For example, when Sigmund Freud’s celebrated client, Little Hans, developed a phobia of horses, Freud’s interpretation to Hans’ father was that this symbolized Hans’ fear of the father’s dangerous masculinity in the face of Hans’ unacknowledged competitive hostility towards his much loved father. The open expression of hostility was unacceptable for so many reasons – Hans was dependent on his father to take care of him; Hans loved his father (though he “hated” him, too, in a way as a competitive for his mother’s affection); and Hans was afraid of being punished by his father for being naughty. So Hans’ hostility was displaced onto a symbolic object, the horse. Hans’ symptoms (themselves a kind of indirect, “virtual reality” expression of suffering) actually gave Hans power, since the whole family was then literally running around trying to help him and consulting “The Professor” (Freud) about what was going on. In short, the virtual reality – now remove the quotes – made present in the case is that the horse is not only the horse but is a virtual stand-in for the father and aspects of the latter’s powerful masculinity.

So add one virtual reality of an imagined symbolic relatedness onto another virtual reality of a simulated visual reality (VR) scenario, the latter contained in a headset and a smart phone. Long before VR technology, therapists of all kinds, including behaviorists, used VR by activating the client’s imagination by asking him or her to imagine the getting on the feared airplane. One may try to escape virtual reality by not going online, but the virtuality follows as long as human beings continue to be symbolizing, imagining creatures.

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

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

The Theory and Practice of Online Therapy: Internet-delivered Interventions for Individuals, Groups, Families, and Organizations, eds., Haim Weinberg and Arnon Rolnick, published by Routledge:

Table of Contents

Acknowledgments

Introduction to the book Haim Weinberg and Arnon Rolnick

Section 1 General considerations for online therapy edited by Haim Weinberg and Arnon Rolnick

Chapter 1 Introduction to the general consideration section: principles of internet-based treatment Arnon Rolnick

Chapter 2 Interview with Lewis Aron and Galit Atlas

Chapter 3 Empathy in Cyberspace: the genie is out of the bottle Lou Agosta

Chapter 4 Sensorimotor psychotherapy from a distance: engaging the body, creating presence, and building relationship in videoconferencing Pat Ogden and Bonnie Goldstein 

Chapter 5 The clinic offers no advantage over the screen, for relationship is everything: video psychotherapy and its dynamic Gily Agar

Chapter 6 Cybersupervision in psychotherapy Michael Pennington, Rikki Patton and Heather Katafiasz

Chapter 7 Practical considerations for online individual therapy Haim Weinberg and Arnon Rolnick

Secion 2 Online couple and family therapy edited by Shoshana Hellman and Arnon Rolnick

Chapter 8 Introduction to the online couple and family therapy section Shoshana Hellman and Arnon Rolnick

Chapter 9 Interview with Julie and John Gottman

Chapter 10 Internet-delivered therapy in couple and family work Katherine M. Hertlein and Ryan M. Earl 

Chapter 11 Digital dialectics: navigating technology’s paradoxes in online treatment Leora Trub and Danielle Magaldi 

Chapter 12 Practical considerations for online couple and family therapy Arnon Rolnick and Shoshana Hellman 

Section 3 Online group therapy edited by Haim Weinberg

Chapter 13 Introduction to the online group therapy section Haim Weinberg

Chapter 14 Interview with Molyn Leszcz

Chapter 15 Online group therapy: in search of a new theory? Haim Weinberg 

Chapter 16 Transformations through the technological mirror Raúl Vaimberg and Lara Vaimberg 

Chapter 17 Practical considerations for online group therapy Haim Weinberg 

Section 4 Online organizational consultancy edited by Rakefet Keret-Karavani and Arnon Rolnick

Chapter 18 Introduction to the online organizational consultancy section Rakefet Keret-Karavani and Arnon Rolnick

Chapter 19 Interview with Ichak Kalderon Adizes

Chapter 20 All together, now: videoconferencing in organizational work Ivan Jensen and Donna Dennis

Chapter 21 A reflexive account: group consultation via video conference Nuala Dent 

Chapter 22 Practical considerations for online organizational consultancy Rakefet Keret-Karavani and Arnon Rolnick 

Epilogue Arnon Rolnick and Haim Weinberg

 

 

 

Book Review: Psychiatry Under the Influence by Whitaker and Cosgrove – Follow the Money

Book Review: Robert Whitaker and Lisa Cosgrove. (2015). Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform. New York and the UK: Palgrave Macmillan. 241 pp. [$33.81 – less if digital]

This is an important book that deserves to be better know, since the consequences of the

Psychicatry Under the Influence by Whitaker and Cosgrove (Cover Art)

Psychicatry Under the Influence by Whitaker and Cosgrove (Cover Art)

self-dealing and conflicts of interest that it documents have not been reversed. This book points powerfully to a post-psychiatry future for individual psychiatric practitioners of integrity, navigating a way carefully between anti-psychiatry and a problematic institutional framework which has failed patients and most providers alike. The authors, Robert Whitaker and Lisa Cosgrove, spent a year at the Harvard Edmund J. Safra Center for Ethics. This work on the American Psychiatric Association (APA) is the result.

Though psychiatric “thought leaders,” principal investigators, researchers, and fellow travellers are now required to disclose the financial fees they receive from pharmaceutical corporations as the result of reforms, the consequences of several decades of self-dealing and conflicts of interests have been embedded in clinical practice guidelines (CPG). Fast forward the five years since this book was originally published and, not withstanding enhanced transparency, the band plays on.

As of this writing (Q1 2020), the APA is still going forward with significant momentum and merely modestly diminished revenues – and, therefore, merely modestly diminished economics of influence and conflicts of interest. The lack of action on the part of health care consumers, insurers, governmental regulators and legislators, indicates that Whitaker and Cosgrove are either being not believed or simply ignored.

My take on it? Whitaker and Cosgrove have a good chance of being prophets like Cassandra, the Trojan visionary and seer. Remember Cassandra was the seer whose curse was to always see and tell the truth but not be believed. Her partners threw a spear against the side of the Trojan Horse – a gift from the Greeks – and it rang hollow – thump – because the bad guys were hiding inside the hollow horse. Cassandra tried to warn her countrymen about Greeks bearing “gifts,” but Cassandra was not believed; and, in the story, a large snake ate her partners [I’m not making this up], so the trick of the Trojan Horse worked; the Greeks breached the impregnable walls of Troy; and Troy was burned to the ground.

I find it hard to accept that anyone who reads Whitaker and Cosgrove’s book would not be persuaded by the detailed marshaling of facts and figures. Therefore, the suspicion is that it is not being read. It is being overlooked. It is not too late to turn that situation around. Hence, this review.

If one were to summarize Whitaker and Cosgrove’s work in a single sentence, it would be: Whitaker and Cosgrove document institutional self-dealing in the form of conflicts of interest and the influence of big money from big pharma, which have decisively and irreversibly compromise the ability of the American Psychiatric Association (APA) to support and promote the health and well-being of patients. (Not to put to fine a point on it, the self-dealing and conflicts of interest are the definition of “corruption.”)

Whitaker and Cosgrove emphasize contextual and systematic explanations rather than bad actors, bad characters, or bad guys. As they say, it is not a matter of bad apples, but the barrel itself has gone bad.

I have searched to see if any of the targets of institutional corruption have tried to answer the charges, which, frankly, I found well-documented, compelling, a source of indignation, and, upon reflection, deeply distressing.

I found only one attempt to answer Whitaker and Cosgrove from D. J. Jaffe who claims the defects of the DSM-5 are widely known and discounted, the errors of the past have been (or are being) corrected, and Whitaker and Cosgrove are distorting and sensationalizing: “For example, the authors spend multiple pages examining the efficacy of a particular class of depression medicines, SSRIs, and find them wanting. But buried in the text is the line it “was only for severely depressed patients…that the SSRIs had provided a benefit.’” (For Jaffe’s review see: https://tinyurl.com/u7jvrmm.)

