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Part Two: Empathy: Spa Treatment for the Soul: Against Stress

This is Part Two of the series on how empathy relates to reducing stress as a “spa treatment for the soul.” In order to understand empathy as a kind of antidote to stress, it is important to know the enemy – in this case, stress. Therefore, this discussion lays out the distinctions that help us understand what makes stress, well – stressful. The third and final part (due out in about a week will then bring it all back home with the evidence-based research on the stress reducing and well-being promoting properties of empathy and a set of related practices.

Listen to Parts 1 and 2 of the blog posts as a podcast on Spotify –

(Note this is not a transcript but a different performance of the same context as the text.)

Stress and inflammation: Some is good, too much is not

As my Grandma Laura understood implicitly (and as detailed in Part 1), stress reduces the body’s immune defenses. The person becomes vulnerable to disease. What is less well understood is how the body responds to social stress; and what the heck is “social stress” anyway? 

We will precisely define all kinds of stress in the next section, but, for the moment, social stress is stress related to competition and conflict between people, who are trying to live together in a human community. 

The body responds with an immune response, because social stress seems to simulate the attack of something coming at the person and the person’s body from the outside such as an infectious agent like a virus or bacteria. The immune system response to the perceived stress results in inflammation, which, in turn, aggravates emotional and psychosomatic disorders. The challenge is to connect the dots between stress, inflammation, physical diseases, emotional disorders, and then intervene with empathy to interrupt this negative cycle. 

“Social stress” is a feature of life for people who have to work and live with other people, which, excepting a few hermits, is all people. Social stress includes the struggle and effort that people confront in careers, relationships, finances, scheduling, and sustaining emotional equilibrium.Social stress occurs in divorces, misbehaving kids, unemployment, adultery, and bankruptcies. Social stress occurs in the competition and aggression between people and groups such as bullying, office politics, stranger danger on the streets, and a host of interpersonal conflicts and pressures too lengthy to list here. 

We have been using the word “stress” as if we knew what it is; and we do know a lot about stress from first-hand experience. Stress is a distressing part of life. Stress is di-stressing. Literally. Chronic stress is a pervasive challenge. However, the complete absence of stress is not an option. The complete absence of stress means you are dead—or at least in a persisting vegetative state. Not good. 

Social stress is a substantial issue in attaining and managing physical and emotional well-being. It is no surprise that empathy has a significant role to play in shifting out of the stress with which the person is stuck and struggling. Let’s define our terms. 

Stress comes in five forms

We use the word “stress” too casually as something to be avoided at all costs. As noted, we forget that zero stress means you are dead, a situation one generally tries to avoid. Yet engaging with stress is, well, stressful. Let us define “stress” and do so precisely by enumerating its different forms. 

Stress comes in at least five forms: 

(1) Acute, time-limited stressor: For example, public speaking is “an acute, time-limited stressor.”[i] When asked “What do you fear the most?” death comes in second place on the list. Number one is public speaking. People for whom public speaking is a stressor feel better as soon as they are able to step down from the podium. In contrast, for those who train as speakers and performers, the stress of speaking can act as a positive stimulant. If a trained speaker does not feel a touch of “butter-flies” in the stomach, prior to a performance, that is considered a bad sign. Such people get worried if they do not experience some stress; because they know the stress will provide them with the extra energy they need to deliver a compelling performance. Thus, stress has a wholesome, healthy dimension when it gets people “on their best game.”

(2) A personal, life defining challenge: People facing a crucial, life defining examination, such as the Bar Exam in law or Medical Boards, experience acute stress. This is different than “stage fright” in that it is not public. Yet one is being tested, judged, and evaluated by those in authority. The risk is of not looking good or not acquiring the required professional license. Still, the stress is time limited. Once it is over, pending a favorable outcome, the stress is noticeably reduced. Once again, some stress in anticipating the exam is useful in providing an incentive to prepare. 

(3) Naturalistic stressors: Different kinds of natural or social events such as death of a family member, loss of a job, or divorce are stressful. These can be highly stressful; yet in every case, a definite end point exists that one can try to imagine. Mourning lasts about a year. People find other jobs. People meet new partners. 

Many of the rituals surrounding the death of a person to whom one is close are designed to facilitate the process of working through the stress. Wakes and funerals, when they function as designed, are calculated to evoke stories about the loved one, and the accompanying tears and laughter serve to process the loss. The storytelling itself is the empathic moment, making present a response in the form of acknowledgement and recognition of the life of the lost loved one. 

(4) Trauma as such: An event in the past that “lives on” emotionally such as the experience of war or rape is stressful. Even if the trauma is separated from the present by a significant interval of time, the stressor may live on. The person may experience and re-experience the trauma as intrusive thoughts, recurring nightmares, blunted affect, amnesia, avoidance, an exaggerated startle response, and so on. In short, criteria for post trauma stress disorder (PTSD) are satisfied, whether or not they rise to a clinically relevant level. This is chronic stress that does not quit. 

The treatment of choice for stressors related to traumatic events that keep coming back and live on is described as “exposure.” The survivor is supposed to do that which he is least inclined to do: expose himself to the trauma again (but now in a controlled and gradual way), redescribing the upset imaginatively or vicariously. In redescribing the experience in relevant detail, the unintegrated emotions and feelings are given a chance to be re-experienced and integrated. The trauma shrinks. Do this repeatedly and the trauma shrinks repeatedly, little-by-little, step-by-step. The trauma becomes manageable, which means it stops being traumatic. 

One gets one’s power back in the face of the upset whereas previously the event was an intrusive, monster-like interruption that one was trying to escape without noticeable success. For example, in eye movement desensitization routine (EMDR), the focusing on the back-and-forth movement of the light sequence or the therapist moving a baton, binds the patient’s attention (and potential fear) while he recalls, talks about, gives an account of, sometimes merely thinks about, and re-experiences the trauma in a non-traumatic, or at least trauma reducing, way. An entire account of trauma and recovery is implied here, and for further details the interested reader is referred to the relevant literature on trauma. [ii]

This is where empathy comes into its own as an intervention. What is often overlooked in accounts of such exposure-directed interventions is that, unless the re-experiencing is undertaken in the context of an empathic relatedness, it is like dental work without Novocain. Some patients who are hurting enough and courageous enough may stick with it; but many will just make other arrangements (such as drinking alcohol to excess), not come back, and continue to struggle in stuckness. The empathic relatedness provides the survivor with the empathic connectedness needed to risk diving again back into the emotional dimension of the trauma (which has previously been held at arms’ length), knowing that he can reconnect empathically with the facilitator to regain his emotional equilibrium. 

(5) Long term stressors: Long term stressors are ones with no defined or obvious end in sight. Examples of long term stress include caring for a loved one who has a progressive, degenerative disease such as Alzheimer’s; suffering from a life-threatening or serious chronic disease oneself; loss of one’s home, that is, becoming homeless; being employed significantly beneath one’s educational level on a long-term basis; financial ruin due to illness or criminal behavior (think of Bernard Madoff’s Ponzi scheme that financially destroyed many middle class lives); legal troubles; growing up being African American in states where racially motivated lynchings occurred (or arguably, growing up African American anywhere in America); being a refugee or immigrant and a stranger in a strange land. 

For example, the United Nations estimates that between (Q3 2017) and Q4 2022 the number displaced persons, refugees, in the world has increased from 60 to 108.4 million. Refugees are under extreme stress. In all of these cases, the stress is chronic and long term. The symptoms may or may not rise to the level of clinical post-traumatic stress disorder (PTSD); or the person may find other ways of responding to the distress and expressing the suffering. Self-defeating behavior, behavioral disorders, substance abuse, promiscuous unprotected sex with different partners or other forms of acting out, allergies, chronic hard-to-diagnose intermittent headaches, backaches, asthma attacks, irritable bowl, hard-to-diagnose chronic pain, and so on, are common. 

Relatively fewer extreme examples such as social isolation, long term loneliness, low socio-economic status (poverty), being the target of repeated bullying, are less immediately destructive of one’s humanity. Yet the cumulative stress entailed is substantial. 

From a completely different perspective, the modern, relatively well-to-do family has to run the gauntlet of seemingly endless micro-stressors. While not comparable with war or rape, “micro-stressors” are the abundant small insults, injuries, frustrations, and misfortunes that occur on a daily basis in fast-paced, modern life. These are “first world problems,” that end up taking seven years off of one’s life expectancy. Getting the kids up at an early hour and delivering them to school prior to a challenging commute to work is stressful. The boss at work is not necessarily an example of empathic understanding. On the contrary, it’s “by the numbers,” “get your numbers,” and if you don’t get your numbers, your days are numbered. If you don’t have any numbers, that itself is a bad sign, and we will find some for you. Relations with coworkers and superiors can be Machiavellian—and conflict-laden.

As noted, and not for the last time, the things that make us good at business—compliance, dealing with competitive pressures, managing technology—do not expand the affection and affinity in our relationships. Cynicism and survival drive out empathy, intensifying stress. Then the reverse commute back home; chauffeuring the kids around to activities such as soccer or play dates, to which they are entitled and which they require in order to become well-rounded, successful human beings; strained relationships with these very kids over homework and with the spouse over the lack of satisfying relatedness much less a sex life, and the drum beat of micro-stressors goes on. The formula for wide-spread chronic stress is complete.

Social stress enters the body through the immune system

The body responds to common bacterial infections and to wounds by becoming inflamed. How this works—and does not work—becomes a tadtechnical, and I have to ask the reader’s patience in laying out the distinctions needed to connect the dots between stress, inflammation, and empathy. 

How does stress get into the body? This is important, because, when stress “gets in,” it sets off a cascade of negative results that affect our physical and emotional well-being. To cut to the chase, scientists believe that stress gets into the body through the immune system. (See the article by Segerstrom and Miller (2004) cited above and listed as a reference below.) Once stress activates immune processes designed to fight infection, the dominoes start falling. Diverse systems of the body can be left in a state of chronic inflammation, which, if left untreated, result in life style disorders and diseases.

These disorders include conditions such as irritable bowel syndrome (IBS), metabolic disorders (obesity, type 2 diabetes, congestive heart failure, chronic pulmonary obstructive disease), migraines and lower back pain (notoriously difficult to diagnose), and numerous allergies (peanut, gluten, lactose, dust) with which many children (and adults) now find their vitality reduced. (This list is not complete.)

The human immune system was developed between 100,000 and a million years ago when our early proto-human ancestors emerged on the plains of present-day East Africa. Now one must be on guard against generating a “just so” story about what life was like in such an early environment of evolutionary origin. 

Our ancestors faced a different set of challenges than we do. If they wanted to get somewhere, they had to walk. If they wanted to do detailed work such as sewing after sunset, they had to light a fire. If they got sick, they had a choice of naturally occurring purgatives, stimulants, or a sweat lodge to try to sweat out the toxins. They were exposed to physical hazards in chasing game such as rabbits or antelope for food through the bush. Injuries such as cuts and abrasions were common; and when such injuries to the skin occurred, the risk of infection was significant. Responding to tissue damage had a priority. If a wound became infected, the entire organism was at risk. Mini-clinics had not yet been invented. 

What the sick person experiences as the disease is actually the beneficial side-effect of the defense mounted by the body’s immune system against disease. Our bodies developed their built-in ability to heal wounds and respond to infections in this physically demanding environment. We are the beneficiaries of millennia of natural selection to protect the organism against wounds and infections—and, in addition, we now have mini-clinics and antibiotics. 

The sick person experiences the disease as the body’s defense

The wound temporarily becomes red—it is inflamed—and the body sometimes becomes feverish in an attempt to kill the intruder by “cooking” it. As part of this defensive response, the body engages in “sick behavior.” It tends to withdraw; wants to lie down in its bed; experiences low energy; and has an increased need to sleep. Such behavior makes perfect sense in terms of rallying the body’s resources to overcome the disease.

The body summons defensive biological agents to the location of the injury. These defensive agents include macrophages—literally “big eaters”—that attack the foreign invaders and encompass and digest (i.e., eat) them. The body’s immune system gets into action and sounds the alarm using messengers called “cytokines.” “Cytokines” have become famous because an entire theory of depression is named after them. More on that shortly. 

These Big Eaters—macrophages—and cytokines congregate at the site of injury or infection, release toxic substances such as oxygen radicals that damage invaders, and break down the invaders and damaged tissue. These defenses have broad effects on the organism, including fever and inflammation, as they promote wound healing. 

Now take this immune system, which was developed to defend against wounds and bacteria, and fast forward about half a million years to our own time. Modern humans no longer face hostile animals and the elements. It is true that parts of our modern cities have become urban jungles, in which people behave in aggressive ways towards their neighbors; but the majority of the population still manages to avoid such situations, granted that is little consolation to those trapped in social injustice (itself a source of social stress). 

Today human beings face social stressors as well as biological ones. Such social stressors are symbolic in that they represent non-material entities such as status, power, a piece of paper or electronic bits called “money,” expectations about the future, access to resources based on educational opportunities (or lack thereof), and meaning making of the kind we explored in world class novels and narratives from George Eliot (May Ann Evans), Thomas Mann, Tennessee Williams, and Shakespeare. Social status is a symbolic good. For our proto-human ancestors, social status in the group translated into access to choose morsels of food and access to superior mating opportunities. Likewise, with us?

For us moderns the symbolic stress now has become chronic and unremitting. It is not that life as such was so much better when the vast majority of the population worked on a farm (or were hunter-gatherers). Let us not idealize the past. Days were long—from sunrise to sunset (since electricity had not been invented). Life was surely physically harder. Disease was not a symbolic threat; it was an ever-present danger and immediately present. Death was a daily companion and a near, not a remote, possibility. 

Still, expectations were probably lower. Resignation and acceptance of one’s fate were embedded more deeply. People were too physically exhausted to worry about whether one’s child would get into a preschool program that would enable her to qualify for Harvard. Perhaps that itself provided relief from chronic stress. 

