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Review: Empathy and Mental Health by Arthur J. Clark

Empathy and Mental Health: An Integral Model for Developing Therapeutic Skills in Counseling and Psychotherapy. London: Routledge 2022 Electronic Version

As a young man, Arthur J. Clark heard Carl Rogers speak and was inspired to devote his life’s work to applying empathy in education, counseling, and talk therapy. This book is the distillation of years of experience and learning, and we, the readers, are enriched and even enlightened in this original synthesis of existing ideas on empathy. It is fully buzz word compliant, diligently calls out the limitations and risks of empathy, and guides the readers in expanding their empathy to make a difference in overcoming suffering and mental illness. It takes a lot of empathy to produce a book on empathy, and empathy is evident in abundance in Clark’s work.  

As noted, Clark’s academic background is in education, as was Carl Rogers’, but the reader soon discovers Clarks’ work with empathy to be generously informed by Freud, Ferenczi, and Adlerian psychoanalysis. Thus Clark quotes [Alfred] Adler (1927): “Empathy occurs in the moment one individual speaks with another. It is impossible to understand another individual if it is impossible at the same time to identify oneself with him” (Clark: 20). At this same time this reviewer was enlivened by the application of distinctions to be found in the Self Psychology of Heinz Kohut and the latter’s colleagues Michael Basch and Arnold Goldberg. This brilliant traversal of the practice and conceptual landscape of empathy inspired Clark’s life work, and is on display here.

The book is filled with short segments of transcripts of encounters between counselor/therapist and client. To the point that empathy is much broader than reflecting feeling and meanings, examples are provided of empathic encouragement, empathic being in the here and now (immediacy), empathic silence, empathic self-disclosure, empathic confrontation, empathic reframing, empathic cognitive restricting, empathic interpretation. Clark’s work with empathic reframing, cognitive restructuring, and interpretation are particularly useful (Clark: 105 – 106). 

“Empathy” is not so much a substantive as a modifier – a manner of being that applies across a diversity of ways of relating to the other individual. (It is a further question, not addressed by Clark, as to the status of these vignettes. Are they disguised, permissioned, ideal types, some combination thereof? Just curious. In any case, they work well and remind me of M. F. Basch’s vignettes in the latter’s Doing Psychotherapy.)

Clark makes reference to the celebrated video (e.g., widely available on Youtube) of Carl Rogers, interviewing the real-world patient “Gloria” about her relationship with her nine-year-old daughter “Pammy.” Rogers’ empathic listening skillfully turns the focus from Gloria’s presenting dilemma of how much information about sex to share with her inquisitive nine-year-old daughter, Pammy, into a willingness on the part of Gloria’s to call out her own blind spots and conflicts over sex. Rogers’ empathic responsiveness shows the way for Gloria to recapture her own integrity around adult sexuality so that she can provide Pammy with the appropriate sex education the child needs, regardless of the details that may be relevant only to the adults. And Rogers does this in about twenty minutes, not months of therapy.

At this point, it is useful to give Rogers’ definition of empathy (p. 11): “To perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as if one were the person, but without ever losing the ‘as if’ condition.” Rogers was definite about excluding the perspectives of the practitioner in conceptualizing empathy in his person-centered approach to therapy. In this regard, he stated, “For the time being you lay aside the views and values you hold for yourself in order to enter another’s world without prejudice.”

Clark’s integration of the diversity of approaches to empathy in history, theory, and practice distinguishes subjective, object and interpersonal empathy: “Subjective empathy encompasses a practitioner’s internal capacities of identification, imagination, intuition, embodiment that resonate through treatment interactions with a client and empathically reflect the individual’s experiencing. Objective empathy pertains to the deliberate use of a therapist’s conceptual knowledge and data-informed reasoning in the service of empathically understanding a client in a relational climate. Interpersonal empathy relates to comprehending and conveying an awareness of a client’s phenomenological experiencing and pursuing constructive and purposeful change through the application of a range of interventions” (Clark: xiv).

Clark started out as a school counselor and he gives the example of the student who comes in and says “I hate school!” The reflection is proposed to be something like “You are feeling angry about school.” This demonstrates just how important the tone in which a statement is made can be. This could indeed be an angry statement, which takes “hate” is a literal way. However, it could also be an expression of contempt, disgust, cynicism, resignation, sadness, or even fear (say, since the student is being bullied). The empathy is precisely to acknowledge that the listener is far from certain that he does knows what is going on with the student and to ask for more data. “Sounds like you are struggling with school – can you say more about that?”

Not afraid of controversy or tough topics, Clark’s contribution is thick with quotations from the founding father of psychoanalysis – Adler and Freud and the literature Freud has been reading such as Theodor Lipps, to whom we owe the popularization in Freud’s time of the term “empathy [Einfühlung].  The subsequent generation of ego psychoanalysts is also well represented Ralph Greenson, T. Reik, Jacob Arlow (and Beres). 

Clark credits and recruits Ralph Greenson’s distinction of the therapist’s inner working model of the patient and uses it to enrich Rogers’ contribution to empathic understanding. “As empathic understandings evolve through therapeutic exchanges and assessment interactions, a model of an individual emerges that becomes increasingly refined and expansive. In turn, by ways of empathically knowing a client, the framework facilitates sound treatment interventions through the engagement of interpersonal empathy” (Clark: 88). Note that Clark aligns with the view that the countertransference is distorting/pathological as opposed to the total response of the therapist. There are many tips and techniques guiding the therapist diligently to monitor and control the countertransference neurosis. 

Since this is not a softball review, I note some issues for productive debate. For example, if Clark had allowed that countertransference included the therapist’s entire reaction to the client, including personal reactions which are not necessarily conflicted or neurotic (on the part of the therapist), then Clark would have been constrained to spend more ink on his own individual responses, empathic and otherwise. Such disclosure, which Clark otherwise separately validates as appropriate in context (and if not this context, then which?), would have enriched a text which otherwise reads like a textbook (and perhaps that was the editorial and marketing guidance).

Also useful is the therapist’s being sensitive to cultural differences and dynamics. In a brief transcript of an interaction between a privileged white school counselor and an African American 8th grader attending the college prep private school (Clark: 42), we are supposed to see objective cross-cultural empathy based on the counselor’s reading of some articles (not specified) on cultural differences. 

By all means, read up on cultural differences. However, I just see a rigorous and critical empathy (my term, not Clark’s), plain and simple. The counselor “gets it.” The student is afraid of being seriously injured or even killed by the criminal element in his neighborhood as he waits for the school bus. Is this breakdown of policing in the inner city really in the cultural article? The counselor also “gets it” that the student’s feelings are hurt by being laughed at by his more privileged classmates because his mom is a house cleaner rather than an executive or doctor or lawyer. It is the counselor’s empathic response based on her empathic understanding of the student’s specific fear and hurt feelings that enables the student to deescalate from his problematic acting out. Even though, like most 8th graders, the student would be the last to admit he has been emotionally “touched,” he was. Thus, Clark’s empathy shines through in spite of his style-deadening need to accommodate behavioral protocols, evidence-based everything, and the plodding style of delivery consistent with training in schools of professional social work and psychology.

“Objective empathy” may seem like “jumbo shrimp,” an oxymoron. Nor is it clear how dream work, with which Clark productively engages, falls into the “objective” rubric. Yet it is a highly positive feature that Clark emphasizes and explores in detail the value of dream work. 

Let one’s empathy be informed by the context: “Consider, for instance, what are the daily struggles like for a client who meets the diagnostic criteria for a bipolar disorder or attention deficit [. . . .] When giving consideration to such challenges through a framework of empathic understanding, a practitioner calls upon reputable data and a spectrum of work with individuals from diverse backgrounds in order to generate a more inclusive and accurate way of knowing a client” (Clark: 35).  

And yet this precisely misses the individual who is superficially described according to labels, but has his own experience of bipolar or attention deficit. Empathy is precisely the anti-essentialist dimension, the dimension that is so pervasive in psychiatry and schools of professional psychology that replace struggling humanity with “You meet criteria for – [insert label].”