The quotation Whitaker and Cosgrove is accurate as far as it goes, but Jaffe is not accurate on the use of this data point. It is not ”buried”; but called out multiple times. Nor are the other defects and errors of the past been reversed, though they have been called out a number of times. The ineffectiveness of such denunciations and the anti-psychiatry movement leads Whitaker and Cosgrove to suspect that the problem is not one of a few (or even many) “bad apples.” The problem is an institutional one and must be addressed at that level.

Whitaker and Cosgrove’s point (contra Jaffe) is that the APA, Big Pharma, and selected researchers consulting to them have undertaken a largely successful marketing campaign: the science of medicine now knows the cause of depression (and other mental illnesses) and has a cure.

Most patients still comes in saying, “I feel depressed – I think I have a chemical imbalance – help me.” The doctor is, of course, helpful – with her or his prescription pad. Yet one theory after another has been exposed as “not proven” – the caricature of the Freudian unconscious, inflammatory cytokines, and the chemical imbalance theory.

The prescription for an antidepressant, mood stabilizer, antipsychotic, or anxiolytic, is going to work in far fewer instances – see below about major mental illness – than patients, front line MDs, and most residents in psychiatry have been led to believe. And this is 5 years after the publication. People are not reading this book, though, I submit, they may usefully do so.

The APA – and those who align with the educational (i.e., marketing) program – are not just “over sold.” They are engaging in ethically problematic practices. It is not just a bad apple, the barrel itself has a problem – the barrel itself is bad. After Whitaker and Cosgrove work, the debate is not about whether institutional corruption has occurred – the documentation is both boring and overwhelming – the debate is about what to do about it. No easy answers here.

When Whitaker and Cosgrove write about the “guild interests” of the American Psychiatric Association (APA), I was taken aback. Are the authors making matters sound like the Teamster’s back in the day when Jimmie Hoffa was running the organization? Hmmm. Whitaker and Cosgrove are surgically austere in their citing of facts and figures – which principal psychiatric investigators were also “thought leaders” working for Big Pharma.

Though Whitaker and Cosgrove are not explicit about this, an argument can be made that the APA gives the Teamsters a bad name. The latter has been required to “clean up its act,” thanks to criminal investigations by large governmental organizations. In contrast, most health care consumer remains relatively uninformed (excepts for this book (and a few others like it)) that the APA would expand diagnostic boundaries in a way that served commercial interests. This is called the APA’s “guild interest,” making money for psychiatrists independent of conflicts with the commitment unconditionally to promote patient health and well-being.

This is a particularly tangled issue in the case of psychiatry – as opposed to other medical specialties – in that psychiatry does not have biological markers such as blood tests (and so on) to identify the diseases and disorders it treats.

“In most other medical specialties, diagnoses are bounded by biological markers, and thus outcomes can be more easily quantified. Does a treatment reduce the size of a tumor? Lower blood pressure? Reduce cholesterol? Reduce or eliminate a virus? And so forth. However, in psychiatry, there are no biological markers that separate a patient with a “disease” from someone without, which renders psychiatry more vulnerable to bias, since it relies more heavily on subjective judgments for making diagnoses and assessing symptoms” (p. 139).

This leaves psychiatry vulnerable to commercial influences when making decisions about diagnoses, treatments, and professional relations (p. 115).

Yes, there is a molecular process hypothesized to exist for every disease entity, we just have no determinate, firm scientific idea what it is in the case of schizophrenia, depression, substance abuse, obsession, personality disorders, and so on. Yes, science is expanding our knowledge of brain processes, endocrinology, and biochemistry at an encouraging rate. But we know the cause of diabetes – lack of insulin. We know the cause of tuberculosis – the specific pathogen. Not so with mental illness, though a biological component looms large along with adverse childhood experiences, trauma, issues of poverty, social justice, domestic violence, access (or lack thereof) to education, jobs, housing, and recreation.

Science speculates and hypothesizes that depression (and so on) is determined in important ways by an imbalance of certain neurotransmitters such as serotonin, dopamine, and norepinephrine. Chemicals up, chemicals down – the influence on behavior, symptoms, and reports of human suffering are such that we are still trying to connect the dots. Human beings have different ways of expressing their suffering the symptoms of which have been collected in the Diagnostic and Statistically Manual, now in its 5th edition. That leaves a lot of wiggle room for human beings to be human beings and game the system.

The example I find most telling – and use with my third year medical students – is as follows: medical treatment can cure person if they have pneumonia and are unconscious in a coma; but that is not the case with substance abuse disorder. “Curing” substance abuse is a matter of body and mind. The patient must be conscious and participate like a commitment in the process. (For those who may have been living in a cave, substance abuse is now considered a disease, thus eliminating the stigma of a moral failing and opening the way to an unbiased, evidence-based approach to treatment.)

Another data point that was eye opening and needs to be better known:

“The NIMH [National Institute for Mental Health] also funded a trial that compared Zoloft to Zoloft plus exercise and to exercise alone, and at the end of ten months, 70 percent in the exercise-alone group were well, compared to fewer than 50 percent in either of the groups treated with Zoloft.19 At least in this study, Zoloft appeared to detract from the benefits of exercise” (p. 122).

Gone are the days when, if I feel the need to work out, I will lie down until it passes.

All of the psychiatrists that I know – and I know quite a few because of my empathy consulting – are dedicated, committed and hard working. No exceptions. The challenge arises when the marketing myth that mental illness is caused by a chemical imbalance gets embedded in the clinical practice guidelines (CPG).

Even though many psychiatrists are properly skeptical from an evidence-based perspective about the universality of this narrative, there are perceived medical risks in deviating from the CPG if treatment goes off the rails for unrelated reasons. It is truly a rock and a hard place scenario.

In addition, marginally informed prospective patients come in and say, “Hey, give me the medicine.” They have a sufficiently compelling narrative, sometimes gleaned from searching the diagnostic criteria on Google to validate the checklist. Rarely do they say, “I want to do the hard work it takes to change my life step-by-step, one conversation at a time, one bullet on my resume at a time, one relationship at a time.” It is deeply cynical and elitist but trending, “Show the people the light, and they will follow it anywhere!”

Here “the light” looks like: “It is just a chemical imbalance.” Millions of dollars, heck, maybe billions when the indirect expenses are included, were invested by the APA, Big Pharma, and their fellow travellers, to embed the idea: “It is just a chemical imbalance.”

One cannot just reduce ties with Big Pharma by rules about disclosing financial payments (which still occur) and expect the idea of mental illness as a chemical imbalance spontaneously to evaporate from the community at large where it is well-entrenched.

One needs a equally extensive educational program to challenge, root out, and transform the inaccuracies – but this time actual education, not marketing – to inform people of the complexity, nuances, and values involved. I see no such program in the offing, though it would be useful to require one perhaps as tobacco companies were required to advertise the consequence of smoking. The black box warning on Paxil (paroxetine) and selected other medications that it may induce suicidal ideation in children under 18 years of age is a start, but hardly a solution to the institutional issues documented here.