If one lived even a hundred years ago, the likelihood was that, if one survived the hazards of childhood, an infectious disease such as influenza, tuberculosis, cholera, or pneumonia would eventually end one’s life. Childhood mortality and death in childbirth were major factors limiting life expectancy; though if one survived childhood, then one’s life expectancy as an adult might approach that which we enjoy today in developed countries with modern medicine.

 The good news is sometimes also the less good news. Today thanks to antibiotics and vaccinations, the vast majority of the population in developed countries survives long enough to develop chronic disorders associated with social stress and life style responses to it.

In the final part of this series, we look in detail at the dots connecting the stress and inflammation reducing properties of empathy with improved well-being and evidence based outcomes in basic medicine. Stand by!


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

[ii] Bessel van der Kolk. (2014). The Body Keeps the Score: Mind, Brain and Body in the Trans- formation of Trauma. New York: Penguin Books.

Note: All the usual disclaimers apply. This is not intended to be, nor is it, medical advice or medical guidelines. Always consult with your medical doctor and other professional counselors about decisions affecting your health and well-being. 

Image Credit: Group Tai Chi practice in a Shanghai park led by Grandmaster Xie Bingcan in 2011. Author: Seattletaijiquan This file is licensed under the Creative Commons Attribution-Share Alike 4.0 International license

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

Empathy – a spa treatment for the soul

My first training in stress reduction through empathy came from my dear Grandma Laura. With Grandma Laura the force of empathy was strong. However, she came from a time and place, prior to the Internet, that did not require much formal education. 

My Grandma Laura may actually have believed that getting caught in the rain caused upper respiratory infections such as the common cold. She was happy to make the chicken soup to sooth my sneezes and colds, and she endorsed chicken soup as the treatment of choice for the common cold. 

Grandma was relying on common sense—and a wisdom that is all-too-rare in our own time. She noted that people who were physically stressed out by exposure to cold and wet weather succumbed to the common cold. She also observed that rest and warm, nourishing liquids—chicken soup—provided relief to the sneezing, sniffling, suffering survivor until the cold had run its natural course. 

Listen to Parts 1 and 2 of the blog posts as a podcast on Spotify –

(Note this is not a transcript but a different performance of the same context as the text.)

I acknowledge the book Chicken Soup for the Soul. I stopped counting how many had been published in the series when the number hit eighteen. [i] Keep up the great work! The point here is that chicken soup, delivered in the proper context, reduces stress; and so it reduces the symptoms of inflammation (runny nose and so on) that occur when the immune system fights back against infection. 

Thus, empathy is compared to chicken soup. It has also been compared to sinking back into a hot bath, and taking the “healing waters” as part of a spa treatment. We shall work with all these metaphors. We shall also continue the work begun in Chapter Four with evidence-based, peer-reviewed, scientific publications that the benefits of empathy for the recipient are closely related to stress reduction. First, some background. 

My Grandma may not actually have had the distinction “immune system.” This distinction provides what we call the “confounding variable” in “Getting caught in the rain causes the common cold.” Of course, the rain does not cause the common cold. The rhino virus causes the common cold. What getting caught in the rain does is reduce the body’s immune system’s defense against viruses such as the rhino virus that already live in the body. 

The sneezing, sniffling, and suffering are the inflammation that occur when the body’s immune system is mobilized and fights back against the virus by producing the bodily defenses called “antibodies,” sending them to the site of the infection (i.e., the nose) to disrupt the viral attack. Antibodies are doing battle against the attacking viruses, the antigens. The result, at thirty thousand feet, is that the person experiences all the annoying symptoms of a head cold. 

In my case, Grandma was spot on in correlating getting wet and physically exhausted by the storm with coming down with a cold. We forgive her lack of scientific rigor. After all, she was a world class cook, even if an unsung one until now, not a immunologist. 

A word of caution. The distinction between “body and mind” is already embedded into our modern science, our thinking, our way of relating to other people, and our way of relating to ourselves. 

We are not going to undo centuries of distinguishing mind and body in this book. Still, we may usefully recall one philosopher’s (Ludwig Wittgenstein’s) anecdote: “The human body is the best picture of the soul.”[ii] Keep that in mind. 

A small set of practices such as receiving empathy, meditation (mindfulness), Yoga, and Tai Chi Chuan, promote recovery and well-being in reducing inflammation. The solution then is a hot bath? A spa treatment? Don’t laugh. There are many less useful interventions available. The limitation of a spa treatment is that it provides symptom relief, not a long-term solution. After the benefits of the spa treatment wear off in a couple of weeks, the person is right back where she or he started. The difference between empathy and a hot bath—granted that both are relaxing—is that empathy provides for structural change to the person’s personality, expanding resilience, emotional stability, and relatedness. Advantage empathy: empathy is superior to a spa treatment for the soul. How is this so? 

Today it is fashionable to say that whatever benefits a person, whether Prozac or mindfulness, rewires the brain. In plain English, practicing empathy, receiving empathy, being empathic, also rewires the brain, that is, it builds new habits. 

Empathy builds new habits in relationships—in engaging in listening to the other person, in interacting across personal boundaries, in reducing conflict, in an expanding toleration of upsets in relatedness, and in building a community of engaged neighbors. 

Expanding one’s empathy enhances one’s ability to deal with personal dynamics in friendships, intimate relationships, and in groups such as the workplace, school, and community. 

Expanding empathy enhances a person’s stability, strength of character, and emotional equilibrium in the face of destabilizing upsets. It enables one to be with people and events that are difficult. Expanding one’s empathy enables one effectively to get results where previously one would have experienced failure and frustration—and the resulting stress. 

With acknowledgement to Donald Hebb, “neurons that fire together wire together.” “Rewiring” is the new buzzword for “building habits.”

If the ideas in biology that we explore in this and the following posts are a tad technical, I am unapologetic. 

Psychopharmacologists and practitioners of behavioral interventions such as cognitive behavioral therapy (CBT) have been less than charitable in engaging with the status of the evidence on behalf of empathy and empathy-related interventions. “Dismissive” is the word that comes to mind; and yet the evidence-based, peer-reviewed distinctions that are engaged in this engagement with empathy cannot be dismissed. Those with economic and territorial incentives to provide a complex and expensive solution do not necessarily welcome a less complex or less expensive one such as empathy. 

The results are now in. Substantial evidence is available of what most people with common sense have appreciated all along, that empathy and being treated empathically are good for people’s health and well-being. Stress reduction works. Empathy works. The work we do in this chapter enables us to expand our understanding of why. 

Stress reduction practices such as meditation, Yoga, and Tai Chi do not necessarily work in the same way as empathy. (Full disclosure: I practiced Tai Chi weekly for four years, but have limited experience with the others.) 

I hypothesize that all these practices create a distance between one’s experience and one’s cognitive and emotional processes. This distance opens up a place for empathy to expand and authentic relatedness to occur. 

When this “distance” between one’s experience and one’s cognitive and emotional responses becomes habitual—today we would say “encoded in the neurons”—then the change is structural and, thus, long lasting and enduring. How does this work? 

The answer to the question awaits the next episode, the next post, in this series due out next week. Stand by for update!


 

Notes

[i] Jack Canfield, Sally Burbank, Terri Elders, and Amy Newmark. (2003). Chicken Soup for the Soul. New York: Soul Publishing (Simon and Shuster).

[ii] Ludwig Wittgenstein. (1951). Philosophical Investigations, tr. E. Anscombe. London: Basil Blackwell, 1968.Blackwell, 1968.

IMAGE CREDIT: Creative Commons Attribution: Logeshwaran Rajendran

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

Edwin Rutsch interviews Lou Agosta: Empathy Curriculum: Overview of the Empathy Lessons Training Seminar (ETLS)

Empathy Curriculum: Overview of the Empathy Lessons Training Seminar (ELTS): Edwin Rutsch interviews Lou Agosta about the ELTS and Lou’s experiences around empathy

To listen to Edwin’s Rutsch’s interview and conversation with Lou Agosta on Sept 1, 2026.

Play interview by clicking

here: Edwin Rutsch Interviews Lou Agosta

[ https://youtu.be/4jQe9ccVfM8?si=lwVibcPIN8D67v3w]

The following summary was generated by AI by Edwin Rutsch.

Edwin Rutsch interviews philosopher, author, and clinical assistant professor Lou Agosta to explore his 10-week “Empathy Lessons Training Seminar.” The discussion covers the philosophical foundations of empathy, its physiological benefits, methods for diagnosing and repairing empathy breakdowns, and the role of rigorous boundary setting.  


“Empathy isn’t drowning in the other person’s ocean of misery – it’s taking a six-ounce pour of their suffering so you can truly understand it without losing yourself.”

10 Week Training Outline

  1. Session One: The one-minute empathy training
  2. Session Two: Empathy and brain science – this is your brain on empathy
  3. Session Three: Empathy breakdowns, breakthroughs and introspection
  4. Session Four: Resistance to empathy
  5. Session Five: The Secret underground history of empathy
  6. Session Six: Empathy and story telling
  7. Session Seven: Empathy and boundary setting
  8. Session Eight: Review of the literature that empathy is good for one’s health and well being
  9. Session Nine: Speaking truth to power – rhetorical empathy in politics
  10. Session Ten: Empathy is the new love – examining love through empathy

This interview series is part of The Empathy Center’s initiative to develop an open-source Empathy Movement Training Curriculum.Join us in creating it.

Short Meeting Overview

Edwin Rutsch interviews philosopher, author, and clinical assistant professor Lou Agosta to explore his 10-week “Empathy Lessons Training Seminar.” The discussion covers the philosophical foundations of empathy, its physiological benefits in healthcare, methods for diagnosing and repairing empathy breakdowns, and the role of rigorous boundary setting. 

Paragraph Meeting Overview

This meeting serves as the inaugural interview in an exploratory series for the Empathy Movement Training Curriculum project, led by Edwin Rutsch, Founding Director of The Empathy Center. Guest Lou Agosta outlines the architecture of his upcoming 10-week training seminar, unpacking a multidimensional definition of empathy that spans receptivity, understanding of possibility, perspective taking, and empathic responsiveness. Agosta shares how his personal background, academic work at the University of Chicago under Heinz Kohut’s circle, and clinical teaching at Ross University Medical School informed his model of a “rigorous and critical empathy.” The dialogue bridges psychological theory and real-world application, detailing how stress reduction, mirror neurons, and repairing empathy breakdowns (e.g., emotional contagion, projection) enable human connection. Finally, both dialogue partners investigate movement-building strategies, discussing the need to articulate the societal value of empathy, embrace assertive public presence (such as the Empathy Tent and potential legislative sit-ins), and synthesize diverse empathy pedagogies into a collaborative, open-source curriculum.
 

Step-by-Step Outline of the Discussion

1. Introductions and Seminar Overview

  • Time code: [00:02] – [05:46]
  • Core Discussion Points:
    • Edwin introduces Lou Agosta (author of A Rumor of Empathyand Empathy and Morality) and frames the interview within the Empathy Movement Training Curriculum initiative.
    • Lou introduces his background: PhD from the University of Chicago, clinical assistant professor of psychiatry at Ross University Medical School / St. Anthony Hospital in Chicago.
    • Lou highlights peer-reviewed clinical research demonstrating that physician empathy measurably improves patient outcomes (e.g., lower cholesterol, improved diabetes markers, reduced stress/inflammation).
  • Outcome: Established the academic, clinical, and practical premise of the 10-week Empathy Lessons Training Seminar.

2. Defining Empathy and Philosophical Foundations

  • Time code: [05:46] – [13:14]
  • Core Discussion Points:
    • Lou details the four core aspects of empathy: Receptivity (affective input), Understanding Possibility (recognizing who the person is beyond breakdown), Cognitive Perspective Taking (viewpoint), and Empathic Responsiveness (giving back what was heard for validation).
    • Empathy Circles are acknowledged as a foundational gateway practice.
    • Lou offers his central philosophical thesis: without empathy, there is no shared humanity (“the zombie apocalypse”). In parenting, teaching, medicine, and business, the other person calls forth the empathy in us.
  • Outcome: Grounded the curriculum definition in a four-part relational process rather than a static trait.

3. Theory of Change and Overcoming Empathy Breakdowns

  • Time code: [13:14] – [20:25]
  • Core Discussion Points:
    • Lou presents his “one-minute empathy training”: drive out aggression, bullying, prejudice, and negative politics, allowing empathy to expand naturally.
    • Lou argues that “there is enough empathy to go around,” drawing an analogy to global food production (Norman Borlaug and the Green Revolution)-starvation and empathy deficits occur because resources are withheld, weaponized, or blocked.
  • Outcome: Framed empathy development around clearing obstacles and blocks rather than manufacturing a scarce resource.

4. Personal Origins, Heinz Kohut, and Rigorous Empathy

  • Time code: [20:25] – [33:20]
  • Core Discussion Points:
    • Lou shares the personal roots of his work: receiving bedtime storytelling empathy from his mother while dealing with a harsh, “boot camp” father.
    • Studies at the University of Chicago during the rise of Heinz Kohut’s self psychology; working with colleagues Michael Basch, Arnold Goldberg, and Ernest Wolf.
    • Defining “rigorous and critical empathy” (concept from Xavier Remy) as disciplined receptivity, interpretation, and responsiveness rather than sentimental (“kumbaya”) agreement.
    • Being deeply listened to (by mentors, his mother, early partners, and psychoanalysts) demonstrated empathy’s life-altering impact.
  • Outcome: Connected self-psychology lineage and experiential childhood background to the necessity of structured empathy training.

