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Freud is explicit about his commitment to empathy. He writes and publishes the following:
It is certainly possible to forfeit this first success [in therapy] if one takes up any standpoint other than one of empathy such as moralizing (“Further recommendations: On beginning the treatment.” Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume 12: 121-144. : 140).
Unfortunately no one knows that Freud wrote that, because it is literally lost in translation. In translating “empathy [“Einfühlung”] from the original German, Alix Strachey writes to James Strachey: “In any case, it’s a vile word [“empathy”], elephantine, for a subtle process.” The words “sympathetic understanding” were chosen as the translation in this case. The rest, as they say, is history; except that it is like Russian history when Stalin had Trotsky’s photos literally cut out of the history books of the Russian Revolution. Talk about repression!
[Note: This post is an excerpt from Chapter Four of my book A Rumor of Empathy: Rewriting Empathy (Palgrave Publishing): to buy the book or have your local library order a copy go here: get A Rumor of Empathy: Rewriting Empathy [https://tinyurl.com/y24ps876]]
Freud’s method was an empathic one, and the dispute, if any, is not that Freud did not use or value empathy. He did. Freud applies empathy in his clinical practice, even when he does not use the word “Einfühlung.” Freud balances his commitment to empathic methods even in the face of the boundary issues of C. G. Jung and S. Ferenczi with their women patients, where Freud took the moral high ground, counseled the need to be dispassionate and “like a surgeon” in neutrality, anonymity, and (above all) abstinence. However, that may all be well and good in practice, but how does that work in theory?
In theory Freud limited his explicit mentions of “empathy.” The reason is Freud’s definition of “introspection.” Introspection is distinct from empathy, but closely connected to it. One dominant modern definition of empathy is “vicarious introspection” (Kohut 1959), where introspection is the royal road to empathy. Introspection is an anchor, making available the spontaneously arising vicarious feelings that are further processed by empathic understanding and interpretation into an empathic response. Yet Freud did not make such a distinction. Rather Freud defines “introspection” in terms of the self-observation of the conscience (one aspect of the superego), that is, as a form of self-criticism and censorship.
In this quotation, empathy is distinguished from “moralizing.” This is a casual reference but a potentially revealing one. By “moralizing” one understands Freud to mean the use of “approval” or “blame” as means of influencing the course of treatment. The exclusion of an ethics of empathy does not rule out the use of empathy for recognition of the humanity of the other person. In this sense, empathy implies a respect for the autonomy of the other which is inconsistent with any attempts to manipulate him by means of approbation and punishment. It is important to keep open a space for the ethical implications of empathy without indulging in “moralizing” in the narrow sense.
As noted,, this is also the text in which “Einfühlung[empathy]” is mistranslated by Strachey as “sympathetic understanding,” thus further obscuring the critical role that it takes in Freud’s practice. Contrary to Strachey, Freud takes significant effort to distinguish “empathy” from “sympathy.”
The effort to distinguish “empathy” from “sympathy” continues in Freud’s “Preface to Aichhorn’s Wayward Youth”(1925: 273). Sadly, so does the mistranslation. Freud acknowledges the contribution of August Aichhorn in working with troubled adolescents: “His [Aichhorn’s] attitude to his charges sprang from a warm sympathy with the fate of those unfortunates and was correctly guided by an intuitive perception [“intuitive Einfühlung” = “intuitive empathy”] of their mental needs.”
The use of “intuition” here is not the over-intellectualization about which Kohut cautioned (e.g., Kohut The Analysis of the Self: 302-305), but rather the recommendation to be guided in relating to the troubled adolescent by one’s perceptive personal reaction, a skill in which Aichhorn excelled.
Freud typically finds a model taken from everyday life for pathological phenomena. Examples include: mourning (normal) and melancholy (depression); dreams (normal) and hallucinatory psychosis (waking dream); religious practices (normal) and obsessional rituals (pathological); love (normal) and hypnosis (abnormal): all present parallels between the everyday and the pathological. Thus, Freud notes the continuum between the pathological state of paranoia and the self-observations of the scrupulously moral conscience:
. . . The self-criticism of conscience is identical with, and based upon, self-observation. That activity of mind, which took over the function of conscience, has also enlisted itself in the service of introspection, which, in turn, furnishes philosophy with the material for its intellectual operations. This must have something to do with the characteristic tendency of paranoiacs to form speculative systems.
It will certainly be of importance to us if we can see in other fields evidence of the activity of this critically watching faculty, which becomes heightened into conscience and philosophic introspection (Recommendations for physicians beginning psychoanalysis, 1914: 96-97).
This definition of introspection as critical self-observation is far from the kind of introspection actually practiced by both the analyst and analysand. The latter’s free associations cannot be generated so long as the conscience is actively censoring one’s thoughts and discourse. The analyst does not deliberately concentrate his attention or listen for anything specific in the analysand’s free associations.
The analyst maintains an attitude of evenly-hovering attention, in which his tendency to “moralize”—approve or blame—is suspended. In this way, introspection on the part of the analyst can disclose vicarious feelings as well as memories analogous to those told by the analysand. In both cases, we have a kind of introspection without inspection (to coin a phrase), which conditions the arousal of empathic receptivity towards the latent content of the analysand’s unstudied associations.
Rehabilitating introspection without inspection is based on an account of empathic receptivity. In so far as empathy is a kind of vicarious introspection, Freud’s ambivalence towards introspection constrains his use of empathy. Having a limited conception of the uses of introspection as “moralistic,” critical self-observation in philosophy constrained Freud’s explicitly using empathy as a means of empathic receptivity towards the introspective accounts of the analysand and the analyst’s own vicarious feelings thus aroused.
In short, Freud’s methods and listening were highly empathic, and if one’s experience today is otherwise, it is only because something has been lost in translation – empathy.
“Okay, I’ve read enough; I want further details”: to buy the book or have your local library order a copy of this book or another of Lou’s empathy books go here: get A Rumor of Empathy: Rewriting Empathy [https://tinyurl.com/y24ps876]
(c) Lou Agosta, PhD and the Chicago Empathy Project
A Lazy Person’s Guide to Empathy, the book, now available: Expand empathy in the individual and community today!
Empathy: A Lazy Person’s Guide is a light-hearted look at a significant and engaging matter: how to expand empathy in the individual and the community – and do so without working too hard. The Guide includes twenty eight illustrations by the celebrated artist Alex Zonis. So if you get tired of reading, look at the pictures! Practically an art book, get a summary in line below and order the book here and now by clicking here: Empathy: A Lazy Person’s Guide.