In section after section, I come away saying the medical literature, press releases, and marketing collateral are just flat out making stuff up. It is fake news before fake news was invented or at least became a top of mind consideration. It was marketing, not science. A sample is useful:

“[…][T]he FDA has assessed the merits of 31 studies for these four drugs [Celexa, Paxil, Prozac, and Zoloft], and even with the FDA’s charitable standards for determining that a study was ‘positive’ – it would often allow the company to sort through the data in a post-hoc analysis, to find a positive outcome – only 14 were positive. There were 14 others that were negative, and three more that were questionable. However, the published literature related to those 31 studies told of 19 positive outcomes and two negative ones” (p. 76)

“The medical literature simply didn’t reflect, in any meaningful way, what clinical trials had revealed about the efficacy of the four drugs, and this was just the tip of the iceberg. Ghostwritten papers from post-marketing studies also filled psychiatric journals, with these repots regularly telling of the drug’s efficacy, and this ghostwriting practice became so accepted that SmithKline Meacham, as it marketed Paxil, organized a campaign called “Case-Study Publications for Peer Review,” which it wittily dubbed CASPPER, mindful of television’s friendly ghost” (p. 76).

Once again, great marketing, but more than a tad short of scientific validity.

The authors go through a similar drill for other classes of medicines – attention deficit medicine, mood stabilizers, and antipsychotics. Though the details are different, the bottom line is similar.

The assessment of the authors? “Within the conceptual framework of institutional corruption, the pharmaceutical industry could be said to have ‘captured’ academic psychiatry and the APA as it tested and marketed the SSI antidepressants” (p. 77).

What was supposed to have been the Gold Standard in determining the efficacy of antidepressant medications produced disappointing results. But these sometimes negative results got embedded in complex statistical tables without explanations. A favorable spin was put on the outcomes using data mining and 20-20 hindsight.

Since this was a National Institute of Mental Health the STAR-D (Sequenced Treatment of Alternatives to Relieve Depression, psychologist Ed Pigott was able to file a “freedom of information” request to get the raw data. Some in the profession suggest this is widely known, but most consumers of psychiatric services do not know it, nor are they informed by their medical doctors (many of whom also do not know it). The results were different than those emphasized in the publications:

“[…] [I]f the protocol had been followed, 38 percent (1,192 out of 3,110) would habe been reported as remitted [free of symptoms] during this acute phase of the study (after all four rounds of treatment) [….] [A]nd if the readers got out their calculators they could discover that 568 of the 1,518 patients who entered the follow-up phase in remission had relapsed. This indicated that 950 patients – or 63 percent – had remained well” (p. 126)

Now we can debate how these data are sliced and diced, but nothing like a 6.3 % long term “cure” rate is EVERdiscussed with patients by providers contemplating SSRIs when quoting this study. That is not because providers are withholding data; it is because the providers do not know about it. It is buried.

John Rush, MD, psychiatrist at Texas Southwestern Medical Center in Dallas, reported his results: “Only 26 percent of the real-world patients responded to the antidepressant during the first year of treatment (meaning their symptoms decreased by at lest 50 percent on a rating scale), and only half of that group had a “sustained response.” Even more dispiriting, only 6 percent of the patients saw their depression fully remit and stay away during the year-long study. These ‘findings reveal remarkably low response and remission rates,’ Rush concluded” (p. 122).

Whitaker and Cosgrove make the case that the APA has been demonstrably unable to self-regulate – “police” itself – over the past three decades. The conclusion is that, therefore, others will have to provide the external regulation that has been missing internally.

The APA is not suddenly going to see the light and start urging its members to clear the schedule and engage in talk therapy with their light or moderately depressed patients instead of summarily reaching for the prescription pad as the default and acting in the face of evidence-based research, the opposite of which, however, has been built into “evidence-based” practices – this time in scare quotes – thanks to an intricate tangle of self-dealing and conflicts of interest spanning decades. It boggles my mind how this mess was created; and it is hard to see any way out, much less an easy one, which is precisely what the APA is counting on.

Thus, I believe that Whitaker and Cosgrove have “given up” on institutional psychiatry (the APA) and with cause:

“[…][T]he APA is already taking steps to ‘re-engage with pharma,’ and is doing so with little apparent appreciation that psychiatry was compromised in a significant way by its close ties to industry. Nor is there any evidence that the APA and academic psychiatry are aware that guild influence have proven to be so corrupting” (p. 199).

Here “guild influences” refer to commitment to expanding the population of diagnosable people – shyness is now “social anxiety,” boisterous kids being kids have “attention deficit,” normal sadness due to life setbacks is “major depression,” more forgetful senior citizens dealing with “mild” neurocognitive disorder, having a diagnosis for every medicine and a medicine for every diagnosis. These issues are supposedly well-know and are being addressed. I have not seen any evidence that is so. It is “baked into” the clinical practice guidelines to offer medications as first line treatments.

Since this is not a softball review, you see the issue. This stuff is dry as dirt and it takes significant effort to disentangle the details. Of course, Whitaker and Cosgrove do that, but it raises the bar on engaging the average health care consumer to expect her or him to follow the argument.

Whitaker’s earlier debunking was equally well documented in its time (see Mad in America), but criticized for being sensational. It was. But it was also accurate. I hasten to add that “sensational” is different than “sensationalism.” Here the conclusions are sensational, too, and they are well-argued, thoroughly documented, and, therefore, all the more dramatic for being understated.

Here the writing is toned-down and befits the neutral, mostly emotionless language of a scientific journal – or the Harvard Edmund J. Safra Center for Ethics. And so the authors get “dinked” with being “boring.” It is truly a case of “no good deed goes unpunished.”

No individual psychiatrist can fix this mess. Having psychiatrists transparently declaring their financial ties to funding organizations as the APA has agreed to do just does not fix the problem, though it does make clear the depth of the influences. Why not? People (and psychiatrists are people) have blind spots and conclude that most other people have a conflict of interest, but the money does not bias me (the psychiatrist in question). Cognitive dissonance causes the individual to make exceptions for themselves.

This is highly ironic because psychiatry was the discipline that promoted the notion in the 1950s through 1980s of the Freudian unconscious as a motivated blind spot. Indeed, even today, if a person takes an implicit bias test as required by many corporate diversity and inclusion programs, virtually everyone is found to have biases – biases against smokers, overweight people, bald people, old people, young people, poor people, rich people, political people, as well as more stereotypical racial and ethnic prejudices. Blind spots are pervasive among human beings as a species. Yet psychiatrists do not have blind spots when it comes to favoring funders who give them money? Hmmm.

Whitaker and Cosgrove conclude that individuals within organized psychiatry are in principle unaware that their behavior has been ethically compromised because such behaviors have become normative – required – within the institution.

Still, there is one instance in which disclosure does work: if it provides the individuals with incentive to free themselves from such ties because of the perceived devaluing cost to one’s societal and professional standing. Don’t hold your breath.

The postpsychiatry future moves beyond the psychiatry versus anti-psychiatry debate. The future belongs to postpsychiatry. Whitaker and Cosgrove conclude that a paradigm shift is required. Take seriously the bio-psycho-social model of the mind and body. Physicians have an important role to play, since biology is involved. We are neurons “all the way down.” However, the neurons then generate consciousness, language, and community.

It is also necessary to include in the team psychologists, social workers, philosophers of mind, and ethicists, that address the kind of life issues that drive people crazy. It is not a conclusion that a medical doctor would be in charge of such a team, outside the biological component of such a group. And that is the conclusion likely to raise hackles and not only at the APA. Ultimately the individual consumer of services is in charge of her- or his own life and well-being. The informed consumer of services – whether medical services, life transformational services, emotional guidance, and so on – needs to be in charge of the team. But in the meantime, as philosopher kings are still in short supply, any adult able to provide grown up supervision will do.

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

Online [cyber] therapy: The genie is out of the bottle

The genie is out of the bottle. The day that the first therapist invited his one-on-one client (who had an urgent need for a conversation but an inability to get to the office) to

CoverArt:Theory and Practice of Online Therapy ed. Haim Weinberg and Arnon Rolnick

CoverArt: Theory and Practice of Online Therapy ed. Haim Weinberg and Arnon Rolnick

put down the phone and dial into Skype, the genie escaped from the bottle.