While Kohut is properly quoted by Clark as one of the innovators in empathy and Kohut’s concise definition glossing empathy as “vicarious introspection” is acknowledged, Kohut’s other definition of empathy as a method of data gathering about the other individual is overlooked. However, it aligns nicely with Clark’s description of “objective empathy.” Maybe my close reading missed something but why not just say “taking the other person’s perspective” is “objective empathy” as opposed to vicarious introspection (“subjective empathy”)? 

The subtitle promises “An integrative model for developing therapeutic skills [. . . ]” Clark substantiates the need for work in critiquing all those training program that model the skill of repeating back to the client words similar to those the client expressed. “In a meta-analysis of direct empathy training, Lam et al. (2011) found that the majority of 29 studies did not clearly conceptualize or define empathy, some did not describe training delivery methods, and almost all of the initiatives failed to present evidence demonstrating individuals’ propensity to behave more empathically after training” (Clark: 140). Clark’s discussion of reframing, cognitive restructuring, and empathic interpretation are relevant and useful in overcoming what amount to a scandal in psychotherapy training.

What Clark is trying to say is this: You think you are being empathic. Think again. A rigorous and critical empathy (my phrase, not Clark’s)  is skeptical about its own empathy. That does not mean being dismissive either of one’s own empathy or the struggle of the other person. It means being rigorous and critical. Empathy is made to shine in the refiner’s fire of self-criticism and a radical inquiry into one’s own blind spots. 

Clark does not escape unscathed from the behavioral and observation protocol dead end. The reader will seek in vain for self-criticism or inquiry into Clark’s own blind spots – instead the reader is awash in the extensive behavioral, cognitive behavioral therapy (CBT) attempts, albeit empathically deployed, to capture therapeutic encounters in a behaviorally observable or reportable protocol. Nor I am saying there is anything wrong with that as such. Yet might not the behavioral and observation protocol swamp precisely be the blind spot where the self-deception lives against which Rogers frequently denounces? To gather the honey of self-knowledge and empathic understanding one must risk the stings of distortion and disguise. 

Clark’s would be a different work entirely if he explored the college of hard knocks in which he forged the empathic integration. He is trying to make what is largely an artistic practice into a rule-governed scientific algorithm. It is worth a try and the reader must judge the extent to which Clark succeeds. Spending a lifetime preparing articles for peer-reviewed publications in education, psychology, etc., does not generally bring life and vitality to one’s practice, manner of engagement, or writing style. However, Clark’s richness of material, wealth of distinctions related to empathy, and organizing virtually every aspect of empathic research and published references goes a long way towards compensating for Clark’s work not necessarily being a “page turner.” Clark’s writing reminds the reader more of the Diagnostic and Statical Manual (DSM) – Ouch! – more than (for example) of D. W. Winnicot, Christopher Bollas, Arnold Goldberg, Freud, who was an expert stylist (granted much is lost in translation), or even Carl Rogers himself.

Thus, Clark’s integrated approach calls for “a diagnosis [as from the DSM] that represents the lived experience of the individual.” Agree. Clark gives an example where the therapist is interviewing Omar who has low energy, lethargy, lack of motivation, and hopelessness about the future. The diagnosis encapsulates and integrates a lot of Omar’s experience, and, though Clark does not say so, Omar may even be relieved to hear/learn that he (Omar) is not to blame for his disordered emotions (“major depression”); and Omar should stop making a bad situation worse by negative self-talk, verbally “beating himself up” in his own mind. The treatment consists in getting Omar to do precisely what the depressed person is least inclined to do – take action in spite of being unmotivated. If one is waiting to be motivated, absent a miracle, it is going to be a long wait. Maybe the empathic response is precisely saying this to the client, acknowledging how hard it is (and may continue to be for a while) to get into action on one’s own behalf. 

This is all well and good. However, narrowly or expansively empathy is defined it is the anti-DSM (diagnostic and statistical manual). The DSM has many uses, especially in aligning terminology such that the community is talking about the same set of criteria when it uses the word “generalized anxiety disorder.” It also has uses in requesting insurance reimbursements. In short, there is nothing wrong with the DSM-5 (2013) or any version – but there is something missing – empathy. In the case of empathy, the recommendation is to relate to the struggling human being who presents himself in therapy, not to a diagnostic label. 

Thus, Clark makes the case in his own terms: “From a humanistic perspective with central tenets focusing on respect for the individuality and uniqueness of a person, employing the DSM to categorize clients through a labeling procedure is thought to impede the growth of authentic relationships and empathic understandings of a deeper nature. In this regard, in a human encounter, perceiving a client through categorical frames of reference and symptomatic functioning hinders an attunement with the individual’s lived experiences and personal meanings. Moreover, applying a label to a client possibly influences a practitioner to shape preconceptions that are objectifying and forecloses a mutual and open-minded exploration of the contextual existence of the individual” (Clark: 27).

Though Clark does not say so, almost every major mental illness involves a breakdown of empathy. The patient experience isolation. “No one ‘gets’ me.” “No one understands what I am going through.” This is the case with most mood disorders, thought disorders, as well as those disorders typically described as “disorders of empathy” such as some versions of autism spectrum and anti-social personality disorders. 

One matter of editing detail may be noted, a consistent misspelling of the name of celebrated primate researcher, philosopher, and empathy scholar Frans de Waal. There are no “Walls” in de Waal’s name – or in his empathy! We will charge this wordo to the editors who otherwise perform an admirable job. 

Returning to a positive register, one of the most important takeaways from engaging with Clark’s work is that short therapy in which empathy is the driving force is powerful and effective. Clark does not specify the elapsed treatment in most cases, but I did not find one that was explicitly called out as being longer than fourteen weeks.

The emphasis is on the use of empathy in relatively brief psychotherapy – which is a powerful and positive approach that pushes back against the assertion that one needs cognitive behavioral therapy for relatively time-constrained encounters. Empathy produces quick results when skillfully applied. It is true that one of the great empathy innovators, Heinz Kohut, had some famous long and multi-year psychoanalyses; but these individuals were significantly more disturbed than Clark’s example of Anna, whose presenting behaviors were largely social awkwardness. 

A strong point of Clark’s work is his debunking of the caricature of Rogers definition of empathy (and indeed of empathy itself) as merely reflecting (i.e., repeating) back to the speaker the words that the speaker has said to the listener. There is nothing wrong as such with reflecting what the other person has said, especially if the statement is relevant or well expressed. However, the mere words are pointers to the other person’s experience and are not reducible to the mere words. This is not a mere behavioral skill of reflecting back language, but a “being with” the other in the complexity and depth of the other’s experience as refined in the therapist’s own experience, and that is something one can best learn in years of one’s own dynamic therapy. Additional processing of the other person’s experience is encapsulated by and captured in the other person’s words, but not reducible to the words. The aspects of empathic responsiveness, embodiment, acknowledgement, recognition, encouragement, immediacy, possibility, clarification, and validation of the other’s experience form and inform the empathic response and the reply to the other. 

A rumor of empathy is no rumor in the case of Clark’s work – empathy lives in his contribution to integrating the diverse and varied aspects of empathy. 

Edwin Rutsch interviews the author Arthur J. Clark:

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

Transference and Empathy: Where Transference Was Empathy Shall Be!

Listen as podcast on Spotify by Anchor: https://open.spotify.com/episode/6ZFSOgaTe0x1fQvFuKFTgJ

[Note: the audio is not a exact transcript and sometimes covers the same or related material using different words]

While empathy is seemingly in exceedingly short supply in the world, you do not need a philosopher to tell you what empathy is. Every mother, every teacher with students, every business person with customers, every doctor with patients, every attorney with clients, every politician with supporters, every person with next door neighbors, knows about empathy. 

We shall start with the folk definition of empathy – take a walk in the other person’s shoes, and add one additional recommendation. However, first take off your own shoes before putting on the other’s – an action that is routinely overlooked – otherwise one gets projection, not an experience of otherness. 