Given current events (Q2 2020), go straight to the section on applying empathy to soothe anger and rage – and setting empathic limits to drive out bullying, prejudice, and bad behavior. In addition –
A lazy person’s guide to empathy guides you in –
- Performing a readiness assessement for empathy
- Cleaning up your messes one relationship at a time.
- Defining empathy as a multi-dimensional process.
- Empathy in the age of coronavirus – don’t miss it!
- Overcoming the Big Four empathy breakdowns.
- Applying introspection as the royal road to empathy.
- Identifying natural empaths who don’t get enough empathy – and getting them [oneself] the empathy one needs.
- The one-minute empathy training. [No kidding!]
- Compassion fatigue: A radical proposal to overcome it.
- Listening: Hearing what the other person is saying versus your opinion of what she is saying.
- Distinguishing what happened versus what you made it mean.
- Applying empathy to sooth anger and rage.
- Good fences (not walls!) make good neighbors: About boundaries.
- How and why empathy is good for one’s well-being.
- Empathy and humor.Empathy, capitalist tool.
- Empathy: A method of data gathering.
- Empathy: A dial, not an “on-off” switch.
- Assessing your therapist,.
- Applying empathy in every encounter with the other person – and just being with other people without anything else added.
- Empathy as the new love – so what was the old love?
The lazy person’s guide to empathy offers a bold idea: empathy is not an “off-off” switch, but a dial or tuner. The person going through the day on “automatic pilot” needs to “tune up” or “dial up” her or his empathy to expand relatedness and communication with other people and in the community.
Practicing empathy includes finding your sense of balance, especially in relating to people. In a telling analogy, you cannot get a sense of balance in learning to ride a bike simply by reading the owner’s manual. Yes, strength is required, but if you get too tense, then you apply too much force in the wrong direction and you lose your balance. You have to keep a “light touch.” You cannot force an outcome. If you are one of those individuals who seem always to be trying harder when it comes to empathy, throttle back. Hit the pause button. Take a break.
Empathy is about balance: emotional balance, interpersonal balance and community balance. Empathy training is all about practicing balance: You have to strive in a process of trail and error and try again to find the right balance. So “lazy person’s guide” is really trying to say “laid back person’s guide.” The “laziness” is not lack of energy, but well-regulated, focused energy, applied in balanced doses. The risk is that some people – and you know who you are – will actually get stressed out trying to be lazy. Cut that out! Just let it be.
The natural empath – or persons experiencing compassion fatigue – may usefully “tune down” their empathy. But how does one do that?
The short answer is, “set firm boundaries.” Good fences (fences, not walls!) make good neighbors; but there is gate in the fence over which is inscribed the welcoming word “Empathy.”
The longer answer is: The training and guidance provided by this book – as well as the tips and techniques along the way – are precisely methods for adjusting empathy without turning it off and becoming hard-hearted or going overboard and melting down into an ineffective, emotional puddle.
Empathy can break down, misfire, go off the rails in so many ways. Only after empathy breakdowns and misfirings of empathy have been worked out and ruled out – emotional contagion, conformity, projection, superficial agreement in words getting lost in translation – only then does the empathy “have legs”. Find out how to overcome the most common empathy breakdowns and break through to expanded empathy – and enriched humanity – in satisfying, fulfilling relationships in empathy.
Okay – I have read enough – I would like to order the book: click here: Empathy: A Lazy Person’s Guide.
(c) Lou Agosta, PhD and the Chicago Empathy Project
People want to know: Can empathy be taught? People complain and authentically struggle: I just don’t get it—or have it. In spite of the substantial affirmative evidence already cited, the debate continues.
The short answer is: Yes, empathy can be taught.
The one minute empathy training is: most people are naturally empathic. Remove the obstacles to empathy and empathy comes forth.
Remove the resistances to empathy and empathy expands.
Eliminate the obstacles to empathy and a space of acceptance and toleration spontaneously comes froth.
What happens is that people unwittingly have been taught to suppress their empathy. People have been taught to conform, follow instructions, and do as they are told. We are taught in first grade to sit in our seats and raise our hands to be called on and speak. And there is nothing wrong with that. It is good and useful at the time. No one is saying, “Leap up and run around yelling” (unless it is summer vacation!). But compliance and conformity are trending; and arguably the pendulum has swung too far from the empathy required for communities to work effectively for everyone, not just the elite and privileged at the top of the food chain.
Now do not misunderstand this: people are born with a deep and natural capacity for empathy, but they are also born needing to learn manners, respect for boundaries, and toilet training. Put the mess in the designated place or the community suffers from diseases. People also need to learn how to read and do arithmetic and communicate in writing. But there is a genuine sense in which learning to conform and follow all the rules does not expand our empathy or our community. It does not help the cause of expanded empathy that rule-making and the drumbeat of compliance are growing by leaps and bounds.
Teaching empathy consists in overcoming the obstacles to empathy that people have acquired. When the barriers are overcome, then empathy spontaneously develops, grows, comes forth, and expands. There is no catch, no “gotcha.” That is the one-minute empathy training, pure-and-simple.
The work at hand? Remove the blocks to empathy such as dignity violations, devaluing language, gossip, shame, guilt, egocentrism, over-identification, lack of integrity, inauthenticity, hypocrisy, making excuses, finger pointing, jealousy, envy, put downs, being righteous, stress, burnout, compassion fatigue, cynicism, censorship, denial, manipulation, competing to be the biggest victim, injuries to self-esteem, and narcissistic merger—and empathy spontaneously expands, develops, and blossoms. Now that is going to require more than a minute!
Studying the Humanities and literature, art and music, rhetoric and languages, opens up areas of the brain that map directly to empathy and powerfully activate empathy. Read a novel. Publish a blog post. Go to the art museum. Participate in theatre. These too are empathy lessons, fieldwork, and training in empathic receptivity.
Reduce or eliminate the need for having the right answer all the time. Dialing down narcissism, egocentrism, entitlement (in the narrow sense), and dialing up questioning, motivating relatedness, encouraging self-expression, inspiring inquiry and contribution, developing character, and, well, expanding empathy.
Yes, empathy can be taught, but it does not look like informational education. It looks like shifting the person’s relatedness to self and others, developing the capacity for empathy, accessing the grain of empathy that has survived the education to conformity. Anything that gets a person in touch with her or his humanness counts as training in empathy.
(Note: Putting the “one minute” into the “one minute training” so that readers would not have to work too hard was hard work. I did the work of reviewing over a hundred publications on empathy training, the two dozen most significant of which are listed here: For evidence-based research on empathy training see the Bibliography and start with this list.