5. Course Structure, Safety, and Stress Reduction

  • Time code: [33:20] – [38:59]
  • Core Discussion Points:
    • Overview of the course audience: broad applicability for leaders, mediators, educators, and anyone wanting to strengthen their “empathy muscle.”
    • The seminar covers approximately 40 distinct empathy lessons across 10 two-hour sessions.
    • Theory of change: “Transformation is instantaneous; change is hard work.” Empathy operates as a stress-reduction mechanism-getting heard is “like sinking into a hot bath” (quoting Kohut).
    • Establishing safety through explicit agreements and confidentiality so participants can explore vulnerabilities without feeling forced to share.
  • Outcome: Defined the seminar pedagogy as alternating 15-20 minute lectures with experiential sharing in a secure environment.

6. Walkthrough of the 10 Sessions (Part 1: Sessions 1-5)

  • Time code: [38:59] – [58:49]
  • Core Discussion Points:
    • Session 1 (Definitions & Mind Reading): Exploring empathic receptivity vs. “mind misreading” (e.g., domestic arguments over toothpaste caps taking on distorted emotional meanings).
    • Session 2 (Brain Science): Mirror neurons, stress pathways, and empathy as a non-pharmacological health intervention.
    • Session 3 (Empathy Breakdowns): Four primary breakdowns-emotional contagion, conformity, projection, and communication loss. Emphasizing self-empathy as the foundation for repairing breakdowns.
    • Session 4 (Resistance & Boundary Setting):Differentiating empathy from empathic distress/burnout. Critiquing Paul Bloom’s Against Empathy, arguing for both empathy and rational compassion. Taking a “six-ounce pour” (data sample) rather than drowning in someone else’s misery.
    • Session 5 (Underground History & Aesthetics): Tracing empathy (Einf�hlung) from 19th-century German aesthetics and art history to psychology. Viewing people with the same reverence and care given to masterpieces.
  • Outcome: Systematized the first half of the curriculum around scientific mechanisms, psychological pitfalls, and historical roots.

7. Walkthrough of the 10 Sessions (Part 2: Sessions 6-10)

  • Time code: [58:49] – [01:13:00]
  • Core Discussion Points:
    • Session 6 (Storytelling & Spirituality): Exploring empathy through narrative (e.g., the Good Samaritan) and managing the vulnerabilities of the “natural empath.”
    • Session 7 (Boundaries & Humor): Distinguishing healthy fences with gates from impassable walls (referencing Robert Frost). Examining how humor discharges tension through boundary-crossing, contrasting aggressive wit with respectful empathy.
    • Session 8 (Trainability & Social Healing): Evidence showing empathy is a trainable skill; empathy as an essential social survival tool (“wear a parachute, use penicillin, lead with empathy”).
    • Session 9 (Rhetorical Empathy & Speaking): Moving beyond empathic listening into empathic speaking and speaking truth to power. Analyzing Malcolm X (“Plymouth rock landed on you”), Abraham Lincoln, and Barack Obama.
    • Session 10 (Empathy and Love / Racism): Examining the spectrum between soothing empathy and “tough love,” reflecting on Edwin’s dialogues with former extremists and Daryl Davis.
  • Outcome: Completed the comprehensive overview of the 10 sessions, emphasizing expressive/rhetorical empathy and tough love.

8. Movement Building, Value Perception, and “Occupy Empathy”

  • Time code: [01:13:00] – [01:22:30]
  • Core Discussion Points:
    • Gaps in the empathy ecosystem: Practitioners often hesitate to articulate the monetary and societal value of empathy. While empathy is a common good like clean air or water, professional empathy instruction must be valued.
    • Reframing interpersonal conflict: Approaching difficult colleagues, challenging customers, or provocative relatives as one’s personal “empathy trainers.”
    • Edwin’s proposal for “Occupy Empathy”: Expanding the Empathy Tent model from street fairs and political rallies to sustained public demonstrations (e.g., occupying legislative capitols until politicians engage in Empathy Circles). Lou expresses enthusiasm and willingness to support public actions.
  • Outcome: Concluded with mutual appreciation and an agreement to collaborate on public empathy activism and curriculum development.

Empathy Movement Curriculum Insights

Mapping the concepts from this interview directly to the development modules of the Empathy Movement Curriculum

  1. Module 4: Definition of Empathy
    • Four-Phase Model: Incorporate Lou’s four distinct phases into the curriculum:
      • (1) Receptivity (mammalian affective communication),
      •  (2) Seeing the Person as Possibility, 
      • (3) Cognitive Perspective Taking, and 
      • (4) Empathic Responsiveness (testing accuracy: “Did I get it right?”).
    • Abundance vs. Scarcity: Adopt the pedagogical stance that empathy is not inherently scarce; like food in the Green Revolution, there is enough to go around. Training should focus on removing systemic and psychological obstacles (aggression, prejudice, bullying) rather than treating empathy as an artificial commodity.
  2. Module 5: Deeper Empathy (Carl Rogers, Self Psychology, & Diagnostics)
    • Heinz Kohut�s “Hot Bath”: Use the clinical framing that receiving genuine active listening lowers biological stress and soothes the nervous system, functioning as a primary non-pharmacological health intervention.
    • Rigorous & Critical Empathy vs. Over-Identification:Teach boundary management via the “six-ounce pour”metaphor. Empathy is data sampling of another person�s experience, not merging or drowning in their distress. This provides facilitators with protection against compassion fatigue.
    • Self-Empathy as Breakdown Repair: Embed exercises where participants identify personal triggers (e.g., emotional contagion, projection) and listen to their own internal reactions before attempting to reflect or engage with an external counterpart.
  3. Module 7: Conflict Resolution & Depolarization
    • “Mind Reading” vs. “Mind Misreading”: Design exercises identifying how minor conflicts (e.g., toothpaste caps, household chores) get distorted into existential accusations (“You don’t love me”). Learning to de-escalate involves separating literal content from invented meaning.
    • The “Empathy Trainer” Reframe: Train participants to view difficult coworkers, contentious family members, or ideological opponents not as adversaries, but as high-leverage “empathy trainers” for practicing active listening.
    • Tough Love Spectrum: Position Empathy Circles along a developmental continuum that includes soothing listening on one end and assertive, boundaried “tough love” on the other when engaging with manipulative or bad-faith actors.
  4. Curriculum Innovation: Rhetorical Empathy (Empathic Speaking)
    • Speaking Truth with Empathy: Expand the curriculum beyond active listening into empathic speaking (Session 9 in Lou�s seminar). Use historical examples (Malcolm X, Lincoln, Obama) to demonstrate how speakers validate audience experiences and cultural metaphors while delivering transformative, challenging truths.
  5. Movement Building & Public Activism (Occupy Empathy)
    • Assertive Action (“Occupy Empathy”): Move beyond passive workshops by taking the Empathy Tent into high-stakes civic arenas. Establish direct-action campaigns (e.g., state capitols, public plazas) facilitating structured Empathy Circles between polarized political factions.
    • Articulating Societal & Economic Value: Overcome reluctance around financial valuation. Empathy advocates must clearly articulate the tangible return on investment of empathy training in healthcare, business, and civic life.
    • (c) Edwin Rutsch and the Culture of Empathy and Lou Agosta, PhD and the Chicago Empathy Project

Registration now open: Empathy Lessons Training Seminar (ELTS) Registration, Syllabus, Agreements

Empathy is oxygen for the soul. Short of breath? Maybe one needs expanded empathy. Get some empathy and expand yours in this seminar. A rigorous and critical empathy says: I know what you feel because I feel it, too, as a vicarious experience, not a merger. It is not as if parents, teachers, doctors, therapists, friends, and neighbors, needed an expert to tell them what empathy is. Ask any parent, teacher, behavioral health professional, and they practice empathy every day, even if they may not always be able to say it out loud. This seminar brings forth what you already know about empathy – what you have already learned since you could not survive without empathy – and expands it with abundant tips, techniques, and real-world transformation in exercising empathy as a power and practice. 

A detailed outline (syllabus) of the seminar, benefits you will obtain by participating, and agreements for participants follow inline. 

Here is how to register: click below (ELTS):

Empathy Lessons Training Seminar Syllabus Outline – this is the outline of the seminar

Empathy Lessons Training Seminar (ELTS)

Empathy is oxygen for the soul. Short of breath? Maybe one needs expanded empathy. Get some in this seminar: I know what you feel because I feel it, too, as a vicarious experience, not a merger. It is not as if parents, teachers, doctors, therapists, friends, and neighbors, needed an expert to tell them what empathy is. Ask any parent, teacher, behavioral health professional, and they practice empathy every day, even if they may work on how explicitly to bring forth what they know. This seminar brings forth what you already know about empathy – and expands it with abundant tips, techniques, and real-world transformation in exercising empathy as a power and practice. 

Schedule: Every Saturday for ten weeks Sept 12, 2026 thru Nov 21, 2026 at 11 am CDT – starts after Labor Day (USA) and ends before Thanksgiving (USA) via Zoom

Seminar Syllabus Outline:

Session One: The one-minute empathy training. 

Talking points:

  • Personal note: The beginning of my empathy training     
  • The multi-dimensional definition of empathy       
  • Empathic receptivity and vicarious experience                    
  • Empathic understanding—understanding of possibility     
  • Where there is “mind reading” there is “mind misreading”
  • The folk interpretation of empathy: Top-down empathy     
  • There is enough empathy to go around, even though it does not seem that way on most days. Why is that?

Session Two: Empathy and brain science – this is your brain on empathy 

Talking points:

  • Mirror neurons – what are those?                                          
  • Stress and inflammation: Some is good, too much is not
  • Social stress enters the body through the immune system  
  • Connecting the dots: stress and inflammation                      
  • Connecting the dots: anti-inflammation and empathy         
  • Empathy as a “Miracle drug”
  • Empathy is a spa treatment for the soul

Session Three: Empathy breakdowns and introspection 

Talking points:

  • Emotional contagion is failed empathy                              
  • The analogy of optical illusions with empathy breakdowns     
  • Empathic receptivity breaks down as emotional contagion    
  • Empathic understanding breaks down as conformity
  • Empathic interpretation breaks down as projection               
  • Empathic response breaks down and gets “lost in translation”       
  • Introspection is the royal road to empathy; be introspective

Session Four: Resistance to empathy

Talking points:

  • Overcome resistance to empathy, and empathy expands
  • Train and develop empathy by overcoming the obstacles to empathy
  • “Listen from possibility” rather than listening from a “position X”:
  • Distinguish between what happened and what one made it mean
  • Empathy is a tuner or dial, not an “on-off” switch
  • Empathy is a method of data gathering about the other person:
  • Be generous with acknowledgement

Session Five: The Secret underground history of empathy

Talking points:

The distinction “empathy” was a part of sympathy, fellow feeling, vicarious feeling, communicability of affect in aesthetics and art history, and storytelling is discussed through different methods of inquiry. The session includes short selections from the philosophers, phenomenologists, and psychoanalysts 

  • David Hume, 
  • Immanuel Kant, 
  • Theodor Lipps, 
  • Sigmund Freud, 
  • Heinz Kohut, 
  • Husserl/Edith Stein, 
  • Max Scheler

Session Six: Empathy and story telling

Talking points:

And, yes, we are going to tell some stories.

  • The “Natural Empath”: Caught between nature and nurture   
  • The Good Samaritan meets the Natural Empath

Examples of empathy from World Literature including

  • Toni Morrison
  • George Eliot (Marion Evans)
  • Thomas Mann
  • Albert Camus
  • Goethe                                                                                                                                   

Session Seven: Empathy and boundary setting

Talking points:

  • Get your power back through empathy
  • Establish and maintain firm boundaries between the self and the Other in relating empathically – but do not forget to practice being inclusive
  • Empathy deescalates anger and rage
  • Empathy is the ultimate anti-bullying anti-dote – 
  • When (why) empathy doesn’t work with bullies, psychopaths, and the criminally insane – and what to do about it
  • Empathy is closely related to humor
  • Empathy lessons are everywhere

Session Eight: Review of the literature that empathy is good for one’s health and well being

Talking points:

  • Empathy is trainable – practice, you get better at it
  • The empathy exams
  • What counts as evidence that empathy works?                         
  • Evidence-based empathy
  • Jumping out of an airplane – be sure to wear a parachute         
  • Common factor, empathy, in social healing practices                 

Session Nine: Speaking truth to power – rhetorical empathy in politics

Talking points:

  • Truth versus politics
  • The first instance of fake news—ever                                
  • Empathic receptivity soothes anger and rage                        
  • Empathic understanding discloses political vision                
  • Empathic interpretation engages intractable problems        
  • Rhetorical empathy: Empathic responsiveness                     
  • Malcolm-X’s rhetorical empathy                                            
  • John Stuart Mill’s rhetorical empathy                                    
  • Governor Altgeld’s rhetorical empathy                                  
  • Ronald Regan’s rhetorical empathy                                       
  • Lincoln’s rhetorical empathy                                                 

Session Ten: Empathy is the new love – examining love through the lens of empathy

Talking points: So If empathy is the new love, what then was the old love?

  • Defining Our Terms: Love and Empathy                            
  • Empathy and love have characteristic breakdowns         
  • The unbearable lightness of empathy                                
  • Design defects of the male brain                                         
  • Women and men want the same things—but differ in priority           
  • The desire of desire                                                              
  • The Positive Aspects of Love as Empathic Relatedness    
  • From Death in Venice (a story) to Empathy in Venice
  • Love as a boundary issue: Empathy as a soothing balm

Top Benefits of the Empathy Lessons Training Seminar – these are the benefits –

The answer is empathy – so what’s the question? Stress pushes people down into survival. People stress other people, being difficult to deal with at home, on the job, in school, or at leisure with friends. In the Empathy Lessons Training Seminar (ELTS) the participants get an opportunity to engage directly the obstacles that stopping them from getting the empathy. Participants acquire the empathic responsiveness needed to experience satisfaction in relationships of all kinds, personal and professional. Participants overcome the obstacles to effective relationships and shift out of survival mode and into empathic responsiveness in which fulfillment and satisfaction occur that did not previously seem possible. 