The reader will recall that in the 1001 Arabian Nightsthe Genie was very powerful but a trickster and nearly impossible to control. Making wishes is tricky, and if one is not careful, the sausages end up stuck to one’s nose and one must waste the last wish to get them off. In this case, the Genie is Internet technology such as Skype and Google Groups and the emerging conveniences, affordances, complexities, entanglements, and even resistances that it offers.

In the Arabian Nights, the hero, Aladdin, had to trick the Genie to getting back in the bottle by appealing to his narcissism. “You are not all powerful,” Aladdin said. “A large creature like you could not possibly fit in that small bottle!” The Genie’s wounded narcissism caused him to prove that he can indeed fit back in the bottle. Aladdin puts the stopper back on – trapped! However, in the case of the Internet and online communication tools, do not look to be able to turn back the clock.

But there is good news. The human face is an emotional hot spot. It is rich in micro-expressions many of which are available and visible even though the “real estate” on the screen in less rich in detail than an in-person experience. Indeed it is not even clear that the face as presented online is “less rich.” It is the only thing being displayed, and the viewer is led to concentrate on it in detail. But here the trade-off of bodily presence versus the imaginary comes into the foreground.

The criticism fails that the online conversation between persons lacks the reality of the in-person encounter. But this criticism fails, in a surprising way. The criticism fails notbecause the online media is so real. Rather the criticism fails because the in-person psychotherapy encounter is shot through-and-through with the imaginary, with symbolism, the imaginary and irreality. The “irreal” includes the symbolic, the imagined, the fictional, the part of reality which is distinct from the real but includes the past and the future and the imaginary, which are not really present yet influence reality.

In psychotherapy, the in-person encounter is precisely about the symbolic and the imagined – the transference. The basic definition of “transference” is that the person relives emotionally the relationship to objects (persons) from the past, persons who are not physically present in the room (or in the virtual space online).

What we are calling the “virtuality” of the technology media adds an additional dimension of irreality to the symbolic and imagined transference relationship. Yes, the media is the message (as Marshall McLuhan famously wrote), but with the arrival of online therapy the media is first and foremost the transference. The message now occurs with a strike-through, message.The online technology itself becomes a source and target of transference.

The one thing that immediately occurred to me: Psychotherapy invokes a virtual reality all of its own – even without cyber space. This is especially the case with dynamic psychotherapy that activates forms of transference in which one relates to the therapist “as if” in conversation with a past or future person or reality, the latter not physical present. Indeed, with the exception of being careful not to step in front of a bus while crossing the street on the way to therapy, we are usually over-confident that we know the reality of how our relationships work or what people mean by their communications. This is less the case with certain forms of narrowly focused behavioral therapies, which are nevertheless still more ambiguous than is commonly recognized. Never was it truer that meaning – and emotions such as fear – are generated in the mind of the beholder.

While virtual reality (VR) goggles as such are not a part of any online therapy group process, VR goggles are currently being used in individual psychotherapy with clients who are dealing with phobias and related individual issues. [See www.psious.com– an engaging start up which is promoting the VR goggles for psychotherapists. The author (Lou Agosta) reports: I have no financial relationship with this company, and I wrote a blog post in 2016: “A Rumor of Empathy at Psious”: https://tinyurl.com/jyuxedq]

For example, it is much easier for someone with a fear of flying to put on a set of VR goggles in the therapist’s office and take a virtual trip to the airport, board an airplane (in VR), and be taxing down the run away (in VR), than it is to do this in the real world. The next step in a group process is to create an avatar that resembles one’s individual physical self, warts and all, and to join the other avatars in an online virtual reality group session. New possibilities are opened up by this form of therapy for dealing with all kinds of emotional and mental issues that are beyond the scope of this article.

Here the point is just to look at how virtual reality (“virtuality”) already lives in the in-person psychotherapy session even as it might have been conducted in 1905.  There is a strong sense in which the conversation between a client and a psychodynamic therapist already engages a virtual reality, even when the only “technology” being used is a conversation is English or other natural language.

For example, when Sigmund Freud’s celebrated client, Little Hans, developed a phobia of horses, Freud’s interpretation to Hans’ father was that this symbolized Hans’ fear of the father’s dangerous masculinity in the face of Hans’ unacknowledged competitive hostility towards his much loved father. The open expression of hostility was unacceptable for so many reasons – Hans was dependent on his father to take care of him; Hans loved his father (though he “hated” him, too, in a way as a competitive for his mother’s affection); and Hans was afraid of being punished by his father for being naughty.

So Hans’ hostility was displaced onto a symbolic object, the horse. Hans’ symptoms (themselves a kind of indirect, “virtual reality” expression of suffering) actually gave Hans power, since the whole family was then literally running around trying to help him and consulting “The Professor” (Freud) about what was going on. In short, the virtual reality – now remove the quotes – made present in the case is that the horse is not only the horse but is a virtual stand-in for the father and aspects of the latter’s powerful masculinity.

So add one virtual reality of an imagined symbolic relatedness onto another virtual reality of a simulated visual reality (VR) scenario, the latter contained in a headset and a smart phone. Long before VR technology, therapists of all kinds, including behaviorists, used VR by activating the client’s imagination by asking him or her to imagine the getting on the feared airplane. One may try to escape virtual reality by not going online, but the virtuality follows as long as human beings continue to be symbolizing, imagining creatures.

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

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

The Theory and Practice of Online Therapy: Internet-delivered Interventions for Individuals, Groups, Families, and Organizations, eds., Haim Weinberg and Arnon Rolnick, published by Routledge:

Table of Contents

Acknowledgments

Introduction to the book Haim Weinberg and Arnon Rolnick

Section 1 General considerations for online therapy edited by Haim Weinberg and Arnon Rolnick

Chapter 1 Intoduction to the general consideration section: principles of internet-based treatment Arnon Rolnick

Chapter 2 Interview with Lewis Aron and Galit Atlas

Chapter 3 Empathy in Cyberspace: the genie is out of the bottle Lou Agosta

Chapter 4 Sensorimotor psychotherapy from a distance: engaging the body, creating presence, and building relationship in videoconferencing Pat Ogden and Bonnie Goldstein

Chapter 5 The clinic offers no advantage over the screen, for relationship is everything: video psychotherapy and its dynamic Gily Agar

Chapter 6 Cybersupervision in psychotherapy Michael Pennington, Rikki Patton and Heather Katafiasz

Chapter 7 Practical considerations for online individual therapy Haim Weinberg and Arnon Rolnick

Secion 2 Online couple and family therapy edited by Shoshana Hellman and Arnon Rolnick

Chapter 8 Introduction to the online couple and family therapy section Shoshana Hellman and Arnon Rolnick

Chapter 9 Interview with Julie and John Gottman

Chapter 10 Internet-delivered therapy in couple and family work Katherine M. Hertlein and Ryan M. Earl

Chapter 11 Digital dialectics: navigating technology’s paradoxes in online treatment Leora Trub and Danielle Magaldi

Chapter 12 Practical considerations for online couple and family therapy Arnon Rolnick and Shoshana Hellman

Section 3 Online group therapy edited by Haim Weinberg

Chapter 13 Introduction to the online group therapy section Haim Weinberg

Chapter 14 Interview with Molyn Leszcz

Chapter 15 Oline group therapy: in search of a new theory? Haim Weinberg

Chapter 16 Transformations through the technological mirror Raúl Vaimberg and Lara Vaimberg

Chapter 17 Practical considerations for online group therapy Haim Weinberg

Section 4 Online organizational consultancy edited by Rakefet Keret-Karavani and Arnon Rolnick

Chapter 18 Introduction to the online organizational consultancy section Rakefet Keret-Karavani and Arnon Rolnick

Chapter 19 Interview with Ichak Kalderon Adizes

Chapter 20 All together, now: videoconferencing in organizational work Ivan Jensen and Donna Dennis

Chapter 21 A relexive account: group consultation via video conference Nuala Dent

Chapter 22 Practical considerations for online organizational consultancy Rakefet Keret-Karavani and Arnon Rolnick

Epilogue Arnon Rolnick and Haim Weinberg

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

Conversion Disorder: The Human Body is the Best Picture of the Soul

Jamieson Webster writes like a combination of an Exocet missile and a feline feather tease. Webster has previously published on The Life and Death of Psychoanalysis (2012) and with Simon Critchley on Hamlet (Stay Illusion! The Hamlet Doctrine (2014)). Her latest contribution is Conversion Disorder: Listening to the Body in Psychoanalysis (Columbia University Press, 2019, 303 pp. ($33)).