 Angera et al. 2006; Antoni et al. 2011; Brunero et al. 2010; Chiu et al. 2011; Coke et al. 1978; Davis et al. 1996; Decety et al. 2012; Del Canale et al. 2012; Golan et al. 2006; Gordon 2005; Hadwin et al. 1997; Halpern 2001; Hojat et al. 2009; Hojat et al. 2011; Levine 2012; Ozcan et al. 2012; PBS 2013; Pace et al. 2009; Pecukonis 1990; Riess 2013; Riess, Kelley et al. 2014; Riess, Kelley et al. 2012; Therrien 1975; Zaki and Cikara 2015 (Note – this required more than one minute!)
For those interested in more than one-minute of training: You do not have to buy the book, Empathy Lessons, to get the research, but if you would like more detail see especially Chapters Four and Six in Empathy Lessons (click here to get EMPATHY Lessons from Amazon). Also of interest: A Rumor of Empathy.
Remove the resistance to empathy and empathy grows, develops, and blossoms. In every instance of resistance to empathy, the empathy training consists in identifying, reducing, or eliminating, the resistance to empathy. When the resistance is reduced, empathy has space to develop, and it does so spontaneously as well as through providing explicit practices, tactics, strategies, and training .
(c) Lou Agosta, PhD and the Chicago Empathy Project
Empathy is good for your health and well-being: Empathy is on a short list of stress reduction practices including meditation (mindfulness), Tai Chi, and Yoga. Receiving empathy in the form of a gracious and generous listening is like getting a spa treatment for the soul. But do not settle for metaphors.
For evidence-based research on empathy, empathy and stress reduction, and empathy training you may start by googling: Antoni et al. 2011; Ciaramicoli 2016; Del Canale et al 2012; Farrow et al. 2007; Irwin et al. 2012; Maes 1995, 1999; Pollack et al. 2002; Rakel et al. 2009; Segerstrom and Miller 2004; Slavich et al. 2013 [this list is not complete].
You do not have to buy the book, Empathy Lessons, to get the research, but if you would like more detail see especially Chapters Four and Six in Empathy Lessons (click here to get book from Amazon).
[Also included are chapters on the Top 30 Tips and Techniques for Expanding Empathy, Overcoming Resistance to Empathy, Empathy Breakdowns, Empathy as the New Love, Empathy versus Bullying, and more.]
The healing powers of stress reduction are formidable. Expanding empathy reduces stress; and reducing stress expands empathy. A positive feedback loop is enacted. Expanding empathy expands well-being. Here empathy is both the end and the means.
A substantial body of evidence-based science indicates that empathy is good for a person’s health. This is not “breaking news” and was not just published yesterday. We don’t need more data, we need to start applying it: we need expanded empathy.
Evidence-based research demonstrates the correlation between health care providers who deliver empathy to their patients and favorable healthcare
outcomes. What is especially interesting is that some of these evidence-based studies specifically excludepsychiatric disorders and includemainline medical outcomes such as reduced cholesterol, improved type 2 diabetes, and improvement in related “life style” disorders.
Generalizing on this research, a small set of practices such as receiving empathy, meditation (mindfulness), yogic meditation, and Tai Chi, promote well-being by reducing inflammation. These practices are not reducible to empathy (or vice versa), but they all share a common factor: reduced inflammation. These anti-inflammatory interventions have been shown to make a difference in controlled experiments, evidence-based research, and peer-reviewed publications.
Using empathy in relating to people is a lot like using a parachute if you jump out of an airplane or getting a shot of penicillin if one has a bacterial infection. The evidence is overwhelming that such a practice is appropriate and useful in the vast majority of cases. The accumulated mass of decades of experience also counts as evidence in a strict sense. Any so-called hidden or confounding variables will be “washed out” by the massive amount of evidence that parachutes and penicillin produce the desired main effect.
Indeed it would be unethical to perform a double blind test of penicillin at this time, since if a person needed the drug and it were available it would be unethical not to give it to him. Yes, there are a few exceptions – some people are allergic to penicillin. But by far and in large, if you do not begin with empathy in relating to other people, you are headed for trouble.
Empathy is at the top of my list of stress reduction methods, but is not the only item on it. Empathy alongwith mindfulness (a form of meditation), Yoga, Tai Chi, spending time in a sensory deprivation tank (not otherwise discussed here), and certain naturally occurring steroids, need to be better known as interventions that reduce inflammation and restore homeostatic equilibrium to the body according to evidence based research.
The biology has got us humans in a bind, since it did not evolve at the same rate as our human social structures. When bacteria attack the human body, the body’s immune system mounts an inflammatory defense that sends macrophages to the site of the attack and causes “sickness behavior” in the person. The infected person takes to bed, sleeps either too much or too little, has no appetite (or too much appetite), experiences low energy, possibly has a fever, including the “blahs,” body aches, and flu-like symptoms. This response has evolved over millions of years, and is basically healthy as the body conserves its energy and fights off the infection using its natural immune response.
Now fast forward to modern times. This natural response did not envision the stresses of modern life back when we were short stature, proto-humanoids inhabiting the Serengeti Plain and defending ourselves against large predators. Basically, the body responds in the same way to the chronic stressors of modern life—the boss at work is a bully, the mortgage is over-due, the children are acting out, the spouse is having a midlife crisis—and the result is “sickness behavior”—many of the symptoms of which resemble clinical depression—but there is no infection, just inflammation.
The inflammation becomes chronic and the body loses its sensitivity to naturally occurring anti-inflammatory hormones, which would ordinarily kick in to “down regulate” the inflammation after a few days. Peer reviewed papers demonstrate that interventions such as empathy reduce biological markers of inflammation and restore equilibrium. This is also a metaphor. When an angry—“inflamed”—person is listened to empathically—is given a “good listening” as I like to say—the person frequently calms down and regains his equilibrium.
Empathy migrates onto the short list of inflammation reducing interventions. The compelling conclusion is that empathy is good for your well-being.
(c) Lou Agosta, PhD and the Chicago Empathy Project
Poverty is bad for your health. Inequality causes poverty. In turn, poverty causes illness and death. Therefore, inequality kills. The evidence is extensive. The data is compelling. The logic is impeccable. But is this not just correlation, not causation?
A causal account comes into view. When the evidence is vast and deep enough, we can
connect the dots between the correlated items – in this case, poverty, inequality, and bad healthcare outcomes (i.e., death) – and provide a causal account.