The top benefits of the empathy lessons training seminar that the participant will receive include expanded empathy and – 

1. reduced conflict in one’s life and one’s organization, reducing dignity violations, shame, and related anger and rage

2. expanded power and freedom in the face of resistance, no agreement, or bullying

3. reduced time to results in personal and professional projects, expanding teamwork 

4. expanded listening one other individuals and to oneself

5. expanded results in personal relationships 

6. reduced compassion fatigue, burnout, professional cynicism or denial  

7. expanded cooperation in one’s personal and professional relations, increasing satisfaction with one’s individual and organizational goals

8. the ability to be with another person no matter how difficult an individual

9. the ability to distinguish what happened from what one made it mean

10. ability to like people and be with people regardless of background 

11. distinguishing empathy effectively from compassion, altruism, and charity (they are not the same!)

12. the ability to recognize and acknowledge the humanness in oneself and others even in extreme situations

13. the ability to set boundaries in relatedness and navigate boundaries with finesse and skill – for example, in dealing with bullies

14. the ability to shift your empathy from being an “on off” switch to being a rheostat that dials empathy up and down as a filter

15. expanded humor, creativity, appreciation of art, and wisdom – all closely related to empathy – relationships, teamwork, and leadership

Also note:

Participants will get the most value from attending all the sessions. However, for those with scheduling challenges, it is not required to attend every session because every session (except the first) contains a short upfront review of terms and what the participant needs to know to get value from the work.  

The Empathy Lessons Training Seminar [ELTS] may be delivered as a stand-alone ten session class for participants who register individually. Alternatively, the ELTS may be delivered as part of an empathy consulting engagement. The organization’s team members are separately interviewed, confidential feedback aggregated anonymously and presented to the leadership, and group work on problem solving, conflict resolutions, issue handling, proceeds in parallel with large group work and small group breakout sessions under the guidance of the organization’s leadership. 

The benefits of the ELTS are most available to participants who attend all the sessions. People may selectively attend one or more session and still obtain significant benefit. Naturally, attending more sessions will result in expanded benefits. Whatever you do you are going to get empathy, and, no surprises here, you get out of it what you put into it.

Empathy Lessons Training Seminar (ELTS) Agreements

The Empathy Training Seminar (ELTS) is delivered through Alleingang, Inc., an Illinois Chapter C corporation, Lou Agosta, PhD, President, responsible for providing diverse services in education, consulting, and publishing. The trainer is Lou Agosta. The participants are the individuals who sign up, pay the fee, agreement to these agreements (hereafter: Agreements) and attend the training.

The ELTS is a ten session, structured conversation designed to expand empathy in the participant and in the community. The ELTS occurs as a two-hour session for ten weeks for a total of some twenty hours. 

The ELTS training material distributed to the participants is copy-righted material and the conversations that occurs in the seminar are confidential and for the personal use of the participants. It may not be recorded, copied, taped or otherwise captured to electronic media. Any notes taken by the participants are only for the personal use of the participants and may not be published, sold, or otherwise redistributed under any circumstances. 

The ELTS is committed to creating an environment where people have the freedom to express themselves and participate without restrictions. Therefore, the ELTS requests that you keep the names and details of what people say in the ELTS confidential. Participants will be separately asked to sign a document in which the person agrees to keep the names and details of what people say in the ELTS confidential, and such signature is a requirement for participating in the ELTS.

Further detailed agreements and background are specified in the online agreement document. The person considering participating is asked to review all these additional agreements carefully, let the trainer (LouAgosta@gmail.com) know of any questions or concerns, and agree to the agreements in completing the registration process. 

Consistent with good business practices and current law, Alleingang, Inc. does not tolerate sexual harassment or other forms of harassment in any of our training programs or events. If you have any questions about our policies regarding sexual or other forms of harassment, please contact Lou Agosta (773-203-0269).

The participant hereby agrees to (in the following “I” – “my” – and so on refer to the participant):

  • To be on time for my sessions as scheduled
  • To discuss and say what is on my mind and what is going on in my life without editing or holding back – to just tell the truth 
  • Same idea as above – to be straight about what I am thinking and feeling – regardless of its significance or lack of significance to me or even if seems embarrassing or trivial
  • If I have an emergency (for example, serious illness, life event, two feet of snow), then I will communicate as soon as I know about it
  • If I have a complaint, concern, or issue with the empathy consultant or with the process of training, then I will come into my session and talk about it to resolve it
  • I understand that on occasion empathy consulting requires me to consider and discuss confronting and difficult personal matters, including but not limited to my own behavior, blind spots, and thoughts 
  • To pay the fee agreed upon for the ELTS with the understanding that it is nonrefundable
  • To pay the fee agreed upon for the ELTS with the understanding that it is nonrefundable, though in the event of an authentic emergency a reasonable effort will be made to include the participant in a similar (“substitute”) future session
  • To be responsible for my health and well-being at all times, in participating in this work

I acknowledge that our conversation and the ELTS are confidential and have received this written statement of confidentiality. Exceptions to confidentiality include [but are not limited to] if the trainer believes the participant is hurting or plans to hurt her- or himself or another person, for example, requiring summoning emergency [911] services. Then confidentiality would not apply.

By entering one’s name and date and related identifying data on the separately published ELTS form, the participant agrees to the Agreements

Here is how to register: click below (ELTS):

This image has an empty alt attribute; its file name is imageofloupointingatgrahamschooltalk.jpg

Image Credit: photo by Alex Zonis of Lou Agosta, PhD making a presentation on the Secret Underground History of Empathy on November 13, 2015 at a local Chicago adult education program.

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

Empathy lesson: Take the other person as your empathy trainer

As an exercise, consider that the other person is one’s empathy trainer. The other individual calls forth one’s empathy. If the Other behaves in a challenging way, the challenge is to one’s empathy. If the other person is in an emotional meltdown, the challenge is to one’s empathic receptivity. If the other person is a conformist, the challenge is to one’s empathic understanding. 

Listen to this blog post as a podcast. (There may be minor differences in phrasing between the written and spoken versions as this is not a transcript.)

If the other person is accusatory, projecting hostility, or just hard to figure out, the challenge is to one’s empathic interpretation. If the other person’s self-expression is lost in translation, the challenge is to one’s empathic responsiveness. 

If the Other is a difficult individual, the challenge is to one’s empathic relatedness. This gives new meaning to the empathy exams. Think of the “secret shopper,” who tests the sales person’s customer service skills, even if the test is just to set boundaries. 

This business of taking the other person as one’s empathy trainer is an indirect reference to a wonderful essay (really a memoire-like story) by Leslie Jamison entitled, “The Empathy Exams,” by which this conversation is inspired, is about Jamison’s experiences working as a medical actor. [i] A medical actor is a person who is hired by a medical school to learn a script. The medical actor portrays a person who has a particular disease. Jamison’s narrative about her work as a medical actor is humorously (and movingly) interwoven with an illness of her own with which she is suddenly confronted. 

The medical actor’s script contains instructions: “Your first line is: ‘I’m having these seizures and no one knows why’.” The backstory in the script, which the actor must memorize, is that there is nothing physically wrong with the patient. She has a hysterical personality disorder. 

The medical student being examined is graded on how close he or she comes to “nailing” the diagnosis through diagnostic questioning. However, more to the point here, the exam is about whether the medical student’s manner of interacting with the patient is warm, cold, energetic, apathetic, authoritarian, indifferent—or empathic. 

The empathy exam is included as part of the feedback provided by the medical actor that goes to form the medical student’s grade. Examining someone—giving a person a test—on something implies that the result can be improved by, training, feedback and practice. One looks for areas for improvement—that is the point of education. 

The empathy exams that medical students take are a reality. But even before these real-world empathy exams, a celebrated science fiction novella included an empathy exam. A masterpiece ahead of its time, Philip K. Dick’s negative fantasy of the future Do Androids Dream of Electric Sheep (1968) received widespread coverage when made into the movie Blade Runner (1982), starring the young Harrison Ford as the bounty hunter, anti-hero, Rick Deckard. [ii]

In Dick’s celebrated novella, six bioengineered replicants (robots), who are virtually indistinguishable from human beings, have escaped from their assigned location on Mars. They have returned to Earth in an attempt to find their designer, and, force him to postpone their auto-destruction coding. They do not want to be retired—that is, they do not want to have to die. What is the one difference between humans and replicants? The replicants lack empathy. 

In the context of the narrative, empathy is detectable by an empathy test, the “Voight-Kampff exam.” No such exam exists. This fictional exam uses a mechanism that is similar to a lie detector as it captures physiological data in response to empathy inspiring questions. For example: “You see a tortoise on its back in the hot sun with its legs flailing helplessly in the air. It cannot turn over without your help. How do you feel?” Or “A little boy shows you his butterfly collection plus the killing jar. What do you feel? What do you say?” 

If the individual being interviewed (suspected of being a replicant) produces particular responses—accelerating respiration, blush, heart rate, eye movement, galvanic skin response—then empathy is present. The interviewee is human, not replicant.

Now the narrative twist that elevates Dick’s story above the average science fiction yarn is that, as the story unfolds, the humans become less empathic and the replicants more so. The replicants make a contribution to the community, are altruistic and socially useful, whereas the bounty hunter, who is trying to “retire” them, behaves increasingly aggressively, selfishly, manipulatively, anti-socially, even psychopathically. His conscience and his empathy are in retreat. 

What is limiting about Dick’s otherwise visionary account of empathy is that the protagonist and other characters in the narrative believe that empathy is invariable. You either have it or you don’t. However, the development of the plot provides evidence that exactly the contrary is the case. Empathy expands in one case, contracts in another. 

Rick Deckard starts out as a human with nuanced emotions. But as he continues killing in his role as bounty hunter, he becomes less empathic, more and more hard-hearted. The replicants, who are attempting to flee from their fate, behave with expanded empathy—and humanity. 

The powerful irony is that the replicants end up being more human than the humans. In spite of what some people may believe, based on practices and actions, a person’s empathy expands—or shrinks. This is further evidence that empathy is trainable – one training tip and technique is to take the other person – regard the other person – as one’s empathy trainer.  

Now let us take a step back and continue to engage with the empathy lesson. This approach is generalizable. “In any encounter with another, consider the other person as one’s empathy trainer.” The newborn baby trains the parent in how to be empathic; the student trains the teacher; the patient, the doctor; the client, the consultant; the customer, the business person selling the product or service; the neighbor, the stranger; and the audience, the speaker. 

This may sound backward and paradoxical. However, by standing things on their head—the customer trains the business person in empathy, the student trains the teacher in empathy, the infant trains the parent in empathy and so on—we get a surprisingly refreshing view of how empathy makes a difference. The survivor is rescued by the Good Samaritan; but the Samaritan is humanized by—gets his humanity from—the survivor, even in addressing the survivor’s temporary loss of humanity as a suffering lump of battered flesh. The baby, the student, the patient, the customer, the neighbor, are the individuals who bring empathy into existence for the parent, the teacher, the business person, the neighbor, respectively. 

Note this give new meaning to the term “dialectical” as in Marsha Linehan’s innovative treatment of Dialectical Behavioral Therapy (DBT). “Dialectical” refers to an apparent contradiction – the baby trains the parent, the customer trains the business person – which upon examination is actually a breakthrough in relatedness. 

Without the baby, there is no parent. Without the parent, there is no empathy with the baby. The baby calls forth the parent’s spontaneous and natural empathy. The baby creates a clearing for parenting to show up as empathic or non-empathic or something in-between. 

Without the customer, there is no business or business person. Without the business person, there is no empathy with the customer. The customer calls forth the business person’s natural and spontaneous empathy. The customer creates a clearing for the encounter with the business to show up as empathic or non-empathic or something in between.

Without the patient, there is no medical practice or medical doctoring. Without the MD, there is not empathy with the patient. The patient calls forth the MD’s natural and spontaneous empathy. The patient creates the clearing for the encounter with the doctor to show up as empathic or non-empathic or something in-between. Likewise, with the teacher and student, client and consultant, and neighors in the community. 

However, surely the baby does not give a lecture with a Power Point. The baby needs to be on the receiving end of empathy before she or he can develop an ability to be empathic in an intentional way towards anyone else. 

Though the empathic sensitivity of children should not be under-estimated, this is an important consideration. We must be recipients of our parents’ and care-takers’ empathy before we are able to turn around and provide empathy to Others, even as we practice empathy in immature, emerging, and developing ways as we grow up.

Yet even without being self-aware, the baby provides an opportunity and possibility for the parents’ empathy lessons. The baby provides a clearing for empathy lessons for the parents even without meaning to do so. The baby creates the possibility of empathic parenting by the baby’s readiness to become human, which at first shows up as a distinct lack of socialization. The baby cannot feed itself and empties its processed waste into its diapers. 

The parent socializes the baby; the baby humanizes the parent, calling the parent not just to its role as parent (though it does that too), but also to its possibility as a human being in a committed relationship to another emerging human (the baby) through trial and error. The baby, by its very existence, gives the parent his humanness, making the parent into an inquirer into what it is to grow up, developing from an immature baby into an adult human.[iii]

Likewise, with the business customer: The customer does not tell the business owner, “I have a need but can’t explain it to you.” Instead, the customer just keeps shopping around. The customer does not tell the business person, “I have a complaint about the service, and I want you to listen to it and make amends.” Instead, the customer just takes his business to the competition. 

In each case, the empathy lesson is a challenge to the would-be parent, teacher, sales person, consultant, therapist, nurse, attorney, taxi driver, neighbor, and so on, to expand one’s receptivity, enhance one’s grasp of the possibilities, appreciative different points of view, and practice rapid empathic response. 