The title statement echoes Freud’s celebrated slogan “Where id was, ego shall be!” Neither of these statements is an “either or” proposition. The id is not going away. Freud did not propose to abolish the id with the ego. It is not even clear what that could possibly mean. The idea is to expand the influence, control, and power of the second term (ego, empathy) over the first one (id, transference). The ego expands its power, including power over primitive aggressive and sexual inclinations; likewise, with empathy. Empathy expands its power in creating an opening for effectiveness and success in fulfilling and satisfying human relationships.

Let us define our terms. Transference is the carrying across of meaning from one context, model, or paradigm to another one. It is difference than metaphor, which means a “carrying across or beyond,” but perhaps not by much. We humans have a tendency to make things mean other things. We humans are “meaning making machines,” in the sense that we are a source of acts of conscious intentionality that brings meaning to our encounters with nature and our fellow humans in community. There is indeed something mechanistic about the way we automatically go about making things mean things. We can’t seem to stop doing it, which results in innovations but also distortions and misunderstanding. We take behaviors, conversations, and circumstances and try to make sense out of them by bringing meaning to them, which sometimes applies, but sometimes doesn’t. 

This definition of transference extends into the realm of so-called behavioral health and psychoanalysis (where it was initially and innovatively defined) into the contexts of diverse forms of psychotherapy, empathy consulting, professional coaching, or community building. At the risk of oversimplification, transference takes a cognitive, behavioral, or emotional response from one context, such as childhood or circumstances in the past that one had to survive, and uses it to respond to the therapist, coach, or trainer in a similar way. Typically this introduces distortion or extraneous issues into the relationship. 

The relationship between transference and empathy is under theorized. This is the case in spite of all the great psychoanalysts from Freud onwards commenting on both subjects, albeit sometimes in widely separated contexts and conversations. There are many reasons for under development of theory, both scientific and political, but it is largely due to the nature of the phenomena themselves. Transference as a distinction is largely structural, even though its emergence and transformation unfold in time in the process of a therapeutic psychoanalysis. Empathy as a distinction is largely a process unfolding in the therapeutic relationship, even though it has structural invariants. 

Empathy and transference are the opposite of one another. How so? In empathy one takes a walk in the shoes of the other person, the better to understand the other and relate authentically to the individual. There are many definitions of empathy, but they converge on the idea that empathy is an authentic form of relatedness. Get rid of the judgments, assessments, and evaluations, and be with the other person without applying labels, categories, and prejudices. 

Now transference is the exact opposite of authentic relatedness. The narrow definition of transference says take a pattern or relating from one situation – such as childhood or an experience in another context – and apply it to the current relationship or situation. The result is a distortion of the relatedness. The result is an inauthentic way of relating. In order to bring forth an empathic relationship one has to interpret and resolve the transference distortions. 

Let us take a step back. The implications of the relationship between empathy and transference, as noted, have not been much theorized. It is true that dozens of publication address empathy and dozens of publications address transference, and some even contain discussions of both empathy and transference (e.g., Racker 1968). But the specific interactions between being empathic in the transference and getting engaged in transference in being empathic in a clinical setting have not been much engaged. 

The recommendation? Think of the relationship between empathy and transference (or perhaps you say “the transference” as if it were a single unified thing) as a dance. Sometimes the one leads and the other follows and vice versa. The implications of the dance between empathy and transference are profound, but complex and entangled.

Lest one imagine these two phenomena – empathy and transference – are inevitably at loggerheads, consider the following example of convergence:

The patient comes in and says he saw the film, Elephant Man (directed by David Lynch (1980)) and he was deeply moved. The narrative is of an individua, David Merrick, suffering from Proteus Syndrome (often confused with Neurofibromatosis), which results in disfiguring folds of tissue on the head and other pulmonary and renal abnormalities. “Deeply moved,” by what aspect in particular, I asked? After being a freak, physically disfigured, lacking humanity, David Merrick meets the doctor who acknowledges his humanity. The recognition of humanity – “I am a human being – I am a man” is the most dramatic utterance – and the empathic moment. The client reports being moved to tears and having had a satisfying cry. Without further discussion, the client then spontaneously speculates, wondering if there was a parallel with our relationship, my having recognized something in him that others had not seen. Without going into confidential details, I had seen around or though the significant blind spot that kept him insensitive to an aspect of father’s behavior which was running his life and in a destructive way, yet not acknowledged. This enabled the client to shift his relationship to his life partner (as well as his father) and move on. The parallelism – transference – the recognition of humanity – empathy. 

To try to prevent misunderstanding, one must distinguish between transference in a narrow sense and transference in an enlarged sense. At risk of oversimplification, when transference was first discovered by Freud, it seemed like an obstacle to treatment, since the patient related to Freud as an authority figure such as The Father (in the case of a male patient) or as a seductive father figure (in the case of a female patient) whereas Freud regarded himself as a kind, even empathic, listener to the patient’s neurotic suffering. 

Eventually Freud realized that the patient was relating to him (Freud) as to an important figure from the patient’s past. Regardless of how Freud tried to treat the patient, the patient treated him- or herself with transference – but responding with a transference of meaning from one area of the patient’s life to the relationship with Freud. Just as significantly, Freud discovered that the patient was doing this in other areas of his life as well – towards his lady friend, towards his superiors at work, in a hundred and one ways in his life – with problematic results that caused the individual to seek treatment for his suffering and conflicts. 

For example, when the patient was a woman, the transference was not hostile but erotic. This can be motivated. If the reader saw Vigo Morgenstern play the middle-aged Freud in the film A Dangerous Method, then you know what I mean. This guy was hot! Though unlike Carl Jung, Freud was clear about professional boundaries: “[…] [T]he patient has transferred on to the doctor intense feelings of affection which are justified neither by the doctor’s behavior nor by the situation that has developed during the treatment” [1917, Introductory Lectures on Psycho-Analysis: 440 – 441]. It is in interpreting this transference – based on behavior different than that of the original seductive parental objects and suitable verbal feedback – that the cure of the neurosis is affected: “At the end of the analytic treatment the transference must itself be cleared away: and if success is then obtained or continues, it rests, not on suggestion, but on the achievement by its means of an overcoming of internal resistances, on the internal change that has been brought about in the patient” [1917, Introductory Lectures: 453]

Since this post is part of a larger project, I take the liberty of including several definitions of “transference” by leading figures who defined it. Those readers who wish less detail may skip ahead.

Thomas Szasz (1963: 432 – 443), who was otherwise a notorious psychoanalytic “bad boy,” denouncing the “myth of mental illness,” was an classic Freudian when it came to defining transference: “Freud conceived of transference love as an illusion because the situation in treatment cannot account for the origin of such feelings” [. . . .] [I]t [transference] is considered an expression of interest ‘basically’ directed towards childhood objects, deflected to the analyst or to the figures in the patient’s current life.”

Peter Giovacchini (1965: 287) writes that: “[. . . .] [T]ransference reaction refers to a person’s reactions to an object as they are determined by infantile unconscious factors. Viewing the object in terms of archaic imagos in a primary process orientation lead to irrational attitudes and distortions.”

Carl M. Grossman (1965: 249 – 250) defines transference in a broad sense that seems to go beyond the psychoanalytic context in a narrow sense: “[. . .] [Transference is] a universal human psychological characteristic which causes the internalized representation of certain objects – such as parents or parental surrogates from one’s infantile past – to be projected onto a succession of later, ostensibly unrelated persons. The transferring person then reacts to new objects with the anachronistically habitual reaction in adult life that he had had towards the originally cathected object in infancy.”