While it remains true that correlation is not causation, a flood of evidence is available – and overwhelming: The high correlation between poverty and ill health points to numerous causes intimately related to low socioeconomic standing, being poor. For example, poverty is stressful. Extremely stressful: “People who are exposed to constant high levels of stress do have biological reactions that can shorten their lives [….] [E]xposure to chronic environmental stress causes biological changes within the body that predispose individuals to develop premature disease” (pp. 66 – 67).
For instance, a person at risk for Type II Diabetes benefits from regular exercise and a balanced, healthy diet, high in protein, fruits, vegetables, and low in “bad fat.” Living in a high crime zip code likely also means they live in a “food desert.” Not only is there no Whole Foods or other high-end grocer available but “convenience stores” are long on junk foods and short on fruits and vegetables. When someone gets hungry, unhealthy calories are a likely outcome – nothing wrong with a Twinkie once in a while, but there is a reason the term “junk food” was invented. The person cannot go out for a vigorous, healthy walk because that results assault by local criminals. This is not a problem that can be fixed by the good advice of a medical doctor in an office visit, beneficial though that advice may be. It requires social change and a confrontation with values that privilege profit and cost reduction over people and their well-being.
This leads the author, David Ansell, MD, to a key distinction, which is itself controversial and unavoidable: structural violence. “It is the cumulative impact of laws and social and economic policies and practices that render some Americans less able to access resources and opportunities than others. This inequality of advantage is not a result of the individual’s personal abilities but is built into the systems that govern society” (p. 8).
Ansell gives a powerful example of one of his patient’s, Windora, who eventually suffers but survives a life-changing stroke that costs her the ability to speak. Ansell becomes her voice in this work.
Windora has a “good job” in the school system but not one that pays enough for her to move out of her impoverished zip code. She has hypertension and would benefit from a vigorous walk everyday, but she can’t go out because the neighbor is unsafe. Joining a gym is too expensive, and there is no YMCA within miles. She would benefit from a healthy diet of fruits and vegetables, but she lives in a food desert with a lot of convenience stores selling junk foods. A double bind? Blame the victim? After a certain point, no amount of personal initiative can overcome the obstacles. But a rental voucher might help.
Part of the “back story” for creating areas of overwhelming poverty, educational disadvantage, and social stress were “racially restricted covenants” in real estate. Even after the US Supreme Court outlawed such real estate deeds in 1947, billions of dollars continued to be spent in building public housing in or near impoverished areas. This virtually guaranteed segregated housing, resulting in de facto segregation in schools, and the resulting loss of upwardly mobile educational opportunities for (mostly) black or underprivileged children. The cycle continues. The examples of stable integrated neighborhoods such as Oak Park or stable black communities such as Chatham were overwhelmed by the unethical, fear inspiring but profitable practices of “block busting,” based on distorted, negative racial stereotypes. (For details on the back-story here see Polikoff’s Waiting for Gautreaux: A Story of Segregation, Housing, and the Black Ghetto (2).)
The media share responsibility for perpetuating stereotypes. In the wake of Hurricane Katrina, white people wading through chest high water, carrying groceries from abandoned food stores are described as survivors “finding” the food they needed in order not to starve whereas people of color doing exactly the same thing with the same bags in the same chest high flood waters are described as “looters” (p. 87). Hmmm.
In addition to structural violence, there is actual violence. Ansell writes: “Between 2007 and 2012, Chicago police shot over four hundred people. There were seventy police fatalities during that period, the most in the nation. Between 2004 and 2014, the cash-strapped city dished out $662 million in police brutality settlements” (p. 164).
Ansell imagines all the good things that could be done with that money for school and health-care. I would add to the list: expanded police training. I do not mean target practice or armored cars. I mean training in conflict de-escalation, community relations, courtesy and conversation. Just because deadly force can be used, does not mean it must be used. Empathy is distinct from compassion (though the world needs more of each). Empathy is a method of data sampling, telling a person what the other person is experiencing. In a police context, this would include whether the other is afraid or angry and, most importantly, is at risk of escalating to an aggressive response. No guarantees, but the widows and orphans of fallen heroes are looking for alternatives to shoot first and ask questions later (my phrase, not Ansell’s).
Meanwhile, Dr Ansell’s recommendation to fellow doctors? A bold statement of the obvious: Follow the Hippocratic oath (Ansell cites the modern version called “the Declaration of Geneva, Physicians Oath”). This action may be more confronting and difficult than most physicians imagine. The language about “consecrating one’s life to the service of humanity” and the first consideration being the health of one’s patients is the critical path. This extends beyond the walls of the office or hospital to personal advocacy.
For example, Ansell cites Paul Farmer reporting that when patients living in poverty took their tuberculosis medication, they got better, but they also got very hungry. The TB actually eliminated their hunger. They were too sick to feel hungry – a well disguised “blessing” indeed – so they stopped taking the medication because they were overwhelmed with hunger. The solution was not to call the patient’s “stupid” for not complying with their doctor’s orders. Once food was delivered with the medications, the patients became adherent with the treatment regime. Is the doctor then responsible to feed the hungry? Well, he who wills the end (health) wills the indispensably necessary means to the end (food + TB medicine).
Ansell makes a powerful case that any doctor refusing to treat a patient who presents with symptoms is violating the Hippocratic oath. Health care is an inalienable human right, along side life, liberty, and the pursuit of happiness (except that it has been alienated to enable monopoly rents to insurance companies, Big Pharma, and the corporate transformation of American medicine). “Health care” is a component of the “life” part of the enumeration of rights with which the Declaration begins.
However, the point is not to force an outcome. No one can force anyone to do something that they do not want to do. (For detailed background on the role of profit in the bio-psychiatry of major mental disorders and “Big Pharma” (a once devaluing term that is now accepted), a vexing trend that Ansell does not engage, see Robert Whitaker (3).)
The point is not to force doctors to make excuses for not treating the poor, which risks impacting the doctors’ livelihood and revenue model. The point is advocacy: to mobilize doctors to take on a system that treats health care as an economic transaction. The point is to mobilize doctors to push back against a system that rations scare resources such that the system, in spite of complex algorithms to determine fairness (see The National Organ Transplant Act (1984)), frequently results in the transplants being allocated to middle-aged white males. It is a disturbing statistic that the poor and people of color are frequently the organ donors while rarely being the recipient of life-saving transplants. Once again, there is something very wrong with this picture.
I hasten to add that Ansell reports a compelling example of community activism resulting in Illinois enacting legislation allowing the undocumented to receive kidney transplants and lifetime medications with State financial support “in part because we listened and tried to help” (pp. 107, 108).