If each of these persons—parent, teacher, business person, neighbor, and so on—begin in any other way than with empathy, they are headed for trouble. The challenge is straightforward: expand one’s listening to include the other individual in the empathic community or fall back into empathic distress; relate from possibility or get mired in stuckness; work on building community or wander aimlessly in the emotional wilderness.

David Axelrod interviews Senator TOm Cotton on June 2, 2017 at a University of Chicago debate


Episode art photo credit: David Axelrod interviews (confronts, debates, talks to) Senator Tom Cotton June 2, 2017 in a photo taken by Lou Agosta at the University of Chicago public debate. As one of the architects of Barack Obama’s presidential program, Ax (as he is affectionately known) would be likely to disagree with many of Senator Cotton’s more-or-less MAGA-oriented views. Take the other person as your empathy trainer! I believe both did! 

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


 

Notes

[i] Leslie Jamison. (2014). The empathy exams in The Empathy Exams: Essays. Minneapolis: Graywolf Press: 1–27. 

[ii] Philip K. Dick. (1968). Do Androids Dream of Electric Sheep? New York: Ballentine Books, 1981. 

[iii] Lou Agosta. (2010). Empathy in the Context of Philosophy. London: Palgrave: 60–61.

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


Automating empathy – issues and answers

I saw an advertisement today: “Empathy can’t be automated” 

Made me think: What is the evidence pro and con?

The obvious question is “Well, can you?”

The debate is joined. This turns out to be a trick question. The intuition on my part is that one cannot automate empathy, but perhaps one can simulate it, and then the simulation turns out to be something quite like the “automating empathy” of the title.

Defining our terms

However, before further debate, we need to define our terms. “Receiving empathy” is defined in rough-and-ready terms as one person (the speaker expressing/sharing something) “feeling heard” by the other person (the listener). “Feeling heard,” in turn, means the speaker believes he or she has been “understood,” “gotten for who the sharer is as a possibility.” The celebrity psychotherapist Carl Rogers said things about empathy such as getting inside the frame of reference of the other person and experiencing (not just intellectualizing) the other’s point of view: “…to see his [her] private world through his eyes” (Rogers 1961: 34). 

If one wants to get a tad more technical about defining empathy, then consider Heinz Kohut’s approach that empathy is “vicarious introspection,” i.e., one knows what the other individual is experiencing, feeling, etc. because one has a vicarious experience of the other’s experience (Kohut 1959). I listen to you and get “the movie of your life.” Less technically, Kohut famously quotes one of his psychoanalytic patients (he was a medical doctor) as saying that being given a good [empathic] listening was like sinking into a warm bath (Kohut 1971; note I will update this post as soon as I can find the exact page). Presumably that meant it was relaxing, de-stressing, emotionally calming. 

“Simulation” is producing a functionally similar result using a different means or method. For example, in the history of science, Lord Kelvin, one of the innovators of thermo-dynamics simulated the action of the ocean tides using a mechanism of ropes and pulleys [Kenneth Craik 1943: 51 (“Kelvin’s tide-predictor”)]. Thus, one does not have a social relationship with a bot, one has a “para-social relationship.” According to Sam Altman, some 1% of ChatGPT users had a “deep attachment” to the app – a kind of “rapport” – sounds like an aspect of “empathy” to me. Maybe not a therapist, but how about a “life coach”? (https://www.nytimes.com/2025/08/19/business/chatgpt-gpt-5-backlash-openai.html)

One misunderstanding needs to be cleared up. Entry level empathy is often presented as reflecting back on the part of the would-be empathic listener what the potential recipient of empathy expresses in words (and sometimes also in behavior). Though the value of being able to reflect the words the other person expresses is great, this is a caricature of empathy. For example, that the client comes in and says “I am angry at the boss” and the listener responds “You feel angry.” Pause for cynical laugh. 

Now one should never underestimate the value of actually comprehending the words spoken by the speaker. Reflecting or mirroring back what is said, more-or-less literally, is a useful exercise in short-circuiting the internal chatter that prevents a listener from really hearing the words that the other person puts into the interpersonal space of conversation. 

The exercise consists in engaging and overcoming the challenge: “I can’t hear you because my opinions of what you are saying are louder than what you are saying; and my opinions drown out your words!” So the empathic commitment is to quiet and quiesce the listener’s internal chatter and be with the other person in a space of nonjudgment, acceptance, and tolerance. In a certain sense, the empathy automaton (“bot”) has an advantage because, while the bot may have a software bug or generate an inappropriate response, it does not have an “internal chatter.”

Entry level empathy automation: repeating, mirroring, reflecting

So far, there is nothing here that cannot be automated

On background, this entry level of empathy was automated – reflect back what was said in at least in a rough-and-ready way – in 1966 by Joseph Weizenbaum’s MIT prototype of a natural language processor, a very primitive “chat-bot,” ELIZA. This was an attempt at natural language processing at a high level and was not restricted to science, therapy, life coaching, business, education, or any random area of conversation. The approach of ELIZA was to reflect, mirror back, repeat the statements made to it (the computer app) by the human participant in the conversation (which used a key board to type the exchange). 

Here’s the surprising, unpredicted result: The example of the software ELIZA, which mirrors back what the person says to it, was experienced by users to be comforting and even “therapeutic,” granted in a hard-to-define sense. As far as I know, no attempts at a sustained therapeutic or empathic relationship were ever undertaken, so the data is anecdotal, yet compelling. 

Could it be that we persons are designed to attribute “mindedness” – that the other person (or, in this case, participant software) has a human-like mind – based on certain behavioral clues such as responding to the speaker with words and meanings used by the speaker or that support the speaker or even disagree with the speaker in a way that takes the input and provides meaningful feedback? This gets one a caricature of the role of therapist of the school of Carl Rogers (whose many innovative contributions are not to be dismissed), in which the listener mainly reflects back the words of the client and/or asks non-directive questions such as “How do you feel about that?” or “Will you please say more about that?” 

In contrast, we find there is more to empathy than mere mirroring and reflection of words. For example, Heinz Kohut (1971, 1977), an empathy innovator, gives the example of meeting a new prospective client who begins the conversation with a long list of the client’s own failings, short comings, and weaknesses, dumping on himself and building a case that he is really a jerk (or words to that effect). The guy is really going full throttle in dumping on himself. The person then pauses and asks, “What do you think of that?” Based on his empathic listening and the feeling that Kohut got in being with the person, he replies “I think you are feeling very lonely.” The man bursts into tears – finally someone has heard him! Now this is just one vignette from a long and complicated process, in which there were many moments of empathic convergence and divergence. The point is this exchange was not a predictable result, nor likely a result to have been produced by mere mirroring; nor is this vignette dismissible by saying that Kohut was merely a master practitioner (which he was), who could not tell what he was doing but just did it. Kohut wrote several books to document his practice, so he tells a lot about what he was doing and how to do it. 

In a prescient reflection, which anticipates the current debate by nearly half a century, Kohut wrote: 

“…[M]an [people] can no more survive psychologically in a psychological milieu that does not respond empathically to him, than he can survive physically in an atmosphere that contains no oxygen. Lack of emotional responsiveness, silence, the pretense of being an inhuman computer-like machine which gathers data and emits interpretations, do not more supply the psychological milieu for the most undistorted delineation of the normal and abnormal features of a person’s psychological makeup than do an oxygen-free environment…” (Kohut 1977: 253)

Empathy is oxygen for the soul. What Kohut could not appreciate – and which computer science could not even imagine in 1977 – is that large language models would be able to simulate affective responsiveness, chattiness, agreeableness, even humor, that would put to shame the relatively unemotional unresponsiveness of the classic approach to psychoanalysis, in which the analyst is an emotionally neutral (and hence “cold”) screen onto which the client project his issues. It should be noted this classic unresponsiveness is a caricature and stereotype to which few real world psychoanalysts rigidly adhere, rather like the cynical anecdote of the analyst who removes the tissue from his consulting room to prevent indulgent weeping instead of talking.

Granted, one should not assume that a therapeutic bot would (or would not) work as well as a human therapist or empathy consultant; but, for the sake of argument, let us suppose that it does work as well (and work as badly?), either in certain circumstances or new, improved future releases, which are to be anticipated with highly probability. 

Fast forward to today’s large language models (LLMs)

Therefore, fast forward these sixty years from Joseph Weizenbaum’s prototype (MIT 1965) to today’s large language models that beat human beings at playing Jeopardy – an elaborate word game requiring natural language – and what then becomes possible? One of the challenges of talk therapy (or empathy consulting, etc.) is that it is powerful and demonstrably effective, but not scalable. It does not scale up to meet the market demands of thousands of people who are struggling with mental illness or those who, while not satisfying criteria for mental illness, would still benefit from a conversation for possibility. 

A human therapist (or empathy consultant) has eight hours in a standard workday and if the therapist meets with emotionally upset people during all those hours, then the therapist is at risk of upset, too, confronting compassion fatigue, burn out, or empathic distress in somewhere between two weeks and two years. Hence, the popularity of fifteen-minute medication management session on the part of psychiatrists (MDs), the current dominant practice design, an approach presenting challenges of its own. Medications are powerful and can address disordered mood, anxiety, and pathological thinking, yet often the underlying (individual, social, community, nonbiological) issues remain unaddressed, due to finances and schedule, and so remain unengaged and unresolved. 

Hence, the current market of long wait times, high costs, high frustration, challenges to find a good fit between therapist and client, all resulting in suffering humanity – above all suffering humanity. (Note also that, while this article often talks about “therapy,” many of the same things can be said about “life coaching,” “consulting,” “counseling,” and so on; and these latter will not be mechanically repeated, but are implicated.

As regards the market, the problematic scalability of one-on-one talk therapy and the lengthy time needed for professional training and the acquisition of a critical mass of experience, results in a market shortage of competent therapists and related empathy consultants. For the prospective patient (i.e., customer) the question often comes down to:  “how desperate are you?” as a client struggling with emotional, spiritual, behavioral health issues. The cynical (and not funny) response is “Pretty near complete panic!” If one is desperate enough – out of work, relationships in breakdown, attracted to unhealthy solutions such as alcohol – then a “good enough bot” just might be something worth trying. Note that all the usual disclaimers apply here – it would be interesting to consider a double-blind test between real human therapists and therapy bots. Unfortunately, the one really un-overcome-able advantage of a human therapist – the ability to be in-person in the same physical space – cannot be double-blinded (at least at the current state of the art) in a test. Having raised the possibility, I have deep reservations about the personal risks of such an approach. That there is a market for such services is different than having such an automated approach imposed on consumers by insurance corporations to expand would-be monopoly profits.  

Another possible advantage of automation (albeit with a cynical edge): People who are socially awkward might prefer to get started with a virtual therapy bot. One clever startup has called their prototype platform a “Woebot”. Get it? Not a “robot,” but a “Woebot.” (Note – the Woebot uses a database of best practices, not a large language model.) 

Now these socially struggling individuals might be a tad naïve as such an approach would prevent them from engaging with the very issue that is troubling them – interacting with people. On the other hand, one might argue it would be like “exposure therapy,” for example, for the person who has a snake phobia and is presented with a photo or a rubber snake as the first step of therapy. Likewise, in the case of an empathic relationship, one would have to “graduate” to an authentic, non-simulated human presence – the real snake!

What is one trying to automate?

If one is going to automate empathy using a therapy-bot, then presumably one should be able to say what it is that one is trying to automate – that is, simulate. There are four aspects of empathy that require simulation – for the client, (1) the experience (“belief”) that one has been heard – that the meaning of the message has been received and, so to speak, not gotten lost in translation; (2) the communication of affect and emotion – that the listener knows what the speaker is feeling and experiencing because the listener feels it too; (3) who is the other person as a possibility in the context of the standards to which the individual conforms in community; (4) putting oneself in the place of the other person’s perspective (“point of view” (POV)). 

Most of these things – taking the other’s point of view, vicarious experience of the other’s experience, engaging with possibilities of relatedness, commitment to clear communication – come naturally to most people, but require practice. Humans seem to be designed spontaneously to assume multiple perspectives – one assumes other people have minds (beliefs, feelings, wants, impulses) like oneself, but then we get caught up in “surviving the day” on “automatic pilot,” and forget the individual is part of the community, throwing away the assumptions and preferring the egocentric one – it’s all about me! It takes commitment to empathy and practice to overcome such limitations. A person experiences a rush of emotions, but then forget it could be coming from the other person and succumb to emotional contagion. Who the other person is as a possibility is not much appreciated in empathy circles, but it an essential part of the process of getting from stuckness to flourishing and requires empathy at every step. 

There is nothing described here, once again, that cannot in theory be automated. Indeed human beings struggle with all these aspects of being empathic, and the requirements of automation are non-trivial, but can be improved by trial and error. The over-simplifications required to automate a process end up feeding back and giving the empathy practitioner insight into the empathic process as implemented in the human psychobiological complex, the complete human being. 

There is nothing wrong – but there is something missing

Ultimately what is missing from automating empathy is the human body – the chatbot is unable to BE in the space with you in a way that a human being can be with you. The empathy is in the interface. And the empathy for the human being is often the face. The human face is an emotional “hot spot.” The roughly thirty muscles in the human face, some of which are beyond voluntary control, can combine in some 7000 different ways to express an astonishingly wide range of emotions starting with anger, fear, high spirits (happiness), sadness and extending to truly subtle nuances of envy, jealousy, righteous indignation, contempt, curiosity, and so on. The result is facial recognition software of which “emotional recognition” is the next step as implemented by such companies as Affectiva (the corporation) (see Agosta 2015 in references). The software that recognizes the emotions and affects of the speaker based on a calculus of facial expressions (and the underlying muscles) as documented by Paul Ekman (2003). Now combine such an interface with an underling automation of empathy by a not-yet-developed system, and the state-of-the-art advances.