Ralph Greenson (1967: 151 – 152) asserts: “[. . . ] [Transference is] a special kind of relationship toward a person: it is a distinctive type of object relationship. The main characteristic is the experience of feelings to a person which do not befit that person and which actually apply to another. Essentially, a person in the present is reacted with as though he were a person in the past. Transference is a repetition, a new edition of an old object relationship” (pp. 151 – 152).” {TI: 339]

Leo Stone (1961: 66 – 67) writes “[…] [Transference is limited] to that aspect or fraction of a relationship which is motivated by persistent unmodified wishes (or other attitudes) toward an actual important personage of the past, which tend to invest a current individual in a sort of misidentification [. . . ] with the unconscious image of the past personage. It is essentially in appropriate to the current situation subjectively misunderstood as to genetic origin until analyzed, and tenaciously resistive to this analysis (pp. 66 – 67).” Stone further notes: “that a nuance of the analyst’s attitude can determine the difference between a lonely vacuum and a controlled but warm human situation, which does indeed offer these gratifications, along with its undoubted rigors” (1961: 21 – 22).” 

In short, transference is what happens when human do what they cannot stop doing – trying to make sense of situations by assimilating them to patterns from key patterns and expectations based on experience. What may have been helpful in one context to enable the person to survive or even flourish is less helpful and even harmful in other situations in that distortions and misunderstandings are introduced.

There is a broader sense of “transference” that developed, in which transference becomes the entire relationship which the patient has towards the therapist. And wherever there is transference can countertransference be far away? Under this idiosyncratic and enlarged meaning, “countertransference” becomes the therapist’s way of relating to the patient. For example, according to Paula Heiman, under this idiosyncratic interpretation of the relationship, “counter- transference” covers all the feelings the analyst experiences toward the patient (see Paula Heiman, 1950. On counter-transference. International Journal of Psycho-Analysis 31: 81 – 84). 

Of course, “counter transference” can mean an unprofessional or pathological response on the part of the therapist, as when s/he behaves in a moralizing, aggressive, or seductive manner; but it can also include appropriate and positive responses such as empathic ones. In the extreme, countertransference comes to mean empathy itself. Heimann’s  thesis is “that the analyst’s emotional response to his patient within the analytic situation represents one of the most important tools for his work. The analyst’s countertransference is an instrument of research into the patient’s unconscious” (1950: 81). The transference is not empathy, but the countertransference is essential input to the empathic process, even if not quite reducible to empathy itself.

While Freud innovated decisively in decoding the meaning of dreams in The Interpretation of Dreams (1900) and the exploration of infantile sexuality, from a clinical perspective, the elaboration of transference defined the clinical encounter between patient and therapist in the context of psychoanalysis. Transference becomes co-extensive with the encounter between patient and therapist. If you can’t form a transference, since the therapy consists in interpreting and raising the transference, the therapy is not going to work. 

We now turn from transference to empathy.

Freud explicitly states that unless the physician begins empathy in engaging in psychoanalysis, that physician is headed for trouble. The issue is that nearly no one knows that Freud said that because the Strachey’s mistranslate “empathy [Einfühlung]” as “sympathetic understanding.” I must insist on the point. We are on firm group as far as Freud’s guidance is concerned. “Empathy” and “sympathetic understanding” are not the same, and what is more, in a kind of Nachträglichkeit – or retrospective consideration – we lose the opportunity to connect to Freud’s guidance (see Agosta 2014). Thus, we have the kind of empathy wars that Heinz Kohut had to fight to demonstrate that empathy had a mutative effect on the structure of the self (presumably and especially including the ego). 

When Freud demonstrated by his empathic way of relating to the patient (including by his verbal interpretations) that he was not the authoritarian or seductive parental figure of the patient’s past or trauma, the patient would often resist, deny, or offer other defensive gestures against Freud’s interventions and interpretations. But eventually the evidence would add up. Freud was not the unkind parent or the seductive uncle – the mischief was coming from the patient’s unconscious (and his circumstances), not from Freud. With this realization, the patient was reliably able to shift out of stuckness and enjoy a new beginning in his work and romantic relatedness thanks to Freud’s revolutionary new method of treatment. 

Although there are numerous definitions of empathy, most include a narrow and an enlarged use of the term. In the narrow sense, empathy is a psychological mechanism, which, in folk psychology terms, as noted, consists in taking a walk in the other person’s shoes. It is rarely pointed out that one must take off one’s own shoes before putting on those of the other or one risks the distortion/defense of projection. As a psychological mechanism, Kohut defines empathy as vicarious introspection, though he does not merely define empathy in that way.

In an enlarged sense, empathy means being present with the other person without applying judgments, labels, or moralizing assessments. When I use the expression “empathic presence,” the word “presence” inevitably invokes Nacht (1962) and Nacht and Viderman (1960), who penetrating and insightful contribution should not be underestimated. However, as I use it the word “presence” should not be understood as a source or justification for any deviations in technique or the frame. If anything “presence” means “being with” one another in a Heideggerian sense or “being” in the sense of “going on being” as Winnicott employed the term. Even though not necessarily visible, if seated behind the couch, the analyst’s listening is a strong presence. 

If one understands “transference” in a broad sense of all aspects of relatedness to the patient, then it tends to merge with an understanding of “empathy” as the foundation of relatedness. 

Anything the analyst does to influence the transference is considered an issue – the question of the background to transference – passivity? Neutrality? Empathy? but empathy is the background to transference.

One of the most enlarged uses of the terms is to be found in Kohut. For Kohut empathy defines the entire field of therapeutic interrelations and one can even give a transcendental argument to that effect

Empathy is not just a useful way by which we have access to the inner life of man – the idea itself of an inner life of man, and thus of a psychology of complex mental states, is unthinkable without our ability to know via vicarious introspection – my explanation of empathy . . . what the inner life of man is, what we ourselves and what others think and feel. (1977: 306)

In this statement, empathy is the foundation of our relations to other individuals. This is a restatement and an expansion of Kohut’s celebrated statement in his 1959 article that empathy is the method of data gathering precisely about what other individuals feel and think. In turn, this method defines the scope and limits of psychoanalysis as a therapy and discipline. The field of empathy that of psychoanalytic therapy become co-extensive. 

As noted, one individual does not directly access the mental states of the other person, but rather had a vicarious experience of the other person’s experience. In empathy one is receptive to the micro-expressions of the other person’s experience – one has an “after image” and a “vicarious” experience of what the other is experience. 

The innovations continue. Kohut innovates around transference in 1971 – the establishment of what was first called idealizing transference and transference of the grandiose self and ultimately becomes selfobject transference is a distinct phase in the history of transference and tends to live like a split off bastion – for example, is there any evidence of a selfobject transference in the Wolfman, who had aspects of the depletion and grandiosity of narcissistic personality disorder? 

The selfobject represents the function that other people have for oneself. Kohut: “[. . .] [T]he general meaning of the term selfobject [is] as that dimension of our experience of another person that related to this person’s function in shoring up [supporting the homeostatis / equilibriating] our self [. . .]” (1984: 49)

In a standard relationship people interact in such a way that they mutually regulate one another’s thoughts, feelings, and actions. This is called “friendship.” It is also the give-and-take at the foundation of many forms of interpersonal cooperation, communication, and collaboration. When one’s spouse comes home from a hard day at the office or clinic or the backroom on Zoom and you give them a good listening as they vent the frustrations, double binds and bullying perpetrated by the boss or client, then you are functioning as a selfobject. Presumably such an interaction or function did not begin with Kohut’s coining the term “selfobject,” though it was more clearly delimited out of the undifferentiated background. 

One significant difference that, unfortunately, has resulted in controversy and lack of clarity, is how Kohut’s selfobject (narcissistic) transference is sustaining to the patient during the long process of interpreting, working through, and dissolving the transference and the inevitable transference distortions. Kohut took considerable pains to emphasize (and empathize!) that confrontational and moralizing methods would unleash reactive narcissistic rage on the part of the patient and that the empathic approach was critical path. 

This lines up with and is complementary to one of Freud’s early discoveries was a later version of this phenomenon – that what seemed to be a source of resistance was actually the way forward. However, the way forward means the possibility of relatedness between internal objects (everything from the superego to hostile introjects to good breasts) and the therapist. Key term: relatedness. Thus, when there are disruptions in the relatedness between the patient and therapist that is conceptualized as a breakdown in the transference – the loss of connectedness, even if the connectedness includes distortions, misunderstandings, and conflicts. But that is usually the way it is thought of or described in the context of classical analysis where the breakdown of the transference often results in what seem like moralistic or objective medical judgments that the patient is not analyzable. 