Now I have read Ansell’s book cover-to-cover, including the extensive footnotes as well as the back cover. The one, flat out error I have found is on the back cover. Contra to the back cover, nowhere does Dr Ansell write “Inequality is a disease” or that it must be treated as a disease.
Ansell does indeed argue at length that inequality causes poverty and that poverty and inequality (and a host of related social injustices) set off a sequence of events that, like the falling dominoes, create a death gap, causing poor people, especially people of color, to die prematurely. For example, carbon monoxide can kill you, too, but carbon monoxide is not a disease (my example, not Ansell’s). It is a substance that the human beings cannot process. It is inimical to life. An environment of poverty is like carbon monoxide for the human body and soul. It chokes the life out of the person, albeit slowly, preventing binding with life-giving resources that the person needs to survive and flourish.
As noted, neither poverty, starvation, arsenic, lead, nor similar phenomena are diseases. Structural violence is not a disease; it creates a negative clearing for disease in the context of social injustice.
Contra the back cover, Ansell’s point is precisely that no medical treatment in itself will cure poverty, prevent the resulting fatalities, or undo the death gap. Reducing and eliminating the death gap requires advocacy: structural reforms and political engagement to combat structural violence. It requires honoring one’s commitment to social justice in the community. It requires a redistribution of sometimes scare resources – health care, education, jobs, law enforcement – from the wealthiest and most privileged on the Gold Coast a couple of miles west and south to neighbor whose numbers read like they were from the third world. It seems the editors of the back cover were blinded by privilege, too.
Ansell has recommendations. Practical proposals are forthcoming: “[Concentrated reinvestment in impoverished communities] will require a redistribution of wealth through taxation from the affluent back to the poor in the form of living wages, access to higher education, health care, and safe housing” (p. 54). “These structural reforms could take many forms, from tax and job policy to the ending of mass incarceration. From the perspective of health reform, the adoption of a single-payer health care system is the only way to create equity in health care. Single-payer health care will be vigorously opposed by the profit-driven private health insurers and by those who will insist it is too costly or not feasible” (p. 182). Speaking personally, I am at a loss as to why certain politicians and parties seem unwilling for people to get health insurance and health care at a cost that also enables them to pay rent, eat, and so on.
One final thought. Today evidence-based medicine is the dominant paradigm and with good reason. Evidence is superior to guess work. In peer-reviewed article after article we can read about a 3% improvement of one pharmacological, procedure, or laparoscopic intervention versus another. Well and good. Empathy and compassion are in short supply in the world, and, in any case, are not enough. Leadership is also required, and Ansell provides that here.
If this book, Ansell’s work, dense with evidence, data, facts and figures that support the subtitle (“Inequality Kills”), does not become the conscience of the medical community and a blue print for transformation and reform, then not only am I a monkey’s uncle, but the collective blind spot of the medical community is the size of the dark side of the moon.
We end where Ansell ‘s book begins. Ansell’s opening quote from Martin Luther King is as true today as it was in 1964: “History will have to record that the great tragedy of this period of social transition was not the strident clamor of the bad people, but the appalling silence of the good people” (p. vii). This book is addressed to the good people. Drop what you are doing and get the book: read it, honor your commitments, follow the recommendations.
(1) David A. Ansell, MD, (2017), The Death Gap: How Inequality Kills. Chicago: The University of Chicago Press.
(2) Alexander Polikoff, (2006), Waiting for Gautreaux: A Story of Segregation, Housing, and the Black Ghetto. Evanston, IL: Northwestern University Press.
(3) Robert Whitaker, (2010), Anatomy of an Epidemic. New York: Broadway Paperbacks (Random House).
(c) Lou Agosta, PhD and the Chicago Empathy Project
Class starts Tuesday March 28th. Empathy is oxygen for the soul. So if you are feeling short of breath due to life stresses, perhaps one needs expanded empathy. Get some here. This is what you need to know to
register. Further details on the course content are in line below. To register for the course, you need to provide basic info and register with the UChicago Graham School of Continuing Education. If you have any special requests, none of this is “chiseled in stone” yet (though it will be by 03/21/2017), so see my contact data below and let me know. There are no prerequisites or grades. This is Continuing Education. Cost is $360.
HUAS 61001 | A Rumor of Empathy in NeuroscienceA rumor is an unsubstantiated report. This course will pursue the rumor of empathy in neuroscience. The rumor is substantiated – empathy LIVES in neuroscience. But there are some conditions and qualifications. Connecting the dots between the mechanisms of neurotransmitters and the first person experience of a conversation for possibility in education is complex. This class will do a close reading of the texts that provide the deep structure of the history of empathy along with the “cliff notes / spark notes” version of what you need to know about neuroscience to engage in a meaningful conversation about the issues. We will aim at making empathy present and palpable in our work in class.
|Course Code:||HUAS 61001|
March 28 to May 16
1:30 PM–4:00 PM
A RUMOR OF EMPATHY IN NEUROSCIENCE
There are a number of relatively short readings – not more than thirty pages a week – that are available for free on the Internet as URLs and/or downloadable PDFs or plain text [licensed under licensed under a Creative Commons Attribution-NonCommercial 4.0 International License]. Short URL: http://tinyurl.com/h5f873s [password needed – and provided by me upon registration]. Please plan on doing the reading before the class so we can have a meaningful conversation.
SCHEDULE: March – May 2017 [Class meets from 1:30 pm – 4:30 pm / Gleacher Center]
March 28, 2017 : [Empathy] Mirror Neurons, Embodied Simulation, and the Neural Basis of Social Identification by Vittorio Gallese. The identification of mirror neurons in the mid 1990s caused a explosion of interest in empathy.
April 04, 2017: The Functional Architecture of Human Empathy by Jean Decety et al: DecetyThe_Functional_Architecture_of_Human_Empathy copy. Even if Decety’s views have continued to evolve, this is the paper that provides an opening to understanding empathy that has still not been surpassed.
April 11, 2017: Resistance to empathy!? Addressing Empathy Failures by Jamil Zaki. For something like empathy that is supposed to be as popular as kittens, motherhood, and apple pie, there is a surprising amount of resistance to engaging closely with it. Find out why.
April 18, 2017: Brainwashed: My Amygdala Made Me Do It – and Neurocentrism by Sally Satel, providing a short glossary of terms needed to debunk voodoo correlations in neural science
April 25, 2017: Empathy [and] The Myth of Mirror Neurons and the Broken [Empathy] Mirror by Gregory Hickok. The debate is joined. Yes, mirror neurons were discovered in Macque monkeys, but what REALLY was discovered and how does it map to human beings?