The skeptic may say, but what if the therapist is a psychoanalyst and you are using the couch so that the listener is listening out of sight, hidden behind the client, who is lying comfortably looking at the Jackson Pollack drip painting on the wall in front of him (or her) or at the ceiling? Well, even then, one hears the therapist clear her (or his) throat or one hears the analyst’s stomach gurgle. So the value added of the in-person therapy is gurgling stomachs, farts, and hiccups? Of course, this is the reduction to absurdity of the process (and a joke). Taking a necessary step back, the suspicion is one has missed the point. The point being? The bodily presence of the other person (including but not limited to the face) opens up, triggers, activates, possibilities of relatedness, possibilities of fantasies of love and hate, possibilities of emotional contagion, possibilities of further physical contact including sex, aggression, gymnastics, breaking bread, inhabiting the same space (this list is incomplete) that no virtual connection can as a matter of principle and possibility fulfill at all. This (I assert) is a key differentiator. 

The emotional bond between the client and therapist, counselor, or consultant becomes the path to recovery. But why cannot that bond be with a bot? Well, without taking anything back anything said so far in this article, the bond can be a “bot bond,” if that would work well enough for you. Still, arguably, there is nothing wrong, but there is still something missing. Like in the major motion picture Her ((2013) Spike Jonze with a young Joaquin Phoenix), in which the lonely, socially awkward but very nice guy has a relationship with an online bot of a “girlfriend” – and then gets invited out on a double date. It is like the date – the other “person” (and the quotes are required here!) – is on speaker phone. So, if you are okay with that, then the sky, or at least cyber space, is the limit. There is another shoe to drop. It then turns out that the relationship is not exclusive as the software is managing thousands of simultaneous threads of conversations and relationships simultaneously. One essential aspect of empathy is that the one person is fully present with the other person. Even if the empathy consultant has other clients and other relationships, the listener’s commitment at the time and place of the encounter is to be fully present with the other person. For at least this session, I am yours and yours alone. Now that is a differentiator, and even in our multitasking, attention deficit world, I assert such serial exclusiveness (different than but analogous to serial monogamy) is critical path to get value from the empathy, whether authentic or simulated.

Advantage: Rapport

This matter of “exclusivity” suggests that the rapport between the speaker and listener, between the receptivity for empathy and its delivery, is undivided, unshared outside of the empathic pair, complete, whole. The parent has several children, but when she or he is interacting with one of them, that one gets the parent’s undivided attention. The parent is fully present with the child without any distractions. That such a thing is hard to do in the real world, show what a tough job parenting is. 

If this analysis of exclusivity is accurate, then that would be a further differentiator between real world human empathy and automated empathy. I may be mistaken, but notwithstanding some people who can manage (“juggle”) multiple simultaneous intimate relationships, the issue of exclusivity of empathy is one reason why most such relationships either fail outright or stabilize as multiple serial “hook-ups” (sexual encounters) without the intimacy aspects of empathy.  

On background, this business of the “rapport” invites further attention. “Rapport” is different from empathy, and it would be hard to say which is the high-level category here, but the overlap is significant. “The rapport” first got noticed in the early days when the practice of hypnosis was innovated as an intervention for hysterical symptoms and other hard-to-define syndromes that would today be grouped under “personality disorders” as opposed to major mental illness. The name Anton Mesmer (1734 – 1815) – as in “mesmerism” – is associated with the initial development of “magnetic banquets,” as in “animal magnetism,” the attraction and attachment between people, including but not exclusively sexual attachment. Mesmer had to leave town (Vienna) in a hurry when he was accused of ethical improprieties in the practice of the magnetic banquets. 

The rapport of the hypnotic state is different than “being in love,” yet has overlapping aspects – being held in thrall of the other in a “cooperative,” agreeable, even submissive way. (It should be noted that Mesmer started up his practice again in Paris (a fascinating misadventure recounted in Henri Ellenberger The Discovery of the Unconscious (1971)). Today hypnosis is regarded as a valid, if limited, intervention in medicine and dentistry especially for pain reduction, giving up smoking, and overcoming similar unhealthy bad habits. One could still take a course in Hypnosis from Erika (not Eric!) Fromm in Hypnotism in the 1970s at the University of Chicago (Brown and Fromm 1986). (Full disclosure: I audited her (Fromm’s) dream interpretation course (and did all the assignments!), but not the hypnosis one.) 

This business of love puts the human body on the critical path once again. Of course, no professional – whether MD, psychologist, therapist, counsel, empathy consultant, and so on – would ethically and in most cases even legally perpetrate the boundary violation of a sexual encounter. Indeed one can shake hands with any client – but hugs are already a boundary issue, if not violation. The power differential between the two roles – provider and client – is such that the client is “one down” in terms of power and cannot give consent. 

However, firmly differentiating between thought and action, between fantasy and behavior, what if the mere possibility of a sexual encounter were required to call forth, enable, activate, the underlying emotions that get input to create the interpersonal attachment (the rapport) that occur with empathy? (This is a question.) Then any approach which lacked a human body would not get off the ground. Advantage: human empathy. 

Once again, skepticism is appropriate. Is one saying the possibility of a boundary violation is an advantage? Of course not. One is saying that the risk of a boundary violation is a part of having a human body, and that such a risk is on the critical path to calling forth the communication of emotions (many of which may be imaginary) need for full-blown, adult empathic encounter. Note also this is consistent with many easy examples of entry level empathy where empathy is not really challenged. If someone raises their voice and uses devaluing language, one’s empathy is not greatly tested in concluding that the person is angry. Virtual insensitivity will suffice. 

In the context of actual emotional distress, the matter is further complicated. Regarding bodily, physical presence, the kind of empty depression, meaninglessness, and lack of aliveness and vitality characteristic of pathological narcissism responds most powerfully and directly to the “personal touch” of another human being who is present in the same physical space. Kohut suggests that the child’s bodily display is responded to by gleam in the parent’s eye, which says wordlessly (“I am proud of you, my boy [or girl]!”). Child and parent are not having an online session here, and, I must insist, any useful and appropriate tele-sessions are predicated on and presupposed a robust relatedness based on being, living, and playing together on the ground in shared physical space. One occasionally encounters traumatic events that impact the client’s sense of cohesive self, if the parent recoils from the child’s body (or cannot tolerate lending the parent’s own body to the child for the child’s narcissistic enjoyment). The risk of the self’s fragmentation occurs (Kohut 1971: 117). So where’s the empathy? The need for the parent’s echoing, approving, and confirming is on the critical path to the recovery of the self. The empathy lives in the conversation for possibility with the other person in the same space of acceptance and tolerance in which we both participate in being together. 

Advantage: Embodiment

Another area where humans still have an advantage (though one might argue it is also a disadvantage) is in having a body. Embodiment. You know, that complex organism that enables us to shake hands, requires regular meals, and so on. If further evidence were needed, this time explicitly from the realm of science fiction, the bots actually have a body, indistinguishable from that of standard human beings, in Philip K. Dick’s celebrated “Do Androids Dream of Electric Sheep” (1968), which is the basis for the major motion picture Blade Runner. Regardless of whether the “droids” have empathy or not, they definitely have a body in this sci-fi scenario – and that makes all the difference. That raises the stakes on the Voight-Kampff Empathy Test considerably (the latter rather like a lie detector, actually measuring physiological arousal, not truth or empathy). 

And while the production of realistic mechanic-biological robots is an ongoing grand challenge, we have left the narrow realm of computing and into biochemistry and binding bone and tissue to metals and plastics and translating biochemical signals into electrical ones. We are now inside such science fiction films as Blade Runner or Ex Machina. For purposes of this article, we are declaring as “out of scope” why we will soon be able to produce autonomous weapon warriors that shoot guns, but not autonomous automatic empathy applications. (Hint: the former are entropy engines, designed to produce chaos and disorder; whereas empathy requires harmony and order; it is easier to create disorder than to build; and automating empathy is working against a strong entropy gradient as are all humanizing activities.) Along with the movie Ex Machina, this deserves a separate blog post.

The genie is out of the bottle

Leaving all-important early childhood development aside, bringing large language models to empathic relatedness is a game changer. The question is not whether the generative AI can be empathic, but the extent to which the designers want it to function in that way and the extent to which prospective clients decide to engage (both open questions at this date (Q4 2025)).

“The day ChatGPT went cold” is the headline in this case. The reader encounters the protest from some Open AI customers about the new release of Chatbot 5.0. This event was reportedly greeted by a significant number of customers with the complaint that “Open AI broke it!” 

The New York Times article (https://www.nytimes.com/2025/08/19/business/chatgpt-gpt-5-backlash-openai.html) tells of a musician who found comfort (not exactly “empathy,” but perhaps close enough) in talking with ChatGPT about childhood trauma, and, as designed, the bot would keep the conversation going, enabling the individual to work through his issues (or, at least, such is the report, which, however, I find credible). Then the new release (5.0) was issued and it went “cold.” The response of the software lacked the previous set of features often associated with empathy such as rapport, warmth, responsiveness, validation, disagreeing in an agreeable way, humor, and so on. Instead the response was emotionally cold: “Here is the issue – here is the recommendation ___. Conversation over.” In particular, customers who were physically challenged as regards their mobility, ability to type (and were using a voice interface), cognitive issues, as well as standard customers who had established a relationship with the software and the interface, complained that the “rapport” was missing. 

Human beings often know that they are being deceived, but they selectively embrace the deception. That is the basis of theatre and cinema and even many less formal interpersonal “performances” in social media. In the media, the entire performance is imaginary, even if it represents historical events from the past, but the viewer and listener welcome it, not just for entertainment (though that, too) but because it is enlivening, activating, educational, or inspiring. Same idea with your therapy-bot. The client enters the therapy theatre. You know it is fake the way the Battle of Borodino in Tolstoy’s War and Peace is a fictional representation of a real battle. Yet for those able to deal with the compartmentalization, perhaps the result is good enough. This assumes that the therapeutic action of the bot is “on target,” “effective,” “engaging,” which, it should be noted, is a big assumption, especially given that even in the real world it is hard to produce a good therapeutic result.

This matter of faking empathy opens up a humorous moment (though also a serious one – see below). Here the definition of “fake” is “fake” the way a veggie burger is a substitute for an actual hamburger.  That may actually be an advantage for some people, though, obviously, in a profoundly different way in comparing how a hamburger relates to empathy as processed by a human being. The veggie burger influences the lower gastrointestinal tract and the empathy (whether automated or not) influences one’s psyche (the Greek word for “soul”). Not a vegetarian myself, I definitely eat a lot less meat than ten years ago, and, with apologies to the cattle industry (but not to the cattle), applaud the trend. The interesting thing is that by branding the products “veggie burgers” or “turkey Burgers,” the strong inference and implication is that the hamburger still sets the standard regarding the experience and taste that the consumer is trying to capture. Likewise with empathy.

In most cases, the automation of empathy relies on the person’s desire and need for empathy.  Empathy is like oxygen for the soul – without it, people suffocate emotionally. Unfortunately, the world is not generous with its empathy, and most people do not get enough of it. Therefore, people are willing systematically, perhaps as a design limitation of the human psyche, to support a blind spot about the source of their empathy. Some will choose the Stephen Stills song: “If you can’t be with the one you love; love the one you’re with!” (1970), which, in this case, will be the bot mandated by the insurance company or the human resources department of the corporation. Deciding not to think about what is in fact the case, namely, this amalgamation of silicon hardware and software has no human body, is not morally responsible, and lacks authentic empathy, the person nonetheless attributes empathy to it because it just feels right; and yet, unless, the bot goes haywire and insults the person, that is often good enough to call forth the experience of having been “gotten,” of “having been heard,” even if there is no one listening.

For all of its power and limitations, psychoanalysis is right about at least one thing: transference is pervasive on the part of human beings. Nor is it restricted merely to other human beings. The chatbot becomes a new transitional object (to use D.W. Winnicott’s term (1953)). To quote Elvis, “Let me be – your teddy bear.” This is “transference,” an imaginary state in which the client imaginatively project, attributes, and/or assigns a belief, feeling, or role to the therapist, which the therapist really does not have. However, the ins-and-outs of transference are not for the faint of heart. What if the therapist really does behave in a harsh manner, thereby inviting the project on the part of the client of unresolved issues around a hard, bullying father figure? The treatment consists precisely in creating an empathic space of acceptance, to “take a beat,” “take a step back,” and talk about it. Of what does this remind you, dear client?” Is this starting to look and sound familiar? 

The suggestion is that such features, including transference, can be simulated and iteratively improved in software. However, the risk is that in “simulating” some of these features – and the comparison is crude enough – it is rather like putting on blackface and pretending to be African-American. Don’t laugh or be righteously indignant. Things get “minstrel-ly” – and not in a positive way. There are significant social psychology experiments in which people have “gone undercover,” pretending to be black – in order the better to empathize with the struggles of black people. The result was fake empathy. (See A. Gaines (2017) Black for a Day: White Fantasies of Race and Empathy and L. Agosta (2025) “Empathy and its discontents.”) In the case of automated empathy software, no one is pretending to deliver human empathy (though, concerningly, sometimes it seems that they are!) and the program may usefully deliver the disclaimer that the empathy is simulated, multi-threaded, not exclusive, and not the direct product of biologically based experience of a human organism. To paraphrase a disclosure from the bot in Her, “I am currently talking to 3231 people and am in love 231 of them.” 

Ethical limitations of “fake it till you make it”

While one can map these empathic functions one-to-one between human beings in relationship (including therapeutic ones), there is one aspect of the relationship that encompasses all the others and does not apply to the bot. That is the ethical aspect of the relationship. When a person goes to a professional for consultation – indeed whether about the individual’s mental health or the integrity of the individual’s financial portfolio or business enterprise – the relationship is a fiduciary one. (Key term: “fiduciary” = “trust”.) That is, one relies on the commitment to the integrity of the interaction including any transactional aspects. One is not going to get that kind of integrity or, just as importantly, the remedies in case of an integrity outage from a bot. Rather one looks to the designer, the human being, who remains the place where the responsibility lands – if one can figure out who that is “behind the curtain” of the faceless unempathic bureaucracy responsible for the product.