Between Jacques Lacan, Giorgio Agamben, and Michel Foucault, Conversion Disorder is

Cover Art: Conversion Disorder

Cover Art: Conversion Disorder

a challenging read, though the effort will be rewarding for many.  The audience for this book is largely academics engaged by the some version of psychoanalysis, drawing mainly on Lacan and Freud. Much is to be admired in this courageous work, but since this is not a softball review, I have some criticisms, too. Webster has given us a brilliant work, though a deeply flawed one.

After such a significant effort, I am going to have some fun with this one.

Webster exemplifies a kind of postmodern writing that assumes one has read everything and therefore context is not required. Ideas streak through the text like ciphers from the Oracle of Delphi, whereas the statements are just ideas of university graduate level complexity being quoted out of context. Summaries are sometimes provided at the end of arguments, resulting in a benefit to those who decide to read the text backwards. Nothing wrong with that as such, but the approach does seem to be limited to intellectual haunts in Southern Manhattan, The New School For Social Research, the academic suburbs of London, and comparative literature seminars at the more prestigious universities.

With any book on psychoanalysis, the recommendation is to read the Appendix and endnotes first. They are the equivalent of a literary slip of the tongue, a symptomatic action, a parapraxis, revealing the subtext. Reading the book backwards works well in this case.

Webster recognizes that her relationship with her own body is troubled – the work is acknowledged as an attempt at self-help. It takes courage to make oneself vulnerable by this manner of self-disclosure: Diets, Pilates, yoga, purges, mega-purges, and more purges. Within the realm of the fundamental unity of mind and body, psyche and soma, this self-treatment triggers a full-blown appendicitis in the author. Literally. What happened? A powerful demonstration of the inseparability of, yet tension between, psyche and soma?

The final three words of the book (p. 272) assert that the conversion disorder in question is “my conversion disorder” – i.e., Webster’s. The microcosm is the macrocosm. “Conversion” is writ large. Very  large. Many other conversions and conversion disorders are engaged along the way.

Webster asserts that her work has aspects of a memoire, and the reader does eventually get to meet the parents (who had their own struggles to survive) in the last ten pages of the book. However, I was disappointed in that I got no sense of the “good parts” of the memoire – what the author had to survive or how she ended up becoming a psychoanalyst, which is surely a courageous project, and not an undertaking for the faint of heart.

Webster repeatedly calls out psychoanalysis as an “impossible” profession, notwithstanding the paradox that she credibly claims to  practice it. Here Webster walks the semi-sacred ground mapped out by Janet Malcolm in a book of the same name (Psychoanalysis: The Impossible Profession, Alfred Knopf, 1977/1981). Webster might usefully have invoked Janet Malcolm and whether her (Webster’s) contribution is a debunking in the same or a different sense than Malcolm’s.  How about a footnote? This is the sort of thing I would have expected the editor (Wendy Lochner) to catch, but editing is not what it used to be.

Another editorial pet peeve: The words “abjection” and “abject” are used as if they are clear to the reader. Context? Julia Kristeva is not in the references, though she is the one who gave “abjection” currency and a certain popularity. It is not otherwise defined. A criteria: If you do not already know what it means or are prepared to live with this uncertainty of not knowing, then this text is not for you. Once again I would have hoped that the editor would have intervened with guidance: “Please define one’s terms.” Once again, editing is not what is used to be.

Meanwhile, on how psychosomatic physical symptoms – migraines, lower back pain, headaches, which are notoriously difficult to diagnose – get “hijacked” by the emotions and become the source of substantial psychic suffering, there are more recent treatments, including Webster’s, but there is quite simply no better one than Arthur Kleinman’s The Illness Narratives (1988). An engagement with Kleinman will decisively change one’s listening – as, of course, will reading Lacan or being hit in the head with a rolled up newspaper – but Kleinman will also deepen one’s empathy, humanity, and toleration of uncertainty, which the former will not do.

Webster engages with biopolitics (key term: biopolitics) and the institutional dynamics around psychoanalysis. On the professional issues confronting psychoanalysis – and there are many self-inflicted wounds here – Kate Schechter’s The Illusion of a Future (2010) deserves honorable mention and more – and Schechter provides a far superior treatment of psychoanalytic gossip than Webster – very juicy indeed and funny in a satirical sort of way – albeit in the context of the Chicago Institute for Psychoanalysis. While Webster talks a lot about “courage” and she demonstrates much, noticeably absent is any trace of speaking truth to institutional power that might ruffle any feathers in the local establishment. Courage indeed.

My complaint? There is something fake about “I don’t want to be a psychoanalyst” – if one does not, okay, then stop and do something else – practice CBT, DBT, ACT, primal scream therapy (joke!) or take up water colors. At no point does the two ton elephant in the living room get noted – the dirty little secret: most of the psychoanalytic “patients” are behavioral health professionals (graduate students in psychology or psychiatric residents) aspiring to be enrolled in the pyramid. Nothing wrong with that. These good folks need help too. And it is a shame that psychoanalysis has fallen on such hard times as it can get results that no other intervention seems able to produce. But what does one have to do to get a piece of the action – a piece of the objet (petit) a? If one has doubts about the viability of psychoanalysis, this text will do little to dispel them.

Therefore, get ready for – biopolitics!? Webster follows Giorgio Agamben, who, in turn, follows Foucault off the biopolitical cliff into the abyss of – what? The objet (petit) a– we are now speaking French – which, according to Lacan, is not to be translated, the unattainable object, the part object (penis, breast, foot) – perhaps the Kantian thing in itself. Another cipher = x,  that which is being converted in somatoform disorder?

If one wants to bring biopolitics into the vicinity of hysteria, then ditch the Agamben. Take a look at Arthur Miller’s The Crucible, which is a re-telling of the Salem Witch Trials using a lens from the 1950 McCarthy Hearings on House Un-American Activities. Politics and hysteria are front and center. Once the authorities agree to admit spectral evidence – not unlike fake news or alternative facts – including the hysterical utterances of over wrought pubertal girls, then the audience of The Crucible knows things are not going to go well for the adults. If one is going to make a deal with the devil, be sure to read the fine print. The pact with the devil results in a commotion – a literal witch-hunt – and a slaughter of innocents. The emotional anguish and suffering is wide spread and the audience is vicariously traumatized.

Webster has considerable “skin in the game.” Webster is suffering, too, though admittedly not to the degree of John Proctor (protagonist of The Crucible). Webster is engaging with conversion because she has a contribution to make in disentangling the complexities of the phenomena. What really  interests her is how the [counter]transference of hysterical symptoms occurs from patient to analyst (e.g., p. 74). Webster is Exhibit A – and proud of it.

Webster tells the reader as much: “Who would want to make themselves the vessel for so many others in this way? To have them repeat their pain and unlived life in your flesh?” [P. 54.] This is her “day job.” Once again, there is nothing wrong but there is something missing – empathy.