Instead, the relationship between transference and empathy comes into its own where, in the face of a breakdown in transference, empathy is used to restore the transference relationship. 

For example, speaking of a patient with significant narcissistic disequilibrium, Kohut writes:

  • When the narcissistic transference has become disrupted, he has the impression that he is not fully real, or at least that his emotions are dulled; he is doing his work without zest, that he seeks routines to carry him along since he appears to be lacking in initiative … ((1971): 16)

The restoration of the relatedness and the transference is brought forward when the therapist, using empathic understanding, shows the analysand that the therapist “gets” how the analysand is struggling with a setback or challenge in his life that he left him emotionally disequilibriated, anxious, lethargic, depleted. When this occurs repeatedly in the course of treatment, psychic structure is built and reinforced in the areas of emotional and behavioral regulation. A cure comes into view.

Kohut (1984: 66) writes: “[. . .] [The] aim and the result of the cure – is the opening of a path of empathy between self and selfobject, specifically, the establishment of empathic in-tuneness between self and selfobject on mature adult levels. [….] …the gradual acquisition of empathic contact with mature selfobjects is the essence of the psychoanalytic cure [. . .]” Of course, one must hasten to add that “empathic in-tuneness” is unlikely, even impossible, unless the distortions and illusions of the transference have been engaged interpretively (and in an empathic way) in course of making contact with mature selfobjects in empathic relatedness  

A number of issues occur here that clearly require further research and clarification of terminology. Why would selfobject transference be considered transference at all? Here “transference” again gets used in the broadest sense of “empathic relatedness.” It represents healthy relatedness, good listening, and interpersonal well-being. Interpretation of the transference is a key bridge between empathy and transference – when the interpretation is experienced as unempathic then the aggression released is not due to a lowering or elimination of defense against the death instinct but a reactive rage at getting one’s feelings hurt at being misunderstood by one’s therapist, being re-traumatized in the transference by unempathic caretakers or disappointed parental idealizations.

If such relatedness with its significant component of a “good listening” is spontaneously constellated in the psychoanalytic therapeutic encounter, then it may at first glance seem to be pure positive transference (the analyst as “good object”) or positive nontransference reality-based relatedness. Indeed, Winnicott’s transitional object is a special case of a selfobject but shows that the selfobject is a standard part of development in which the imaginary is integrated into the rich system of conventions and symbols known as everyday life. In that sense, the family pictures on one’s writing desk are reminders of why one works, making the absent present in what is literally a picture of health. 

Where transference was empathy shall be!

References

Szasz, Thomas. (1963). The concept of transference. International Journal of Psychoanalysis 44: 432 – 443. 

Stone, Leo. (1961). The Psychoanalytic Situation. New York: International Universities Press. [TI: 239]

Reich, Annie. (1966). Empathy and countertransference. In Annie Reich, Psychoanalytic Contributions. New York: IUP Press, 1973: 344 – 360.

Nacht, S. (1962). Empathy as a psychological mechanism and empathy as presence (of course it is both). Symposium The curative factors in psycho-analysis. II International Journal of Psychoanalysis 43: 206 – 211

Kohut, Heinz. (1984). How Does Analysis Cure? Eds. Paul Sepansky and Arnold Goldberg. Chicago: University of Chicago Press.

Kohut, Heinz. (1977). The Restoration of the Self. New York: International Universities Press.

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

Grossman, Carl M. (1965). Transference, countertransference, and being in love. Psychoanalytic Quarterly 34: 249 – 256. 

Greenson, Ralph R. (1967). The Technique and Practice of Psychoanalysis vol 1. New York: International Universities Press.

Giovacchini, Peter L. (1965). Transference, incorporation and synthesis. International Journal of Psychoanalysis 46: 287 – 296. 

Agosta, Lou. (2014a). Rewriting empathy in Freud. A Rumor of Empathy: Rewriting Empathy in the Context of Philosophy. New York: Palgrave Macmillan: 66 – 82. DOI:10.1057/978113746534.0009.

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

Left stranded when the music stops: What to do about the shortage of talk therapists actually available

An article in the Washington Post by Lenny Bernstein: “This is why it is so hard to find mental health counseling right now” (March 6, 2022) struck a chord with many readers.[1]

The article begins by describing an individual in the Los Angeles area who said she was willing to pay hundreds of dollars per session and called some twenty-five therapists in the area but was unable to find an opening. The person willingly shared her name in the article. Be careful not to blame the survivor or victim – the report is credible – and she maintained a spreadsheet!

One of the main points of the article is that after several years of pandemic stress prospective clients and patients are at the end of their emotional rope and providers (therapists) are over-scheduled and burned out too. No availability. 

The problem is systemic. There seems to be no bottom in sight as regards the opportunistic behavior of insurance companies, the lack of behavioral health resources, and the suffering of potential patients. The WP article goes on to document other potential patients with significantly less resources who cannot even get on a wait list. The article documents third party insurance payers whose “in network” providers are unwilling to see prospective patients due to thin

Wait listed? Therapy delayed is therapy denied

reimbursements from the payer – once again, the individual is unable to get on a wait list or get help urgently needed; supply side shortages are over the top in the programs that train psychiatrists, a specialty in medicine. Psychiatrists, when available, are most often interested in lucrative fifteen-minute medication management sessions, but unless they are “old school” and were psychoanalytically trained in the “way back,” they are rarely available for conversations. This all adds up to a crisis in the availability of behavioral health services. 

This leads to my punch line. Often time depression, anxiety and emotional upset are accompanied by negative self-talk, shaky or low self-esteem. One reaches out and asks for help but instead has an experience of powerlessness that is hard to distinguish from the original emotional disequilibrium. The conversation spins in a tight circle – “maybe I deserve it – no I don’t – this sucks – I suck – help!” The person resigns himself to alife of gentile poverty, thinking she or he is not worthy of financial well-being. The prospective patient is left aggrieved. This grievance is accurate and real enough in context, but it is hard to identify what or who can make a difference. Nevertheless, there is no power in being aggrieved. One still has to do the thing the person in distress or with shaky self-esteem is least inclined to do – invest in oneself because one is worth it!

I have spoken with numerous potential and actual clients who pay a lot of money for health insurance. However, when they want to use the insurance for behavioral health services, they find the insurance is not workable. Not usable. The service level agreement is hard to understand, and having a deductible of a couple of thousand dollars is hard to distinguish from having no insurance at all. If the client goes “in network,” the therapists are unresponsive or inexperienced. If the client goes out of network, the therapists are often more experienced and able to help, but onerous deductibles and copays rear their heads. Why don’t the experienced therapists go in network? There are many reasons but one of them is that the insurer often insists the therapist accept thirty cents on the dollar in compensation, and some therapists find it hard to make ends meet that way. In short, as a potential patient, you think you have insurance, but when it comes to behavioral health, you really don’t. 

My main point is to provide guidance as to some things you can do to get the help you need with emotional or behavioral upset and do so in a timely way. Turns out one has to give an informal tutorial on using insurance as well as on emotional well-being. I hasten to add that “all the usual disclaimers apply.” This is not legal advice, medical advice, insurance advice, cooking advice or any kind of advice. This is a good faith, best efforts to share some brain storming and personal tips and techniques earned in the “college of hard knocks” in dealing with these issues. Your mileage may vary. 

Nothing I say in this article should be taken as minimizing or dismissing the gravity of your suffering or the complexity of this matter. If you are looking for a therapist or counselor, it is because you need a therapist or counselor, not a breach of contract action against an insurance company. You want a therapist not a legal case or participation in a class action law suit, even if the insurance contract has plenty of “loop holes.” For the moment, the latter is a rhetorical point only.

When a person is anxious or depressed or struggling with addiction or other emotional upset, being an informed assertive consumer of behavioral health services is precisely the thing the person is least able to do. “I need help now! Shut up and talk to me!” 