A significant part of the ethical challenge here is that automated neural networks – whether the human brain implemented in the organic “wetware” of the human biocomputer or, alternately,  a computer network implemented in the software of silicon chips – seem to have emergent properties that cannot be rigorously predicated in advance. (On this point see  Samuel Bowman (2024): Eight things to know about large language models: https://read.dukeupress.edu/critical-ai/article/doi/10.1215/2834703X-11556011/400182/Eight-Things-to-Know-about-Large-Language-Models. Thus, human behavior, which is often predictable, is also often unpredictable. So human communities have instituted ethical standards of which law enforcement and organized religions are examples. Our standards for chatbots and similar platforms are still emerging. 

Thus, the prognosis is mixed. Is automating empathy a silver bullet – or even a good enough lead bullet – to expand empathy for the individual and community and to so at scale, for example, for Henry David Thoreau’s “modern mass of men [persons] leading lives of quiet desperation”? Or our cyber age equivalent of a blow-up sex doll for the socially awkward person playing small and resistant to getting out of the person’s comfort zone? At the risk of ending on a cynical note, given the sorry state of human relations as demonstrated in the news of the day, maybe, just maybe, any form of expanded empathy, whether fake or authentic, if properly managed to mitigate harm, is a contribution. 

In any case, the key differentiators between automated empathy and humanly (biologically) based empathy are the human body (or lack thereof), the exclusivity of the empathic rapport, and the ethical implications, including the locus of responsibility when things go right (and wrong). We humans will predictably fake it till we make it; and automating empathy does not produce empathy – it produces fake empathy. 

References 

(in alphabetical order by first name)

Alisha Gaines. (2017). Black for a Day: White Fantasies of Race and Empathy. Chapel Hill: University of North Carolina Press.

Carl Rogers. (1961). On Becoming a Person, intro. Peter Kramer. Boston: Houghton Mifflin, 1995.

Daniel P. Brown & Erika Fromm. Hypnotherapy and hypnoanalysis. Hillsdale, N.J.: L. Erlbaum Associates, 1986. 

Donald W. Winnicott. (1953 [1951]). Transitional objects and transitional phenomena. A study of the first not-me possession. International Journal of Psycho-Analysis, 34, 89-97.

Dylan Freedman. (2025/0819). The day ChatGPT went cold. The New York Times:https://www.nytimes.com/2025/08/19/business/chatgpt-gpt-5-backlash-openai.html

Henri Ellenberger. (1971). The Discovery of the Unconscious. 

Heinz Kohut. (1959). Introspection, empathy, and psychoanalysis. Journal of the American Psychoanalytic Association, 7: 459–483.

Heinz Kohut. (1971). The Analysis of the Self. New York: IUP Press.

Heinz Kohut. (1977). Restoration of the Self. New York: IUP Press.

Joseph Weizenbaum. (1966). ELIZA –  A computer program for the study of natural language communication between men and machines,” Communications of the ACM, 9: 36–45. (See also ELIZA below under Wikipedia.)

Kenneth Craik. (1943). The Nature of Explanation. Cambridge: Cambridge University Press, 1967.

Lisa Bonos (2025/10/23): “Meet the people who dare to say no to artificial intelligence”: https://www.washingtonpost.com/technology/2025/10/23/opt-out-ai-workers-school/

Lou Agosta. (2025). Chapter Three: Empathy and its discontents. In Radical Empathy in the Context of Literature. New York: Palgrave Macmillan: 55 – 82. (https://doi.org/10.1007/978-3-031-75064-9_3 )

Lou Agosta. (2019). Review of The Empathy Effect by Helen Reiss: https://empathylessons.com/2019/01/27/review-the-empathy-effect-by-helen-riess/

Lou Agosta. (2015). A rumor of empathy at Affectiva: Reading faces and facial coding schemes using computer systems: https://empathylessons.com/2015/02/10/a-a-rumor-of-empathy-at-affectiva-reading-faces-and-facial-coding-schemes-using-computer-systems/

Paul Ekman. (2003). Emotions Revealed. New York: Owl Books (Henry Holt).

Philip K. Dick. (1968). Do Androids Dream of Electric Sheep. New York: Ballentine Books.

Samuel Bowman (2024): Eight things to know about large language models: https://read.dukeupress.edu/critical-ai/article/doi/10.1215/2834703X-11556011/400182/Eight-Things-to-Know-about-Large-Language-Models.

Shabna Ummer-Hashim. (Oct 27, 2025). AI chatbot lawsuits and teen mental health: https://www.americanbar.org/groups/health_law/news/2025/ai-chatbot-lawsuits-teen-mental-health/

Spike Jonze. (2013). Her. Major motion picture. 

Stephen Stills. (1970). Love one you’re with. Lyrics: https://www.google.com/search?client=safari&rls=en&q=words%3A+love+the+one+you%27re+with&ie=UTF-8&oe=UTF-8 [checked on 2025/10/31]

Wikipedia: “ELIZA: An early natural language processing computer program”: https://en.wikipedia.org/wiki/ELIZA

Zara Abrahams. (2025/03/12): “Using generic AI chatbots for mental health support: A dangerous trend”: https://www.apaservices.org/practice/business/technology/artificial-intelligence-chatbots-therapists

Update (Nov 5, 2025). This article just noted: They fell in love with AI Chatbots: By Coralie Kraft : https://www.nytimes.com/interactive/2025/11/05/magazine/ai-chatbot-marriage-love-romance-sex.html [The comments note that people being self-expressed is generally a good thing, including self-expressed to and with Chatbots; and the individuals may usefully continue to try to find an actual human being with whom to talk and relate. Less charitably, other commentators have said things like “I hope the person gets the help they need.”]

UPDATE May 2, 2026: ChatGPT Wrestles With Its Most Chilling Conversation: How Do I Plan an Attack? by Georgia Wells: https://www.wsj.com/us-news/chatgpt-mass-shooting-openai-78a436d1?st=xC4zMB&reflink=desktopwebshare_permalink

UPDATE (June 28, 2026): The Three Chatbot Behaviors That Can Drive Humans to Delusional Thinking by Julie Jargon: https://www.wsj.com/tech/personal-tech/ai-chatbots-psychology-delusion-662a3663?st=tYwNLJ&reflink=desktopwebshare_permalink

IMAGE Credit: (c) Adler University – “Empathy Can’t Be Automated” republished with kind permission

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

Empathy Lessons, 2nd Edition, is now available as an ebook…

The release of the ebook version of Empathy: Lessons ,2nd Edition, coincided with a major astronomical event – the total solar eclipse that traversed North America on Monday April 8, 2024. The gods are watching and winking at us humans to encourage expanding our empathic humanism! 

Empathy is oxygen for the soul (see Chapter 6: Evidence-based empathy training). So, if you are short of breath due to life stress, get the expanded empathy delivered in this book. Just as the body needs oxygen to live physically, the soul needs empathy to live emotionally. Most people are naturally empathic, but the cynicism and denial needed to survive everyday life drives empathy away. Remove the obstacles to empathy and empathy naturally develops and grows. That is the empathy lesson in a nutshell without all the guidance and practice needed to succeed. Find out how to take your empathy to the next level.


In addition to all the features of the First Edition—a readiness assessment for empathy, tips on overcoming resistance to empathy, evidence-based empathy training, empathic techniques of stress reduction, applications to dealing with bullying, healthy well-being, and capitalism—the enlarged Second Edition includes new chapters on rhetorical empathy in politics, the limitations of empathy (and what to do about them), and an expanded chapter on empathy as a lens on love and romance. Not to be missed!

The empathy lessons include how—
To perform a readiness assessment; establish a set up for success in cleaning up inauthenticities that block empathy so that empathy can expand and flourish;

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

Empathy works as a method of data gathering about the other person, providing a vicarious experience of the other person without being flooded by the experience;

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

Empathic receptivity overcomes emotional contagion, creating a set up for clear communication of feelings and experiences;

Empathic understanding overcomes conformity and enables shifting out of stuckness into contribution, transformation, and leadership, including satisfying and flourishing relationships;

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

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

Scientific, peer-reviewed, evidence-based research confirms that empathy reduces inflammation and stress;

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

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

In rhetorical empathy, the speaker’s words address the listening of the audience in such a way as to leave the audience with the experience of having been heard. The speaker articulates the experience the audience is hiding harboring in their hearts yet have been unable to express.

To expand empathy, start with and stick with integrity and authenticity – start with creating a safe space of acceptance and toleration. Fake in; fake out. Empathy is based on integrity and being straight with the other person to and with whom one is trying to relate.

Decline the choice between empathy and compassion, between expanding empathy and fighting and reducing the empire of prejudice, imperialism, the pathologies of capitalism, and violence. 

Some have tried to force a choice between compassion and empathy. The world needs both more compassion and expanded empathy.

My colleagues and friends are telling me, “Louis, you are sooo 20th Century – no one is reading hard copy books anymore! Electronic publishing is the way to go.” Following my own guidance about empathy, I have heard you, dear reader. The electronic versions of all three books, Empathy Lessons, 2nd Edition, Empathy: A Lazy Person’s Guide, and A Critical Review of a Philosophy of Empathy – drum roll please – are now available. 

Feeling like you are thrown “under the bus” again and it’s getting crowded under there? Get the empathy you need to fight back and flourish in this book. Get expanded empathy here!

Order from author’s page: Empathy Lessons, 2nd Edition: https://tinyurl.com/29rd53nt

Order from author’s page: Empathy: A Lazy Person’s Guide: https://tinyurl.com/29rd53nt

Order from author’s page: A Critical Review of Philosophy of Empathy: https://tinyurl.com/29rd53nt

Read a review of the 1st edition of Empathy Lessons – note the list of the Top 30 Empathy Lessons is now (2024) expanded to the Top 40 Empathy Lessons: https://tinyurl.com/yvtwy2w6

Read a review of A Critical Review of a Philosophy of Empathy: https://tinyurl.com/49p6du8p

Empathy Lessons, 2nd Edition, Cover art by Alex Zonis (Memory Bocks: Shimon")

Above: Cover art: Empathy Lessons, 2nd Edition, illustration by Alex Zonis, original oil paint on board, entitled “Memory blocks: Shimon”

Empathy: A Lazy Person's Guide Cover Art by Alex Zonis, illustrator/artist
Empathy: A Lazy Person’s Guide Cover Art by Alex Zonis, illustrator/artist

Order from author’s page: A Critical Review of a Philosophy of Empathy: https://tinyurl.com/mfb4xf4f

Cover art by Alex Zonis

Above: Cover art: A Critical Review of a Philosophy of Empathy, illustration by Alex Zonis

In conclusion, let me again say a word on behalf of hard copy books – they too live and are handy to take to the beach where they can be read without the risk of sand getting into the hardware, screen glare, and your notes in the margin are easy to access. Is this a great country or what – your choice of pixels or paper!?!

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

Empathy: A Lazy Person’s Guide is now an ebook – and the universe is winking at us in approval!

The release of the ebook version of Empathy: A Lazy Person’s Guide coincides with a major astronomical event – a total solar eclipse that traverses North America today, Monday April 8, 2024. The gods are watching and wink at us humans to encourage expanding our empathic humanism!

My colleagues and friends are telling me, “Louis, you are sooo 20th Century – no one is reading hard copy books anymore! Electronic publishing is the way to go.” Following my own guidance about empathy, I have heard you, dear reader. The electronic versions of all three books, Empathy: A Lazy Person’s Guide, Empathy Lessons, and A Critical Review of a Philosophy of Empathy – drum roll please – are now available. 

A lazy person’s guide to empathy guides you in – 

  • Performing a readiness assessment for empathy. Cleaning up your messes one relationship at a time. 
  • Defining empathy as a multi-dimensional process. 
  • 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 the empathy you need. 
  • The one-minute empathy training. 
  • 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. 
  • Setting boundaries: 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 empathy therapist. Experiencing a lack of empathic responsiveness? Get some empathy consulting from Dr Lou. Make the other person your empathy trainer. 
  • 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? 

Okay, I’ve read enough – I want to order the ebook from the author’s page: https://tinyurl.com/29rd53nt

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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. However, if you are not just lazy, but downright inert and numb in one’s emotions – and in that sense, e-motionless – then be advised: it is going to take something extra to expand your empathy. Zero effort is not the right amount. One has actually to practice and take some risks. 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 trial 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 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. 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.

Order from author’s page: Empathy: A Lazy Person’s Guide: https://tinyurl.com/29rd53nt

Order from author’s page: Empathy Lessons, 2nd Edition: https://tinyurl.com/29rd53nt

Read a review of the 1st edition of Empathy Lessons – note the list of the Top 30 Empathy Lessons is now (2024) expanded to the Top 40 Empathy Lessons: https://tinyurl.com/yvtwy2w6

Read a review of A Critical Review of a Philosophy of Empathy: https://tinyurl.com/49p6du8p

Order from author’s page: A Critical Review of Philosophy of Empathy: https://tinyurl.com/29rd53nt

Empathy: A Lazy Person's Guide Cover Art by Alex Zonis, illustrator/artist
Empathy: A Lazy Person’s Guide Cover Art by Alex Zonis, illustrator/artist

Order from author’s page: Empathy Lessons, 2nd Edition: https://tinyurl.com/mfb4xf4f


Above: Cover art: Empathy Lessons, 2nd Edition, illustration by Alex Zonis

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Order from author’s page: A Critical Review of a Philosophy of Empathy: https://tinyurl.com/mfb4xf4f

Above: Cover art: A Critical Review of a Philosophy of Empathy, illustration by Alex Zonis

Finally, let me say a word on behalf of hard copy books – they too live and are handy to take to the beach where they can be read without the risk of sand getting into the hardware, screen glare, and your notes in the margin are easy to access. Is this a great country or what – your choice of pixels or paper!?!