The lack of well-regulated empathy leads to compassion fatigue, burn out, and empathic distress. Apparently it also leads to an appendicitis. Her own appendicitis (see the Appendix) is not a hysterical pregnancy, but then again her patient is confronted with one of those – and see Freud’s comments on Negation. (When the patient says “now that is not my mother,” then strike though the not: not. Who do you think it is?)

The word “empathy” plays no explicit role in the text, though I suggest empathy’s breakdown is the underlying mechanism is many examples of conversion. I am not saying Webster has too much empathy. I am not saying Webster lacks empathy. I am saying: expanding empathy is hard work. Webster is no natural empath, as near as I can see from here, but a committed professional – and a celebrity academic. She is on the path of bearing witness and self-disclosure, but something is off the rails. Webster suffers from a breakdown of empathy specifically in the regulation of empathic receptivity.

Webster “picks up” the patient’s somatization – whether it is mirror neurons, neuropeptides, the adrenal pituitary axis or simple muscle mimicry (which is not so simple). The emotional receptivity breaks down into an individual form of emotional contagion so the therapist suffers too. The educated guess is that, being all-too-human, some unprocessed sex and aggression lurks near by, but mostly unprocessed narcissism, a term conspicuous by its absence.

People seeking dynamic psychotherapy (and its extreme form in psychoanalysis) are suffering. Sometimes after much work and effort and self-overcoming these same people become therapists. All well and good. The process is daunting and not to be made light of. However, Webster is so overwhelmingly taken with the significance of the process that no room remains available to enjoy a lighter moment. In addition to expanded capacity to love and work, Heinz Kohut (dismissed by Webster in the closing pages) pointed out how a successful psychoanalysis of the self may expect to transform frozen narcissism into expanded humor, empathy, and even wisdom. Here the narcissism is ultimately untransformed – and unconverted?

Webster quotes the Diagnostic and Statistical Manual of Mental Disorders, Version 5 (2013), the deeply flawed but consensus-forming, boundary defining “bible” of the behavioral health world. Webster “gets it” that something essential is missing. “Hysteria” in the narrow sense of a signification (representation/symbolization) of an underlying sexual or aggressive content was removed from the manual several editions ago. Yet hysteria in the narrow sense lives on in Webster’s practice, in her transference, and (here is the courageous part) especially in her counter-transference.

In the DSM itself, mental and emotional disorders are described at the level of behavior and constellations of symptoms. It is a check list manifesto (with apologies to Atul Gawande) that enables the therapist (or prescribing psychiatrist) to map symptoms to treatments without having to unmask, go “under the hood,” or seek for hidden causes = x. Ideal for those prescribing psychotropic medications.

While Webster is a strong advocate for a close reading of Freud, this is precisely the area in which she is significantly at risk. The hazard of  Jacque Lacan’s guidance of “getting back to Freud” is that what Lacan really means is “replacing Freud with Lacan.”

In a separate interview, the Webster notes: “When I read him [Lacan], it changes the way I listen.” Of course it does. So does being beaten about the head with a rolled up newspaper (once the ears stop ringing).

My concern? I believe that it is possible for one to read too much Lacan or Foucault – like sniffing too much glue – it does make one high, but after a certain point the consequences are irreversible. [See Webster’s interview with Cassandra Seltman (01/05/2019 https://blog.lareviewofbooks.org/interviews/cost-alone-cassandra-seltman-interviews-jamieson-webster/ )].

For Webster, “conversion” is not restricted to the somatization of psychic or emotional conflict into physical systems that present in a human body. “Conversation” also refers to religious transformation as might have interested William James or Giorgio Agamben or any radical discontinuity in experience that profoundly shifts the experience of the subject in a lasting and sustainable way. So it’s all fair game and whatever comes up, comes up. Quite a lot comes up.

“Conversion” is writ large, as noted, but I suspect most readers will require more guidance than is provided by Webster. For example, a person is under extreme stress. The person develops irritable bowel syndrome, lower back pain, or migraine headaches. That is direct somatization – conversion of the stress into a physical symptom (pain) – depending on whether one has a weak head, intestine, or lower back – depending on whether one has a disposition or microscopic, subclinical injury that is exacerbated by the stress.

Next comes extreme stress resulting in hypochondriasis – now called “illness anxiety” – where the person is not in pain but is literally worried sick, for example, believing the sebaceous cyst in his neck is incurable cancer or the headache means an inoperable brain tumor.

The third form (which is the one Freud engaged with most insightfully) is exemplified as the conversion disorder takes on an unmistakable symbolic expression. The patient’s

Jean Martin Charcot working with a hysterical patient

Jean Martin Charcot (one of Freud’s mentors) working with a hysterical patient

hand is neurasthenic – loses feeling and the patient is unable to control it. The paralysis ends at the wrist, which confirms that the paralysis does not map to standard neural anatomy. The patient’s leg is paralyzed, but in such a way that his paralysis does not map to standard neural anatomy. The patient is asked to free associate and her reflections go in the direction of her shame and conflict over masturbation – with the hand in question.

In a different example, Freud’s patient Frau Emma von N is accused by her late husband’s relatives of poisoning him (an accusation that is fake and self-serving). Emma develops a persisting burning on her face – on her cheek – as if she had been slapped!? Insulted? Trigeminal neuropathy? Freud after all was a neurologist. (Note this is Freud’s example, not Webster’s.) She talks about it with Freud, and it gets better.

For Freud when libido (desire) is directly transformed into bodily symptoms, the result is an “actual neurosis” (better translated as a “contemporary neurosis,” but, in any case, a technical term) – the body directly translates the psychic suffering as physical symptoms – paralysis, cramps, in extreme cases symptoms like epilepsy – except there is no anatomic lesion.

In some cases, these symptoms are painful; in other cases they are just disruptive of daily life – as when the patient loses consciousness. However, for Freud, when libido (desire) is unable to be directly expressed in bodily symptoms due to repression, then the desire (libido) gets expressed in bodily symptoms that enact sexual  representations. Desire finds a way to become articulate, symbolizing forth what it has to express by means of bodily signifiers (i.e., symptoms).

For instance, the patient is conflicted over marrying her brother-in-law (once again Freud’s example, not Webster’s), the husband of her late sister (who has just died). The patient is free to remarry and (a crucial condition) such a thought is abhorrent to the patient. It has no where else to go to be expressed than to be translated into a bodily symbol.

Although I believe Webster gives examples of this third kind, to the best of my knowledge (and I have read every word), no where does she make the point that the symbolism expresses sexual or aggressive or a conflict-inspiring violations of conventional community standards – which is precisely what has fallen out of the latest editions of the DSM.

By the way, Ludwig Wittgenstein, who was a tortured soul for reasons completely unrelated to conversion disorder, wrote: “The human body is the best picture of the human soul” (Philosophical Investigations, 1950, tr E. Anscombe, p. 178e).

Perhaps it is so obvious to Webster that it does not require mentioning; yet unless one is steeped in these matters, this loss in the DSM is of the essence. In short, if one is looking for a book on conversion disorders that does for them what the late Oliver Sacks did for migraines, Tourette’s syndrome, music, or diverse anomalous neurological disorders (a high bar indeed!) that work has yet to be written.

References

American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders. DSM-5, Fifth Edition. Arlington, VA: American Psychiatric Association.

© Lou Agosta, PhD and the Chicago Empathy Project

The Brain that Changes Itself: A Powerful Message of Hope – and Hard Work!

I have been catching up on my reading.

Norman Doidge’s book, The Brain that Changes Itself (Penguin, 427pp. ($18)), was published in 2007, now some twelve years ago. This publication occurred towards

Cover Art: The Brain That Changes Itself by Norman Doidge

Cover Art: The Brain That Changes Itself by Norman Doidge

the beginning of the era of neuro-hype that now has us choking on everything from neuroaesthetics to neurohistory, from neuromarketing to neurozoology. So pardon my initial skepticism.