Notwithstanding my commitment to expanding a rigorous and critical empathy, here’s the tough love. Without minimizing your struggle and suffering, the thing you least want to do is what you are going to have to try to do. If one is emotionally upset, the least thing you want to do is be an assertive consumer of services designed to get you back your power in the face of emotional upset or whatever upsetting issues you are facing.

The recommendation is to speak to truth to power and assertively demand an “in network” provider from the insurance company or invest in yourself and pay the private fee for an experienced therapist whom you find authentically empathic, then you already be well on the way to getting your power back in the face of whatever issues you are facing. 

If your issue is that you really don’t have enough money (and who does?), then you may need to get the job and career coaching that will enable you to network your way forward. An inexpensive place to start is The Two Hour Job Search by Steve Dalton. Highly recommended. Note the paradox here – the very thing you do not want to do keeps coming up. You definitely need someone to talk to. Once again, the very things with which you need help are what re stopping you from getting help  

The bureaucratic indifference of insurance companies is built into the system. The idea of an insurance is a company committed to making money by spreading risk between predictable outcomes and a certain number of “adverse” [“bad risk”] events. It is not entirely fair (or even accurate) but by becoming depressed or anxious (and so on), you are already an adverse event or bad risk waiting to happen. You may expect to be treated as such by most insurance companies.

In a health insurance context, the traditional model for the use of services is a broken arm or an appendicitis (these are just two examples among many). You definitely want to have major medical insurance against such an unfortunate turn of events. Consider the possibility: Buy major medical only – and invest the difference saved in your therapy and therapist of choice.

But note these adverse medical events are relatively self-contained events – page the surgeon, perform the operation, take a week to recover or walk around in a sling for awhile. The insurance company pays the providers (doctors and hospitals) ten grand to thirty grand. That’s it. With lower back pain, headaches, irritable bowel syndrome, autoimmune disorders, it is a different story. These are notoriously difficult to diagnose and treat. Yet, modern medicine has effective imaging and treatment resources that often successfully provide significant relief if not always complete cures for the patient’s distress in these more complex cases. 

Consider similar cases in behavioral health. Start by talking to your family doctor. Okay, that is advice – talk to your family doctor for starters. Front line family doctors have the authority – and most have the basic training – needed to prescribe modern antidepressants (so called SSRIs), which also are often effective against anxiety, to treat simple forms of depression and anxiety due to life stresses such as an ongoing pandemic, job loss, relationship setbacks. 

Even though I am one of the professionals who has consistently advocated “Plato not Prozac,” I acknowledge the value of such psychopharmacological interventions from a medical doctor to get a person through a rough patch until the person can engage in a conversation for possibility and get at the underlying cause of the emotional disequilibrium. Note this implies the person wants to look for or at the underlying dynamics. This leads us to the uncomfortable suggestion that it is going to take something on the part of the client to engage and overcome the problem, issue, upset, which is stopping the client from moving forward in her or his life.

There is a large gray area in life in which people struggle with relationship issues, finances, career, education, pervasive feelings of emptiness, chronic emotional upset, self-defeating behavior in the use of substances such as alcohol and cannabis (this list is not complete). 

A medical doctor or other astute professional may even provide a medical diagnosis when the interaction of the person’s personality with the person’s life falls into patterns of struggle, upset, and failure. Insurance companies require a medical diagnosis. One thinks of such codable disorders as adjustment disorder or personality disorders (PD) such as narcissistic, histrionic, schizoid, antisocial, or borderline PD. These are labels which can be misleading and even dangerous to apply without talking to the person and getting to know them over a period of time. It’s not like the Psychology Today headline – top three ways to know if you are dating a narcissist. I am calling “BS” on that approach. 

Nevertheless, if after a thorough process of inquiry, some such label is appropriate (however useless the label may otherwise be except for insurance purposes), then the cost will be right up there with “fixing” an appendicitis – only you won’t be able to do it in a single day – and it won’t be that kind of “fix”. An extended effort and of hard to predict duration must be anticipated, lasting from months even to years. This is not good news, but there are options. 

My commitment is to expanding a rigorous and critical empathy in the individual and the community. I consider that I am an empathy consultant, though at times that is hard to distinguish from a therapeutic process and inquiry into the possibilities of health and behavioral well-being. Therefore, and out of this commitment, I have a sliding scale fee structure for my consulting and related empathy services. People call me up and say “I make a lot of money, and want to pay you more.” Of course, that is a joke. I regularly hear from prospective clients whose first consideration is financial. They do not have enough money. I take this assertion seriously, and I discuss finances with them. Between school debt and the economic disruptions of three years of pandemic, people are hurting in many ways including financially. One must be careful NEVER to blame the victim or survivor. 

The best way for such financially strapped individuals to go froward is to find an “in network” provider. Key term: in network. But we just read the Washington Post article that furnishes credible evidence such networks are tapped out, in breakdown, not working. Those that are working well enough often deal with the gray area of emotional upset and life challenges by moving the behavioral health component to a separate corporate subsidy at a separate location to deal with all aspects of behavioral health. (See above on “bad risk.”) When I had such an issue years ago, I had to search high and low to get the phone number, web site, or US postal address. You can’t make this stuff up. This is because ultimately, the issues that come up are nothing like an appendicitis or even hard to diagnose migraines. Moving the paying entity to a corporate subsidy is also a way that the insurance company can impose a high deductible and/or copay by carving out that section of the business and claims processing. There are other reasons, too, but basically, they are financial. 

You may be starting to appreciate that many health insurance contracts are not really designed to provide behavioral health services (e.g., therapy) the way they are designed to address a broken leg or appendicitis. There is a way forward, but it is more complex (and expensive in terms of actual dollar, though not necessarily time and effort). I will address this starting in the paragraph after next, because, sometimes in the case of behavioral health, people who have insurance do not  really have useable, workable behavioral health insurance. For all intents and purposes, they think they have insurance, but, in this specific regard, they have a piece of paper and a phone number that is hard to find. I hasten to add I am not recommending going without major medical health insurance, inadequate though it may be in certain respects.

This brings us to those individuals who decide to go without insurance. What about them? Such individuals choose to take the risk. They are living dangerously because if they do break an arm or incur an appendicitis, then they are going to have another $30K in medical debt [this number is approximate and probably low], along with a mountain of school debt, credit card debt, and bad judgment debt (this list is not complete). These good people need insurance, not so much to get therapy – because, as the accumulating evidence indicates, it really doesn’t work that way – as to be insured against a major medical accident. Many people are not clear on this distinction, but I would urge them to consider the possibility. 

I spoke with this one prospective client who began with a long and authentically moving narrative that she did not have enough money and could not afford therapy. This is common and not particularly confidential or sensitive. As part of a no fee first interview to establish readiness for therapy, I acknowledged her courage in strength in reaching out to someone she did not really know to get help with her problems. I acknowledged that one of her problems was she did not have enough money. A bold statement of the obvious. I asked if there was anything else she wanted to work on. It turns out that she was a survivor of a number of difficult situations and would benefit from both empathy consulting, and talk therapy – and I might add job coaching. Here’s the thing – when a person is hurting emotionally, they do not want to look for another job – or a better job that pays more money. But one just might have to do that, at least over the short term, with someone who can provide that kind of guidance to those who are willing. I encouraged her to be assertive with her insurance company and I heard she found someone in network at a low rate. 