May 02, 2017: Empathy [and] Mindblindness: Am Essay on Autism and Theory of Mind by Simon Baron-Cohen.
May 09, 2017: Empathy on the Inpatient Unit: Plato Not Prozac! Chapter 3 from Lou Agosta’s A Rumor of Empathy: Resistance, Narrative, Recovery
May 16, 2017: Empathy and Trauma: The Body Keeps the Score: Mind, Brain and Body in the Transformation of Trauma by Bessel van der Kolk. An essential text of working with empathy and trauma. How not to succumb to compassion fatigue or burnout and make use of empathy as a method of guarding against these empathic breakdowns.
The course follows an ascending path from a natural history of empathy, in which
empathy is defined, through methods of disclosing and engaging empathy, to applications of empathy in neurology, trauma (human suffering), and so-called diseases of empathy such as autism. The approach to class discussion is to discuss a close reading of the texts; but time is also available to discuss what one might call “empathy tips and techniques” in expanding one’s empathy in class and daily life. In empathy, one is quite simply in the presence of another human being. Join me in making empathy present and expanding empathy in our lives and in the community.
Lou Agosta, Ph.D. is the author of three academic books on empathy. He is assistant professor medical humanities at Ross University Medical School. His PhD is in philosophy (University of Chicago).
This work aims to be educational in a brain-storming way about the role of empathy in the community and the market for empathy services. Hanna Holborn Gray has said that “education should not be intended to make people comfortable, it is meant to make them think.” I hereby also add: The intention of education is to expand one’s empathy. Amazingly enough that is not as comfortable as many people might imagine, which brings up to the first trend – resistance to empathy.
10. Resistance to empathy grows and is acknowledged. I may be a tad late with this one, since it is actually front section news in the New York Times, but just in case you have been living in a cave: Empathy is supposed to be like motherhood, apple pie, and puppies. What’s not to like? Yet people can be difficult – very difficult – why should empathizing with them be easy? Yet most of the things that are cited as reasons for criticizing and dismissing empathy – emotional contagion, projection, misinterpretation, gossip and devaluing language – are actually breakdowns of empathy. With practice and training, one’s empathy expands to shift breakdowns in empathy to breakthroughs in understanding and building community.
9. Empathy is not an on-off switch; it is rather a dimmer or rheostat (and the public debate acknowledges this). Engaging with the issues and sufferings with which people are struggling can leave the would-be empathizer (“empath”) vulnerable to burnout and compassion fatigue. The risk of compassion fatigue is a clue that empathy is distinct from compassion, and if one is suffering from compassion fatigue, then one is doing it wrong. The listener may get a vicarious experience of the other’s issue or problem, including their suffering, so the listener suffers vicariously, but, strange as it may sound, not too much. As noted, if one is over-whelmed by suffering, one is doing it wrong, and one needs to increase the granularity of one’s empathic receptivity. Empathy is like a dimmer – tune it up or tune it down. Empathy is like a filter – increase the granularity and get more of the other’s experience or decrease the granularity (i.e., open the pores) and get less. That is the whole point of a vicarious experience – and training one’s vicarious experiences as distinct from merger or over-identification – to get a sample or trace of the other’s experience without being overwhelmed by it. Empathy is not so much an on-off switch as it is a dimmer or rheostat to gradually turn the lights up or down – gradually expand or contract the granularity of one’s empathic receptivity. This point is completely missed in the otherwise engaging and spirited public debate feature in the New York Times where Hamid Zaki identifies empathy with compassion – and – how shall I put it delicately? – it is a conversation of deaf persons about the importance of listening from that point onwards[see http://tinyurl.com/gwmfpxp%5D. The recommendation? Listen, interpret the resistance and apply conflict resolution principles – identify and express grievances, invite self-expression, apply the soothing salve of empathy to the narcissistic injuries, elicit requests/demands, propose compromises / action items, iterate – until resolution.
8. Empathy is too important to be left to the psychologists. For psychologists empathy is by definition a psychological mechanism. For example, identification or transient identification or projection plus introjection (or visa versa) or mirroring or mirroring plus recognition of the other or inner imitation or motor mimicry. (This list goes on and this is not complete.) And while there is nothing wrong with psychological mechanisms or neuropsychological narratives built around their operation in the cerebral neural cortex and basal ganglia, there is something missing – empathy. So what then is empathy? Very short definition: It is being in the presence of another human as a human being with nothing else added. This [big word trigger alert] is the ontology of empathy – being in the presence of the other individual without anything else added. (This is called “ontology” – the study of being and ways of being, and it is definitely not psychology.) For example, Heinz Kohut, a psychiatrist from a time when psychologists were either psychoanalysts (or behaviorists), had a definition of empathy as vicarious introspection. This has an key ontological dimension as Kohut says “the idea of an inner life of man and thus of a psychology of complex mental states, is unthinkable without our ability to know via vicarious introspection – my definition of empathy […] what the inner life of man is, what we ourselves and what others think and feel life of the other individual would be inconceivable without empathy” (Kohut 1977: 304). The point is that empathy is both deeper and broader than a psychological mechanism – it is the basis for relatedness between individuals. Without empathy, no relatedness. Empathy grants being to relatedness. This matter of being with the other individual, in turn, becomes the foundation for community in an expanding circle of inclusion. As soon as one adds diagnostic categories, labels, arguments – which, admittedly, can be required in some contexts – empathy mis-fires, relatedness goes missing, and resistance to empathy expands. Thus, an empathic conversation is frequently challenged to find the equilibrium between using categories and distinctions to access the experience of the other individual while being with the other and being receptive to the vicarious experience of their suffering (or joy) as another human being.
7. Life coaching gets traction as empathy consulting. Empathy and life coaching intersect (again). The reason an Olympic athlete has a coach is not because she is not good at what she does. Positively expressed, people get a coach when they want to take their game – their performance – to the next level. Many people are already good at what they do and are committed to expanding their results in one area or another such as career, relationships, physical well-being, contribution to community, or peace of mind, in which their experience indicates something is missing. People get a therapist when they want a diagnosis or when they are pushed into survival and need to find a way out. Nothing wrong with that – indeed it can be critical path to transforming suffering into productive results. However, there is good news here – many people are not suffering but have an area in their lives that needs work to provide the results to which they are committed. This is where empathy is oxygen for the soul and can facilitate breathing easier in climbing the stairs to self-satisfaction in accomplishment. Yes, performance may usefully be measured “by the numbers” with meaningful data, but you don’t just need data, expanded empathy is required too.