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

Summer Reading: The Song of Our Scars by Haider Warraich

I have been catching up on my summer reading: Haider Warraich. (2023). The Song of Our Scars: The Untold Story of Pain. New York: Basic Books, 309 pp. 

Haider Warraich, MD, has provided an account of our relationship with pain and suffering that is a “physician heal thyself” moment and narrative. Warraich’s work is a powerful combination memoire and biological-clinical briefing on the distinction between acute and chronic pain. Now an assistant professor at Harvard Medical School, the author experienced a life altering back injury while he was in medical school. Suffice to say, the results were an entire encyclopedia of pains, extending from acute to chronic and back, and providing the reader with a compelling narrative of what medical science does not know about pain. Warraich has a way with words and catchy phrases. For example, regarding pain, “The human brain is not just staffing the ticketing booth as the [pain] circus – it is the ringleader” (p. 10). Just so. 

Warraich argues: “To course-correct our approach to pain, we need to change the story of chronic pain – pushing back on the voices attempting to convince us all pain is catastrophic and life threatening and needs immediate attention over everything else right now” (p. 253). And yet the good doctor acknowledges that pain puts the person in pain in prison (p. 78). Chronic pain mirrors incarceration (p. 78); and, as for acute pain, the house is on fire and the patient is in it. Summon emergency services!? Elaine Scarry’s The Body in Pain (pp. 232 – 233) is quoted approvingly as additional reading demonstrating that pain presents as requiring urgent attention. Pain resists language, and, when inflicted, for example, in torture, can destroy one’s humanity and integrity and world, requiring long, arduous, and doubtful recovery. 

Warraich provides a series of engaging briefings on aspects of pain. The reader gets three basic distinctions differentiating: acute from chronic pain; pain as such versus painful emotions such as fear (e.g., pp. 54, 65), which this reviewer would gloss as “suffering”; and pain in the context of the relationship between mind and body. 

Acute pain is exemplified by such experiences as an appendicitis, a broken bone, closing the car door on one’s finger, or dropping a brick on one’s toe. Ouch! In contrast, chronic pain is morning body ache and other intermittent and recurring aches, cramping from irritable bowel syndrome, osteoarthritis, hard-to-describe headaches, or the consequences of multiple back surgeries to the spine. Chronic stress – the boss is a bully, the kids are misbehaving, the spouse is having a midlife crisis,the commute back to the office is unavoidable, the toilet is clogged – results in chronic pain (p. 177). “When people become trapped in the clutches of chronic pain and chronic stress, their lives become engulfed in an eternal, inextinguishable fire – a fire as ferocious as the one that drives the hunger for profit that fuels many modern pharmaceutical giants” (p. 179). Thanks to neuro-plasticity (a key distinction further defined below), chronic pain reorganizes the nervous system. The body expresses the imbalance, the dis-equilibrium, of the mind and its emotions (the latter, admittedly, not distinctions covered in medical school in any detail). Chronic pain stops being a symptom of an injury and it takes on a life of its own, presenting as if the pain were a disease in itself instead of a signal of an underlying or related bodily injury. Chronic pain leads to suffering, a term that Warraich mentions but does not explicitly elaborate. For example, if pain is the dentist hitting an exposed nerve, suffering is being in the waiting room anticipating the dentist hitting the nerve. 

According to Warraich, medicine is very good at anesthetizing the mammalian nervous system against such acute pain, but the use of the same anesthetics and analgesics against suffering is a deal with the devil. It might work in the short term; but be sure to read the fine print. The road to hell is paved with such agreements, which, it turns out, is a redescription of the opioid epidemic. In the following, Warraich writes “pain”, but it would be more accurate to say he means “suffering”: “The confluence of advances in medicine and a barrage of pharmaceutical companies marketing directing to doctors and patients birth a movement that deemed suffering unacceptable. As spiritual voids gaped inside those economically left behind and loneliness became a way of life, people in pain [i.e., suffering] kept being sent exclusively to doctors’ offices and pharmacies [for opioids to numb the pain]” (p.147). Loneliness is indeed painful, and poverty is definitely bad for one’s health, but not in the same way as a toothache or appendicitis – loneliness and poverty are chronic and make a person cry real tears of frustration, isolation, neglect, and anger. Yet the suffering is not localized like a toothache or peripheral injury, but seems to pervade the head and chest, calling forward a sense of being burdened by something imponderable and diffuse throughout one’s upper body. In chronic pain and the suffering brought forth by chronic pain, instead of the injured organism telling the brain of the peripheral injury in the limb by means of a pain signal upward to the brain, the brain (or, to be exact, the thoughts in it) are sending the signal in the other direction – downward – telling the organism to hurt. This may be specific, if there is a specific injury able to express the suffering, but more likely the pain points are diffuse and mobile – hard to define lower back pain (e.g., Warraich’s injuries), headaches, irritable bowel syndrome, autoimmune disorders. In short, acute pain is the organism telling the brain it (the skin or peripheral limb) is hurting; whereas chronic pain is the brain telling the organism it is hurting. However, the message is highly susceptible of distortion. In some ways, chronic pain can become the memory of pain, which may or may not indicate a current injury. Chronic pain can become the fear of pain itself, expanding into pain in the here and now. In short, opioids are effective in treating acute pain but are ineffective and harmful – I would say “a deal with the devil” – in treating chronic pain (p. 174). 

The poster child that not all pains are created equal is phantom limb pain. Documented as early as the American Civil War by Silas Weir Mitchell, individuals who had undergone amputation, felt the nonexistent, missing limb to itch or cramp or hurt. The individuals experienced the nonexistent tendons of the missing limb as cramping and even awakening the person from the most profound sleep due to pain (pp. 110 – 111). 

Fast forward to modern times and Ron Melzack’s gate control theory of pain marshals such phantom limb pain as compelling evidence that the nervous system contains a map of the body and its pains point, which map has not yet been updated to reflect the absence of the lost limb. In effect, the brain is telling the individual that his limb is hurting using an obsolete map of the body – the memory of pain. Thus, the pain is in one’s head, but not in the sense that the pain is unreal or merely imaginary. The pain is real – as real as the brain that is indeed in one’s head and signaling (“telling”) one that one is in pain. 

One question that has not been much asked is whether it is possible to have something similar to phantom limb pain even though the person still has the limb functionally attached to the body. For example, the high school football player who needs the football scholarship to go to college because he is weak academically but actually hates football. He really incurs a painful soft tissue sports injury, which gets elaborated emotionally and psychologically, leaving him on crutches for far-too-long and both physically and symbolically unable to move forward in his life. Thus, due to the inherent delays in neuroplasticity – the update to the map is not instantaneous and one does not have new experiences with a nonexistent limb – pain takes on a life of its own. That is the experience of chronic pain – pain has a life of its own – pain becomes the dis-ease (literally), not the symptom. What then is the treatment, doctor?

Warraich radicalizes the issue of pain that takes on a life of its own before suggesting a solution. After providing a short history of opium and morphine and opioids, culminating “in the most prestigious medical school on earth, from the best teachers and physicians, we [medical students] were unknowingly taught meticulously designed lies” (p. 185), that is, prescribe opioids for chronic pain. The reader wonders, where do we go from here?  To be sure opioids have a role in hospice care and the week after surgery, but one thing is for certain, the way forward does not consist in prescribing opioids for chronic pain.

After reviewing numerous approaches to integrated pain management extending from cognitive behavioral therapy and acceptance and commitment therapy (ACT) to valium, cannabis and Ketamine – and calling out hypnosis (hypnotherapy) as a greatly undervalued approach (no exteranl chemicals are required, but the issue of susceptibility to hypnotic suggestibility is fraught) – Dr Warraich recovers from his own life changing back injury in a truly “physician heal thyself” moment thanks to dedicated PT, physical therapy (p. 238). If this seems stunningly anti-climactic, it is boring enough to have the ring of truth earned in the college of hard knocks, but it is a personal solution (and I do so like a happy ending!), not the resolution of the double bind in which the entire medical profession finds itself (pp. 188 – 189). The way forward for the community as a whole requires a different, though modest, proposal. 

Let us allow Dr Warraich to speak for himself: “I have come to believe a good doctor has an almost magical quality to feel what their patients feels – to see how they view the world, understand where they have been and what they’ve have seen all in an instant – as well as the knowledge and expertise to respond ethically to what they see from the other side. This superpower has a name: empathy” (p. 238). Never underestimate the power of a good listening. “’Mental distress may be perhaps the most intractable pain of all,’ she [Cicely Sanders] wrote, and the answer to it was not always more drugs, because for some ‘the greatest need is for a listener’” (p. 159). 

Putting pain in the context of the relationship between soul and body, the body in pain expresses the suffering of the soul. While psychiatry and neurology do not even believe in the soul, they do begrudgingly allow that there is such a thing as “mental status,” which, for example, can be compromised by the hormonal imbalance of puberty, existential anxiety, jet lag, alcohol, delirium, or other insults to the organism such as blunt trauma, which, in turn, implies a conscious mind to have such a mental status. Here’s the issue: humans are neurons “all the way down,” but then the neurons start to generate consciousness – consciousness generates meaning – meaning generates language and relatedness, language and relatedness generates community, culture, art, literature, science, and humanity. However, there are numerous details that need to be filled in here, which are still the target of inquiry and ongoing research, and you won’t learn or be allowed to study them in medical school. I hasten to add that if you are experiencing a compromised mental status due to delirium, don’t call a hippie or professor of comparative literature – you need a medical doctor! 

Notwithstanding my whole-hearted endorsement of Dr Warraich’s contribution – get multiple copies of this book and give it to your friends to read – this is not a softball review. Three criticisms come to mind. 

First, Warraich rightly criticizes Rene Descartes’ (1596 – 1650) abstraction of the mind (including consciousness and consciousness of pain) from the body. Having divided the unity of the human being into two parts, mind (soul) and body, Descartes then needed a way to explain the communication between them. The mind obviously does not direct the body the way the pilot of a boat steers the craft. Absent neuro-pathology, the mind and the body are a near perfect unity. The body is the perfect servant of the mind – it prepares a cup of tea without my having to communicate the desire as if to a separate entity. It just knows and starts boiling the water. Descartes solution was to propose the pineal gland as the seat of the soul in the body. Warraich does Descartes one better by developing an entire narrative about the brain’s posterior insular cortex and anterior insula, identifying a novel kind of neuron, a von Economo neuron (p 63), from which pain emerges as an emotion generated by a physical sensation. An ingenious solution, which, however, is still a category mistake. What is missing – and here it is not Warraich’s issue but a general shortcoming of philosophy of science – is an account of emergent properties such as, for example, how mental states come forth from physical processes and, just as importantly, how mental states cause physical ones (as when one literally worries oneself sick).

Second, as regards the personal parts of the author’s narrative, pick a story and stick to it. The personal narrative starts out that the potentially life changing back injury is described as tissue damage (p. 5) – the painful consequences of which should never be underestimated. But by page 91 this is redescribed as a “broken back.” Literally? The value here is in describing how the patient’s relationship to pain influences his life and how Warriach has to transform his relationship to pain in order to recover his life as a medical doctor and his contribution to healing. Of course, one could have both tissue damage and a broken back. Here highly recommended reading, in comparison to which Warraich is a modest contribution, is Arthur Kleinman’s The Illness Narratives. Stories about how chronic pain transforms one’s life, including (for example) how repeated surgeries result in a “failed back” (which technically is different than a “broken back”). Such narratives are bound to give the reader pause that medical science (or even comparative literature) understands the relation between mind and body.  

Finally, regarding the magical quality of empathy, I am a strong advocate of empathy, having published extensively on its applications. Never underestimate the power of empathy, and Warraich properly calls out the “empathy gap” in medicine (p. 244). But Warraich gives empathy a bad name in that he leaves empathy vulnerable to the critique that the above-cited magical power of empathy leads to compassion fatigue, empathic distress, and burn out. It can and does. This requires treatment too. Human beings are a complex species. They can be kind, generous, and empathic; but, as painfully demonstrated by the opioid epidemic, they can also be greedy, grasping, aggressive, territorial, bullying, experts in know-it-all-ism that obstructs listening, and exploiters of politics in the negative sense.  The short empathy training is to drive out all these negatives, and empathy naturally and spontaneously comes forth. People (i.e., doctors) want to be empathic and will be so if given half a chance. The challenge is that the healing professions are constantly exposed to pain, suffering, trauma, and patients who can be difficult and unempathic precisely because they are in pain – or because they were difficult people prior to getting sick or hurt. A rigorous and critical empathy knows it can be wrong, breakdown, or misfire, so such an empathy also knows it can be validated. This reviewer believes Warraich’s compelling narrative may usefully have begun where it ends – with empathy and how empathy made a difference in his recovery and his daily life in the world of corporate medicine and at the Veteran’s Administration (VA). The VA has been criticized – “taken heat” – for not addressing post-traumatic stress disorder (PTSD) until it is dismissed and returns as substance abuse, but, based on Warriaich’s reports (p. 248), the VA is doing breakthrough work in integrated pain management, meditation and hypnotherapy, ACT, reduction in prescribing opioids, and they may become a model for other providers. Dr Warraich’s matriculation in the college of hard knocks of chronic back pain gives him standing to elaborate such an empathic approach, and perhaps he will do so in a follow up publication. 

Additional Reading

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

Arthur Kleinman. (1988). The Illness Narratives. New York: Basic Books.

Elaine Scarry. (1985). The Body in Pain. Oxford: Oxford University Press.

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

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