And if you are a therapist who believes such job coaching compromises the purity or neutrality of the therapy, I would agree. However, never say never. In the aftermath of World War I, when the victorious allies maintained a starvation blockage on Germany and Austria even into 1919, Freud (that would be Sigmund) was reportedly seeing a client in exchange for a substantial bag of potatoes. I have no facts – none – but I find it hard to believe they were discussing matters pertinent to individual and collective survival. So far no one has offered me a bag of potatoes (I am holding out for a quantity of olive oil and basil to make pesto), but see the above cited article from the Washington Post

We circle back to where we started. If the individual named in the Washington Post article has not yet found a therapist, then I believe there are many in the Chicago area would welcome the opportunity to make a difference for her. She has a budget for therapy, she says. If you have a budget, the work goes forward. It can be confronting and difficult to contemplate, but if you were buying a car, you would look at your budget. If you were planning a vacation, you would think about your vacation budget. If you were thinking of going back to school, you would look at your education budget. You get the idea. What is your budget for empathy consulting, counseling, talk therapy, cognitive retraining, life coaching, or medication management services (this are all distinct interventions, appropriate in different circumstances)? Zero may not be the right number. Just saying.  Of course, if the client is in LA and the empathy consultant is in Chicago, it would be a conversation over Zoom. That starts a new thread so I may usefully clarify that I prefer to meet with people in person – the empathy is expanded in person – but the genie is out of the bottle and online can be good enough in some circumstance. (See my peer reviewed article “The Genie is Out of the Bottle”: https://bit.ly/37vxJ0L.)

The insurance system is broken as regards behavioral health (as evidenced by the WP article). There is a vast gray area of people with modest emotional disregulation who genuinely need help. These are not only the “worried well,” but people whose understandable lack of assertiveness in navigating an indifferent (and it must be said unempathic) bureaucracy leaves them high and dry with their moderate but worsening emotional, spiritual, and behavioral upsets. These people deserve help, and are entitled to it even under the specific terms of their insurance contracts. Indeed they are entitled to help even if they do not have insurance, though the revenue model is simpler in that case, though not less costly. 

The insurance company has been unable to make money off of this gray area – therefore, the insurance company does what it does best – it turns to making money off of you. But you need health insurance against a major medical event or accident. You want a therapist, not a breach of contract case in small claims court (where the small claim often goes up to $100k). Therefore, it does little good to document having called ten or twenty-five in network providers with no result. Or does it? You – or a class action attorney firm – have a case for breach of contract. Go out of network and forward the invoices to the payer by mail with a tracking number, requesting that the full therapy fees be treated “in network” for purposes of reimbursement, and, therefore, no or low deductible and copay. Of course, one would have to have funds for that upfront, and lack of money is where this circle started. Back to expanding one’s job search skills?

This is crazy – and crazy making behavior – though only as a function of a system that is crazy. You see the problem. I’ll bet dollars to donuts that the insurance payer, when confronted with an actual summons to small claims court, would then find you a therapist – of course, the therapist might be relatively inexperienced or someone who (how shall I put it delicately?) is less motivated than one might hope. Thwarted again! 

As I wrap up this post, it occurs to that while it would be crazy for an individual to seek legal redress – it might even be “acting out,” there might be a basis for an enterprising law firm to establish a system wide “class action” for breach of contract. This will not solve your  problem of getting help in the next two weeks, but it might be a necessary step to benefit the community. You know the insurance company has the money! 

As noted above, your grievance in being over sold unworkable behavioral health insurance may be [is] accurate and real. Nevertheless, I am sticking to my story: the guidance: there is no power in being aggrieved. You still have to do the thing the person in upset or with shaky self-esteem is least inclined to do – dig down, including into your pockets, and find self-confidence – or enough self-confidence for the moment – and invest in yourself because you are worth it!

The one minute empathy training – runtime is actually five minutes, but a personal introduction is included: https://youtu.be/747OiV-GTx4


[1] https://www.washingtonpost.com/health/2022/03/06/therapist-covid-burnout/

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

I have been catching up on my reading.

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

Cover Art: The Brain That Changes Itself by Norman Doidge

Cover Art: The Brain That Changes Itself by Norman Doidge

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Doidge ends with a flourish:

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

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

Empathy, Stress (Reduction), and Brain Science – Fall Program

The image depicts a mirror neuron – the neurological basis for empathy – admiring itself in the mirror. But do mirror neurons even exist? If not, what is the underlying neural slide1implementation mechanism for empathy? At another level of analysis, how is empathy like oxygen for the soul, reducing stress and enabling possibility? Find out more here …

To register or for more info call Elizabeth Oller: 1-312-935-4245 or email: JosephPalomboCenter@icws.edu

Empathy, Stress Reduction, and Brain Science

A famous person once said: “Empathy is oxygen for the soul.” So if one is feeling shortness of breath, maybe one needs expanded empathy! This course will connect the dots between empathy and neuroscience (“brain science”). For example, empathic responsiveness releases the compassion hormone oxytocin, which blocks the stress hormone cortisol. Reduced stress correlates to reduced risk of such life style disorders as cardiovascular disease, diabetes, weak immune system, depression, and the common cold.

We will engage each of the following modules in the discussion segment, including suggested readings. Except for the first two topics, we can take them in any order and the participants will get to select:

  1. This is your mind on neuroscience – mirror neurons: do they exist, and if not, so what?
  2. Sperry on the split brain: the information is in the system: how to get at it
  3. The neuroscience of trauma – and how empathy gives us access to it
  4. MRI research: as when Galileo looked through the telescope, a whole new world opens

Presenter: Lou Agosta, PhD, is the author of three scholarly, academic books on empathy, including A Rumor of Empathy: Resistance, Narrative, Recovery (Routledge 2015). He has taught empathy in history and systems of psychology at the Illinois School of Professional Psychology at Argosy University and offered a course in the Secret Underground Story of Empathy at the University of Chicago Graham School of Continuing Education. He is a psychotherapist (and empathy consultant) in private practice in “on the forward edge in the Edgewater Community” in Chicago.

Date: Saturday December 03, 2016

Time: 9 AM – noon

Registration Fee: $35

Location: to be provided upon registration: at or near ICSW at 401 S. State St Chicago, IL

Registration: Call Elizabeth Oller: 312 935 4245 or email: JosephPalomboCenter@icsw.edu 

Virtual Reality Goggles for Treating Phobias: A Rumor of Empathy at Psious

Virtual reality (VR) is coming to psychotherapy. Based on a briefing on July 08, 2016, a company named “Psious” provides VR technology. Psious’ collaboration agreement, available temporarily to Chicago-area mental health professionals, includes training for

virtual-reality-phobia-treatment

An Actor Depicts a Confronting Situation [Therapist is present, but not shown]

the therapist on how to use the VR technology. Online manuals integrating the simulated scenarios provide step-by-step guidance from psychologists on how to help patients shift out of fear, expanding positive responses to a variety of stress-laden situations that people find confronting such as fear of heights, flying in airplanes, insects, and more (to be detailed momentarily).

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

Positioning an intervention that exploits VR in any psychotherapy clinical practice raises numerous issues that must be engaged, and the economics of virtual reality mean the time is now. Flight simulators in which airplane pilots train still cost millions of dollars. The initial “one off” VR goggles used to cost hundreds of thousands of dollars. Psious brings the goggles, plus the necessary software subscription for a compelling price of $1299 a year not including the hardware (Samsung Gear VR goggles and Samsung Galaxy smartphone), the platform on which the software operates). Hardware bought on Amazon for about $700 is discounted to $259 with an annual subscription. The total cost is about $1558 a year for access and ownership of the hardware. At current rates for psychotherapy that is about ten session to break even.

The therapist has a display on his computer of what is being presented in the Goggles to the client. For example, in the scenario in which the patient is dealing with fear of public speaking, one is presented with a “speaker’s eye view” of an audience. Controls allow the therapist to incorporate the patient’s expectations and feedback on what he is ready to confront. The therapist controls different scenarios – a member of the audience gets up and walks out, members of the audience are audibly talking with one another and not listening to the speaker, applause, booing, questions are shouted out (e.g.) “What is the weakness in your proposal?” The list goes on. Close coordination is required between the therapist operating the controls and the subject of the therapy in order for this simulated speaking experience not to become re-traumatizing. Of course, even the latter could become a therapeutic opportunity if the patient is flooded but is enabled to recover his equilibrium thanks to an empowering conversation with the therapist at the moment of the upset.