However, this book is the real deal. To those suffering from a variety of neurological disorders or issues, extending from major strokes to learning disabilities or emotional disorders, Doidge’s narratives offer hope that hard work pays off. If more authors and editors would have read (and understood!) it, today’s neuro-hype would be a lot less hyped.

Let me explain. There is neural science aplenty in Doidge’s exposition and defense of the flexibility – key term: plasticity – of the brain. There are also plentiful high tech devices (prostheses) that make for near science fiction innovation, except that they are engineering interventions, not fictions.

 However, what distinguishes Norman Doidge’s contribution is that, in every case without exception, the neural science “breakthrough” on the part of the patient is preceded by substantial – in some cases a year or more – of hard work on the patient’s behalf to regain lost neural functionality.

 Yes, from the point of view of our everyday expectations of what can be attained in six weeks of twice a week rehabilitation, the results are “miraculous”; but upon closer inspection the “miracle” turns out to be 99% perspiration and 1% inspiration.

I hasten to add that the exact distribution of effort varies. But the point is that, while the “miraculous” is supposed to be uncaused, lots of hard work on the part of the patient, properly directed, is a key determining factor. This in no way detracts from the authentic innovations and corresponding effort on the part of the neural scientists and engineers engaging in the rehabilitation process.

The woman who lost her sense of balance tells of a woman (Cheryl) whose ability to orient herself in space is “taken out” by an allergic reaction to an antibiotic (gentamicin) administered to treat an unrelated condition. Balance is sometimes considered a sixth sense, for without it the person literally looses her balance and falls over. Thus, Cheryl became the woman perpetually falling.  She becomes a “Wobbler.”

While such a condition does not cause a person to die, unless the fall proves fatal, but it destroys the ability to engage in the activities of daily living. Enter  Paul Bach-y-Rita, MD, and Yuri Danilov (biophysicist) (p. 3), who design a helmet that transmits orientation data to Cheryl through an ingenious interface that she can hold on her tongue like a small tongue depressor. It transmits a tingling sensation towards the front of the stick if she is bending forward, towards the back of the stick if she is bending backwards, and so on. Who would have thought it? Turns out that the tongue is a powerful brain-machine interface.

After some basic training as Cheryl wore it, she was able to orient herself and not fall over. After awhile, she took the helmet off and found that the ability to orient herself lasted a few minutes. There was a residual effect. With more training, the persistence of the after effect was extended. Finally, after a year of work, she was able to dispense with the helmet. She had “magically” regained her sense of balance. The neural circuits that had been damaged were in effect by-passed and the functionality taken over by other neural areas in the brain based on the training. Cheryl was no longer a Wobbler.

This is the prelude to the narrative of the dramatic recovery of Bach-y-Rita’s own father, the Catalan poet Pedro Bach-y-Rita, who has a massive disabling stroke, leaving him paralyzed in half his body and unable to speak.

After four weeks of rehabilitation based on pessimistic theories that the brain could not benefit from extended treatment, the father, Pedro, was literally a basket case. Enter brother George – Pedro’s other son. Now George did not know that rehab was supposed to be impossible, and took the father home to the house in Mexico. They got knee pads and taught him to crawl – because it is useful to crawl before one walks, which Pedro eventually did again after a year of effort. Speech and writing also returned after much effort copying and practicing phonetics.

Pedro returned to teaching full time at City College in New York (p. 22) until he retires years later. After Pedro’s death, a routine autopsy of his brain in 1965, showed “that my father [Pedro] had had a huge lesion from his stroke and that it had never healed, even though he recovered all these functions” (p. 23).

The take-away? What modern neural science means when it asserts that nerve cells do not heal is accurate. But “plasticity” means that the brain is able to produce alternative means of performing the same messaging and functional activity. “The bridge is out,” so plasticity invents a detour around the damaged area. Pedro walks and talks again and returns to teaching.

Conventional rehab usually lasts for an hour and sessions are three times a week for (say) six weeks. Edward Taub has patients drill six hours a day, for ten to fifteen days straight. Patients do ten to twelve tasks a day, repeating each task ten times apiece. 80 percent of stroke patients who have lost arm functionality improve substantially (p. 147). Research indicates the same results may be available with only three hours a day of dedicated work.

 In short, thanks to plasticity, recovery from debilitating strokes is possible but – how shall I put it delicately? – it is not for the faint of heart. Turn off the TV! Get out your knee pads?

So when doctors or patients say that the damage is permanent or cannot be reversed, what they are really saying is that they lack the resources to support the substantial but doable effort to retrain the brain to relearn the function in question – and are unwilling to do the work. The question for the patients is: How hard are you willing to work?

The next case opens the diverse world of learning disabilities. Barbara Arrowsmith looms large, who as a child had a confusing set of learning disabilities in spatial relationships, speaking, writing, and symbolization. Still, she had a demonstrable talent for reading social clues. She was not autistic, but seemingly “retarded” – cognitively impaired. She had problems with symbolic relationships, including telling time.

With the accepting and tolerant environment provided by her parents, who seemed really not to “get” what was going on, Barbara set about to cure herself. She (and her parents) invented a series of exercises for herself that look a lot like what “old style” school used to be: A lot of repetitive exercises, rote memorization, copying, and structure. Flash cards to learn how to tell time. There is nothing wrong with the Montessori-inspired method of letting the inner child blossom at her or his own rapid rate of learning, except it does not work for some kids. Plasticity demonstrates that “one size fits all” definitely does notfit all.

The result? The Arrowsmith School was born, featuring a return to a “classical” approach:

“[…] [A] classical education often included rote memorization of long poems in foreign languages which strengthen the auditory memory […] and an almost fanatical attention to handwriting, which probably helped strengthen motor capacities […] add[ing] speed and fluency to reading and speaking” (pp. 41–42).

This also provides the opportunity to take a swipe at “the omnipresent PowerPoint presentation – the ultimate compensation for a weak premotor cortex.” Well said.

Without having anything wrong with their learning capabilities as such, some children have auditory cortex neurons that are firing too slowly. They could not distinguish between two similar sounds – e.g., “ba” and “da” – or which sound was first and which second if the sounds occurred close together (p. 69):

“Normally neurons, after they have processed a sound, are ready to fire again after about a 30-millesecond rest. Eighty percent of language-impaired children took at least three times that length, so that they lost large amounts of language information” (p. 69).

The solution? Exploit brain plasticity to promote the proliferation of aural dendrites that distinguish relevant sounds and sounds, in effect speeding up processing by making the most efficient use of available resources.

 Actually, the “solution” looks like a computer game with flying cows and brown bears making phonetically relevant noises. Seems to work. Paula Tallal, Bill Jenkins, and Michael Merzenich get honorable mentions, and their remarkable results were published in the journal Science(January 1996). Impressive.

Though not developed to treat autism spectrum disorders, such exercises have given a boost to children whose sensory processing left them over-stimulated – and over-whelmed, resulting in withdrawal and isolation. Improved results with school work – the major “job” of most children – leads, at least indirectly, to improved socialization, recognition by peers and family, and integration into the community (p.75). Once again, it seems to work.

As a psychoanalytically trained medical doctor, one of Doidge’s interests is in addiction in its diverse forms, including alcohol and Internet pornography. For example, Doidge approvingly quotes Eric Nestler, University of Texas, for showing “how addictions cause permanent changes in the brains of animals” (p. 107). This comes right after quoting Alcoholics Anonymous that there are “no former addicts” (p. 106). Of course, the latter might just be rhetoric – “don’t let your guard down!” Since this is not a softball review, I note that “permanent changes in the dopamine system” are definitely notplasticity. A counter-example to Doidge’s?