6. “Hug a stranger” becomes an empathy trend. I am not making this up – well, okay, in a way, I am. The human body is the best picture of the human soul. So hugging another person is not just an emotional and physical but also a spiritual gesture. In this case, hugging and the “space of hugging” starts a journey of discovery that gives us access and reveals that there are far fewer strangers in the world – possibly none – then we at first imagined. I learned about this trend from Stone Kraushaar who distinguishes the physical embrace – the hug [with permission] – between two people from the “space of hugging,” which (on a good day) opens up a whole universe of empathy, sharing, transforming, building community, and being with mutual humanity. While acknowledging that hugging is not empathy, in the context of Stone’s work (and pending book), it is – in the deep sense of being in the presence of another human being without anything extraneous being added or subtracted. So if you see people walking down the street stopping for conversation, asking permission, breaking out in spontaneously hugging one another, you will know they have been engaging with Stone’s provocative proposal. You just might see yourself and encounter your own humanity in another in a new way you had not previously imagined. The empathic point is that you start by thinking these other people “out there” are strangers but when you get to know them well enough to be comfortable with a hug, you and they belong to the same community – you are not strangers after all.
5. Health insurers promise empathy, do not deliver, and continue to collect monopoly rents. The empathy gap widens. Health insurers maintain a firm grip on the market for empathy-related “behavioral health” services without actually providing any. This is the only candidate trend from last year that I am repeating, since it is still accurate but a work in progress – and, unfortunately, picking up speed, going in the wrong direction. The Affordable Health Care Act (“Obamacare”) – reportedly to be terminated with extreme prejudice as this piece is about to be posted – promised to equalize benefits for medical benefits such as annual physical health checkup (including $800 worth of blood work) with mental health services such as psychotherapy. At the risk of being cynical, I don’t know if the reader has tried to collect lately or services rendered. The war stories, pretexts for nonpayment, and simple violations of their own rules – e.g., timely response – by insurers continue to mount. One feels a certain dissatisfaction with the lack of solutions. What to do about it? In spite of claims to the contrary, the recommendation from insurers seems to be: “But your majesty, the people have no mental health benefits. Then let them pay cash! And then let them eat cake.”
4. Medical doctors “get it” – empathy is good for your health. Empathy gets traction as an evidence-based intervention. “Evidence-based everything” is the gold standard in medical and so-called “behavioral health” interventions; and that is as it should be (Jeremy Howick, (2011)). The “gold standard” of the “gold standard” is double-blind testing, which works especially well in the cases of drugs in which one can indeed “double-blind” the test so that neither the researcher nor the recipient knows who is getting what pill. While judgments based on clinical practice, tacit knowledge, and deep life experience will continue to have a role, these need to be qualified by the best available evidence. But here is the issue: There are some interventions such as penicillin and using a parachute when jumping out of an airplane that seem to limit or even defy the gold standard. It would be unethical not to give someone penicillin if they were infected with an infection serious enough to require such treatment, since it is a matter of historical accident that penicillin was invented prior to the “evidence based” paradigm shift. And, as regards using a parachute, that case is the reduction to absurdity of not using common sense as a criteria in deciding what counts as evidence. What is going on here? The answer: The effect size is so large that it outweights and overwhelms any hidden confounding factors and so rises to the level of evidence (without quotation marks) [Howick: 5, 11]. The :effect size” is a function of the the fact – the evidence – that there are so many examples and so much experience that penicillin works – that parachutes – work that the risk of one’s over-looking some other confounding variable is vanishingly small. It really was the penicillin, not (say) the effects of the alignmnet of the planets hidden behind the penicillin. Likewise, with empathy. The trend here is that research will emerge that puts the use of empathy in human relations as demonstrably so effective in the medical and behavioral health contexts in question that not to apply empathy would be like not prescribing antibiotics against a bacterial infection. Empathy has been effective in shifting the suffering and transforming the psychic pain throughout history. The criticism of empathy has usually been that it results in burnout, compassion fatigue. But penicillin, too, has to be properly dosed or the results will be unpredictable. Regarding empathy, see the discussion above about empathy not being an on-off switch but a rheostat that requires training to get just right. Examples of peer-reviewed publications exist in which empathy was shown to be effective (in comparison with less empathy) in correlating with favorable outcomes in diabetes, cholesterol, and the common cold (?!) and are cited in the bibliography (see M. Hojat et al, (2011), John M. Kelley, Helen Riess et al, (2014), David P. Rakel et al, (2009)). Expect this work to expand and gain traction in other areas such as psychiatry and cognitive behavioral therapy. In short, not to begin with empathy would be like jumping out of the airplane without a parachute or not providing penicillin when the infection was bacterial. Curiously enough, among medical doctors, psychiatrics are alleged to be “lagging adopters”; among psychologists, those specializing in cognitive behavioral therapy are – note that Arthur Ciaramicoli claims to have it both ways (in a book (2016) that I wish I had written).
3. The culture of empathy taps into the power of empathy. Empathy gets in touch with its own power and becomes self-aware as being powerful. This is (and would be) completely unpredictable. At least initially that looks like the culture of empathy partnering with assertiveness training, fair fighting, and being self-expressed. The culture of empathy gets traction in conflict resolution, building community, setting limits to the anti-empathic methods of bullies; and this trend gets the attention that it so richly deserves. The CultureOfEmpathy [one word] is the web site and brain child of Edwin Rutsch, whose has literally interviewed dozens of empathy scholars and researchers (including myself) and is one of the most inclusive people I have ever met. Here is the issue: in fighting off bullies how does one do so in such a way that one does not become a bully oneself? The recommendation is direct: empathy is about setting boundaries between self and other and crossing boundaries between self and other in a way that enhances mutual understanding and community. No one was ever required by empathy to be a door matt. Since empathy works best and seems to require that people relate as equals in the matter of their humanity, the relation between empathy and power has always been fraught. It requires work. When the power relations as too asymmetrical or when force (violence) is being used to coerce an outcome, then a level playing field has to be reestablished for empathy to get traction. Then the empathic thing to do is fight back – self-defense is its own justification. Simple as that (though, as usual, the devil is in the details). Bullying – and related forms of aggression are the contrary of empathy – crossing boundaries in ways that generate misunderstanding and the dehumanizing aspects of shame and humiliation. Set firm boundaries.
2. Empathy becomes known as reducing inflammation and restoring homeostatic equilibrium to the body according to evidence based research along with mindfulness (a form of meditation), Yoga, Tai Chi, sensory deprivation and certain naturally occurring steroids (Antoni MH, Lutgendorf SK, Blomberg B et al. (2011), David Black, Steve Cole, Michael Irwin et al, (2013), Michael R Irwin and Richard Olmstead, (2012)). Although an over-simplification, when the human body is attacked by bacteria, it mounts an inflammatory defense that sends macrophages to the site of the attack and causes “sick behavior” in the person. The infected person takes to bed, sleeps either too much or too little, has no appetite (or too much appetite), experiences low energy, possibly has a fever, including the “blahs,” body aches, and flu-like symptoms. This response has evolved over millions of years and is basically healthy as the body fights off the infection using its natural immune response. However, fast forward to modern times. This natural response did not imagine the stresses of modern life back when we were short proto-humanoids inhabiting the Serengeti plain and fending off large predators. Basically, the body responds in the same way to the chronic stress of modern life – the boss at work is a bully, the mortgage is over-due, the children are acting out, the spouse is having a midlife crisis – and the result is “sickness behavior” – many of the symptoms of which resemble clinical depression – but there is no infection. The inflammation become chronic and the body loses its sensitivity to naturally occurring anti-inflammatory hormones, which would ordinarily kick in to down regulate the inflammation after a few days. Peer reviewed papers demonstrate that interventions such as those indicated above reduce biological markers of inflammation and restore equilibrium. This is also a metaphor for when an angry [“inflamed”] person is listened to empathically, they [often] calm down and regain their equilibrium. The trend here is that empathy migrates onto the short list. Now for something completely different …
1. A definable market for empathy software and business services emerges. Virtual reality (VR) software meets and expands empathic understanding. A company named Psious [psious.com] has developed a diverse set of applications for virtual reality goggles to simulate situations that psychotherapy clients may find anxiety inspiring such as flying on a commercial jet, public speaking, shots (e.g., with needles) at doctor visits and many more (see my Blog post on Psious (http://tinyurl.com/jyuxedq)). Two other companies that are a software initiative relating to empathy include Affectiva [affective.com], which automates Paul Ekman’s facial action coding scheme (see my blog post (http://tinyurl.com/hymj3mj)), and Empathetics [empathetics.com], not yet reviewed. From admittedly incomplete reports, the engaging thing about Empathetics is that its value proposition is to train medical doctors in empathy using biofeedback under a program licensing intellectual property developed at Massachusetts General Hospital in Boston. In addition, this medical initiative is distinct from but related to two companies (Business Solver and Maru/VCR) which call out “empathy” explicitly as a key differentiator in what they offer their business clients. Business Solver is branding an empathy monitor for business success in a human resources platform and related services. This includes the disturbing data point that some 61% if business leaders see their firms as being empathic whereas only 24% of employees do. What to do about it constitutes the bulk of the engagement. Maru/VCR has a database based on the Vision Critical Research platform that enables its clients to build customer communities and get access to breakthrough innovations and insights in market research.
0. Businesses “get it” – empathy is good for business. Profit is a result of business operations, not “the why” that motivates commercial enterprise. And if profit shows up that way (as the “the why”), then you can be sure that, with the possible exception of commodities hedging, it is a caricature of business and a limiting factor. Business prospers or fails based on its value chain and commitment to delivering value for clients and consumers. However, some of the things that make people good at business make them relatively poor empathizers. Business leaders lose contact with what clients and consumers are experiencing as the leaders get entangled in solving legal issues, reacting to the competition, or implementing the technologies required to sustain operations. Yet empathy is on the critical path for serving customers, segmenting markets, positioning products (and substitutes), psyching out the competition [not exactly empathy but close enough?], building teams and being a leader who actually has followers. When the ontology of empathy exposes it as the foundation of community, then expanding empathy becomes nearly synonymous with expanding business. For example, building customer communities, building stakeholder communities, team building, are the basis for brand loyalty, employee commitment, and sustained or growing market share. Can revenue be far behind? Sometimes leaders don’t need more data, we need expanded empathy, though ultimately both are on the path to satisfied buyers, employees, and stakeholders. Specific firms that have emerged – albeit in the context of an early market – to address these aspects of empathy in business and are called out in trend #2 above.
[These ten top trends in empathy for 2017 should be read in connection with the score for those from last year (2016) [see http://tinyurl.com/gub7pew]. And, yes, I know that there are actually eleven this year – bonus!?]
Antoni MH, Lutgendorf SK, Blomberg B et al. (2011), Cognitive-Behavioral Stress Management Reverses Anxiety-Related Leukocyte Transcriptional Dynamics. Biological Psychiatry, 2011; 15: 366-372.
David Black, Steve Cole, Michael Irwin et al, (2013), Yogic meditation reverses NF-kB and IRF-related transcriptome dynamics in leukocytes of family dementia caregivers in a randomized controlled trail. Psychoneuroendocrinology, 2013 March 38(3): 348 – 355.
Arthur Ciaramicoli, (2016), The Stress Solution. New York: New World Library.
Jodi Halpern, (2013), “What is Clinical Empathy?” J Gen Intern Med 2003 Aug: 18(8): 670 – 674.
Hojat et al, (2011), Physicians empathy and clinical outcomes for diabetic patients, ACAD MED MAR; 86(3): 359 – 64: doi: 10.1097ACM.0b013e3182086fe1
Jeremy Howick, (2011). The Philosophy of Evidence-Based Medicine, Wiley-Blackwell, 2011.
Michael R Irwin and Richard Olmstead, (2012). Mitigating Cellular Inflammation in Older Adults: A Randomized Controlled Trial of Tai Chi Chih. American Journal of Geriatric Psychiatry. 2012 September; 20(9): 764 – 722.
John M. Kelley, Helen Riess et al, (2014), The Influence of the Patient-Clinician Relationship on Healthcare Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, PLOS ONE [Public Library of Science], April 2014, Vol. 9, Issue 4.
Heinz Kohut, (1977). The Restoration of the Self. New York: International Universities Press.
David P. Rakel et al, (2009),”Practitioner Empathy and the Duration of the common Cold, Fam Med 41(7): 494 – 501.
Lou Agosta, (2015). A Rumor of Empathy: Resistance, Narrative, and Recovery. London: Routledge.
_________ (2014). A Rumor of Empathy: Rewriting Empathy in the Context of Philosophy. New York: Palgrave Pivot.
__________ (2010). Empathy in the Context of Philosophy. London: Palgrave Macmillan.
(c) Lou Agosta, PhD, and the Chicago Empathy Project