Doidge gets high marks for inspirational examples and solid, innovative neural science reporting. But consistency?

A conversation for possibility – that is, talk therapy – which evokes the issues most salient to being human – relationships, work, tastes, and loves – activate BNGF [brain-derived neural growth factor], leading to a proliferation or pruning back of neural connections. This is perhaps the point to quote another interesting factoid: “Rats given Prozac [the famous antidepressant fluoxatine] for three weeks had a 70 percent increase in the number of cells in their hippocampus” [the brain area hypothesized to be responsible for memory translation in humans] (p. 241). This is all good news, especially for the rats (who unfortunately did not survive the experiment), but the devil, as usual, is in the details.

On a positive note, Freud was a trained neurologist, though he always craved recognition from the psychiatric establishment [heavens knows why – perhaps to build his practice]. In a separate chapter including a psychoanalytic case (“On Turning Our Ghosts into Ancestors,” an unacknowledged sound byte from Hans Loewald, psychoanalyst), Doidge’s points out in a footnote that having a conversation with a therapist changes one’s neurons too. The evidence is provided by fMRI studies before and after therapy (p. 379). This is the real possibility for – get ready, welcome to  – neuropsychoanalysis.

Like most addictions – alcohol, street drugs, gambling, cutting – Internet porn is a semi-self-defeating way of regulating one’s [dis-regulated] emotions. The disregulated individual may usefully learn expanded ways of regulating his emotions, including how to use empathy with other people to do so. Meanwhile, the plasticity of addictive behavior turns out to be more sticky and less flexible than the optimistic neuro-plasticians (if I may coin a term) might have hoped. 

Doidge has an unconventional, but plausible, hypothesis that “we have two separate pleasure systems in our brains, one that has to do with exciting pleasure and one with satisfying pleasure” (p. 108). Dopamine versus endorphins? Quite possibly. Yet one doesn’t need neuropsychoanalysis to appreciate this. 

Plato’s dialogue Gorgias makes the same point quite well (my point, not Doidge’s). Satisfying one’s appetites puts one in the hamster’s wheel of endless spinning whereas attaining an emotional-cognitive balance through human relations, contemplation, meditation, or similar stress reducing activities provide enduring satisfaction. The tyrant may be able to steal your stuff – your property, freedom, and even your life – but the tyrant is the most miserable of men. The cycle of scratching the itch, stimulating the need further to scratch the itch, is a trap – and a form of suffering. Suffering is sticky, and Freud’s economic problem of masochisms looms large and still has not been solved.

Doidge interweaves an account of a breakthrough psychoanalysis with a 50 plus year old gentleman with a narrative of Eric Kandel’s Nobel Prize winning research. Kandel and his team published on protein synthesis and the growth of neural connections needed to transform short- into long-term memory. While it is true that humans are vastly more complicated than the mollusks in Kandel’s study, the protein synthesis is not.

Thus, another neural mechanism is identified by which Talk Therapy changes your brain. Mark Solms – founding neuropsychoanalyst – and Oliver Turnbull translate Freud’s celebrated statement “where id was ego shall be” into neural science: “The aim of the talking cure […] from the neurobiological point of view [is] to extend the functional sphere of the influence of the prefrontal loves” (p. 233).

Even if we are skirting close to the edges of neuro-hype here, it is an indisputable factoid that Freud, the neurologist, draws a picture of a neuronal synapse in 1895 (p. 233). At the time, such a diagram was a completely imaginative and speculative hypothesis. Impressive. Freud also credibly anticipates Hebb’s law (“neurons that fire together wire together”), but then again, in this case, so did David Hume (in 1731) with his principle of association.

Meanwhile, back to the psychoanalysis with the 50-something gentleman who has suffered from a smoldering, low order depression for much of his life. Due to age, this is not considered a promising case. But that was prior to the emerging understanding of plasticity.

This provides Doidge with the opportunity to do some riffing, if not free associating, of his own about trauma, Spitz’s hospitalism, and psychopharmacology. “Trauma in infancy appears to lead to a supersensitization – a plastic alteration – of the brain neurons that regulate glucocorticoids” (p. 241). “Depression, high stress, and childhood trauma all release glucocorticoids and kill cells in the hippocampus, leading to memory loss” (p. 241). The result? The depressed person cannot give a coherent account of his life.

The ground breaking work of Rene Spitz on hospitalism – of children confined to minimum care hospitals (anticipating the tragic results in the Rumanian orphanages after the fall of the USSR) – is invoked as evidence of the damage that can occur. When the early environment is sufficient to keep the baby alive biologically but lacks the human (empathic) responsiveness  required to promote the emotional well-being of the whole person, the result is similar to acquired autism – an overwhelmed, emotionally stunted person, struggling to survive in what seems to the individual to be a strange and unfriendly milieu.

I summarize the lengthy course of hard work required to produce the result of Doidge’s successful psychoanalysis. The uncovering of older, neural pathway gets activated and reorganized in the process of sustained free association, dream work, and the conversation for possibility in the psychoanalytic “talking cure”. Through an elaborate and lengthy process of working through, the patient regains his humanity, his lifelong depression lifts, and he is able to enjoy his retirement.

So far neural plasticity has been a positive phenomenon and a much needed source of hope and inspiration to action. However, plasticity also has a dark side. For example, if one loses a limb due to an amputation, the brain takes over what amounts to the now available neuronal space on the neural map. One’s physical anatomy has changed, but the brain seems plastically committed to reusing the neural map of the body for other purposes.

The limb is no longer there, but it hurts, cramps, burns, itches, because the neural map has not been amputated. However, the patient suffers – sometimes substantially – because one cannot massage or scratch a limb that does not exist. Yet the pain LIVEs in the neural system – and that makes it real.

Pain is the dark side of plasticity. Pain is highly useful and important for survival. It protects living creatures from dangers to life and limb such as fire or noxious substances. We have a painful experience and learn to avoid that which caused the pain.

Yet pain can take on a life of its own. Anticipating pain can itself be painful. Once pain is learned it is almost literally burned into the neurons and it takes considerable work (and ingenuity) to unlearn – to extinguish – the pain.  

“Our pain maps get damaged and fire incessant false alarms” (p. 180). V. S. Ramachandran has performed remarkable work with understanding that most recalcitrant of phenomena, phantom limb pain. Ramachandran’s is deservedly famous for many reasons. But his simple innovation of the mirror box really requires an illustration. It is literally done with a mirror.

Illustrating mirror box therapy with an intact limb being reflected so as to create the appearance that the amputated limb is present: the individual experiences the presence of his missing limb

Illustrating mirror box therapy with an intact limb being reflected so as to create the appearance that the amputated limb is present: the individual experiences the presence of his missing limb

The subject with the missing hand is presented with a reflected image of the good, intact hand, which in reflection looks just like the missing hand. The subject experiences the limb as being a part of his body. (That in itself is a remarkable effect – the neural “socket” is still there.) In effect, the individual gets the hand back as something he owns. He is able to experience closing his missing hand by closing the good hand. This relieves cramps and stiffness.

In other experiments, the lights are turned off and various areas of the body are touched. The area that was once the [now missing] hand is used to map sensations on another area of the body, for example, one’s face. Scratching an itch on the phantom limb by scratching just the right spot on one’s face becomes possible because the neural map of the missing limb has been taken over and is now being used to map a different part of the anatomy

Doidge ends with a flourish:

“V. S. Ramachandra, the neurological illusionist, had become the first physician to perform a seemingly impossible operation: the successful amputation of a phantom limb” (p. 187). He did this by changing the brain – in effect deconditioning (deleting) the representation of the phantom limb from the brain. Thus, the promise and paradox of plasticity.

 (c) 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

 

 

 

 

 

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