Modules are currently available for fear of flying, needles, heights, public speaking, animals/insects, driving, claustrophobia, agoraphobia, social anxiety, and generalized anxiety. Given that as soon as one is confronted with fear the intervention also involves imagining or activating a “safe place” from which to function in the face of fear, positive modules are available that provide coaching in breathing exercise, mindfulness, and Jacobsen Relaxation (progressive muscle relaxation).

While the VR technology is innovative and disruptive in many ways, a moment’s reflection suggestion continuity between VR technology and the “virtual reality” of the transference in classic psychodynamic therapy. There is a strong sense in which the conversation between a client and a psychodynamic therapist already engages a virtual reality, even when the only “technology” being used in a conversation is English or other natural language. For example, when Sigmund Freud’s celebrated client, Little Hans, developed a phobia of horses, Freud’s interpretation to Hans’ father was that this symbolized Hans’ fear of his father’s dangerous masculinity in the face of Hans’ unacknowledged competitive hostility towards his much loved father. The open expression of hostility was unacceptable for so many reasons – Hans was dependent on his father to take care of him, Hans loved his father (though he “hated” him, too, in a way as a competitive for his mother’s affection), Hans was afraid of being punished by his father for being naughty – so the hostility was displaced onto a symbolic object. Hans’ symptoms (themselves a kind of indirect, virtual expression of suffering) actually gave Hans power, since the whole family was now literally running around trying to help and consulting The Professor (Freud) about what was going on. In short, the virtual reality made present in the case is that the horse is not only the horse but is a virtual stand-in for the father and aspects of the latter’s powerful masculinity. So add one virtual reality of an imagined symbolic relatedness onto another virtual reality of a simulated visual reality (VR) scenario, the latter contained in a headset and a smart phone.

Psious was founded in 2013 in Barcelona, Spain. It has operations in Barcelona, and is opening a branch in Chicago, which is where I met with Scott Lowe. Psious has about 50 employees worldwide and some 400 clients using the technology in a clinical or closely related setting.

Psious’ claim is that virtual reality based therapy (VRBT) is superior to CBT alone, when the latter uses merely the patient’s imagination [see references to peer-reviewed articles at the end]. For example, if one is so afraid of flying that one is unable to do one’s job because it requires travelling on an airplane for business, one is sitting there in the therapist’s office imagining boarding an airplane and taxiing towards the runway for takeoff. Instead of closing one’s eyes and imaging a trip to the airport, put on the VRBT goggles and find oneself sitting in a seat in coach. For someone seriously stressed by such a situation, the person’s pulse is accelerating, sweat is breaking out, fear is escalating faster than the airplane, and comfort is in free fall until one wants to jump up and run screaming down the aisle and try to open the emergency exit. Not good.

Presumably one would work with the therapist to adjust, adapt, and accommodate to the environment in small steps during which the client’s comfort level is monitored in an on-going conversation with the therapist (and the available biofeedback tool, a galvanic skin sensor). First, are you willing to put on the headset and sit in the airplane seat? Close the cabin door? Taxi towards the runway. Rev up the engines? Start rolling down the runway? Picking up speed? Nose wheel off the ground? Wheels up? Vibration in the cabin as the plane gains altitude? Shaking from side-to-side as the plane ascends through turbulence? Big bump as the plane picks up and enters the jet stream? While the headset provides compelling visual and sound clues, the seat does not vibrate. Still, up until now, if one wanted to confront one’s fear of flying (in an airplane), one had to charter an airplane, time in a flight simulator, or use one’s imagination. It’s a whole new world with Psious.

Let me say up front that I have gone to the demo for the fear of heights, heard the presentation, put on the headset, and I am inclined to say that this technology has legs. At the risk of paradox, virtual reality therapy is the real deal. However, as the Psious people make clear, it is not a replacement for a therapist, it is a tool that can augment the process of confronting and engaging one’s fears under the guidance of a therapist. Why? Because the virtual reality goggles put the client back in a simulated situation that is most calculated to arouse the anxiety that requires treatment. The conventional wisdom is that one cannot overcome one’s fear without engaging with it. However, the engagement must find a stretch to the client’s comfort zone, no matter how narrow, that does not result in retraumatization. In short, the kid gloves are on. The head set should not cause the patient to run screaming from the room as he or she did from the spider or public bathroom. This scenario motivates the need for fine-grained controls as well as training the therapist in how to use them and how to talk the client through an empowering – or at least survivable – experience with the fearful.

The knock against individual dynamic psychotherapy has been that it does not scale. It is highly individual, one size definitely does not fit all, and a third of the population would have to be therapists in order to treat all the members of the armed forces who are suffering from some significant measure of PTSD. If one could define a process that enabled the wounded warrior to bring CBT tips and techniques such as interrupting the pathogenic thought and going to his or her “safe place” while confronting the trauma, perhaps initially in a diminished presentation, then it just might make a scalable difference in treating significant numbers of clients using a method that really works (presumably as opposed to medications with substances that may be addictive).

The fear of horses that manifest itself in Little Hans’ fear of going out onto the street (due, in turn, to fear of encountering a horse) was actual fear. Hans was not faking. He was really terrified. However, his fear was inauthentic in that it masked his unexpressed hostility and ambivalence toward his father and his new baby sister. He was not afraid of horses; he was afraid of being punished for wishing to do away with his new sister. “The stork should take it back.” “Throw it down the drain (that is, the sister).” Remember has was only four years old. However, it is in the nature of an emotion such as fear to glom (“adhere”) onto an available object. This binds the fear to a specific target that may be able to be avoided or otherwise managed in a survival drill rather than have free-floating fear paralyze the entire organism, endangering the survival of the whole. There may even some objects such as spiders, snakes, and thorns that we humans are biologically and evolutionarily predisposed to experience as automatically and inevitably arouse fear. What then of the technology?

The Psious technology is still relevant to address the delta between one’s ordinary uneasiness towards a spider that allows one to take a napkin and remove it from the kitchen and someone else extreme distress that causes them to hyperventilate and, as noted, run screaming from the room. True, they may just have an intensified biological disposition, but they may also be adding expanded meaning based on their individual experience. As far as I can tell, the scenarios are useful in evoking the feared object regardless of the cause, but the therapy still has to intervene with a narrative to shift the fear in the direction of a manageable de-escalation of the fear. Whether the narrative is a CBT one that send the individual to his “safe place by the calming waters” or one that deconstructs the fear as a transference displacement from one’s reaction to one’s father’s scary masculinity, is independent of the technology. It remains a function of the therapeutic intervention.

I am excited by these developments for three reasons. First, the scenarios presented in the goggles are compelling. I have climbed mountains and I regularly fly on airplanes, but I still have a lurking fear of heights. When I put on the goggles and found myself near the glass bottomed sky deck, I was literally unable to step forward over the visual cliff. Amazingly enough, it did not even help when I closed my eyes – since I still vividly imagined being in the scenario. However, taking off the goggles worked just fine in interrupting the process. I do not know if the other scenarios are as compelling. However, I do not have a fear of any of the other things quite as visceral as my fear of heights, or more properly speaking, the visual cliff.

Second and more importantly, this technology may enable individuals who are unable to be helped any other way (“treatment resistant”) to get the treatment they require. We can debate whether or not it is the best treatment; but I am persuaded that if someone is suffering, then a treatment that works is one worth engaging. If a person is so confronted that they are unwilling or unable to imagine a scenario in which they encounter their fear, this technology gives the client an opportunity, with his permission, to puts himself in the fear arousing situation – which, if I am any judge, can be “tuned down” to a significant degree such that a gradual “on ramp” is available to client with the encounter.

Third, some individuals who need help but do not value a conversation for possibility with another person (such as a therapist) may be persuaded to engage by using the goggles as a kind of lever to open up access to their upset. The same people who are fascinated by the technology of the functional magnetic imaging (fMRI) apparatus that shows what area of the brain lights up as they are empathizing with the pain of another will be able to engage in a conversation with the therapist while in the process of using the goggles. Some may say it is a “gimmick”; but I say if this be gimmickry, make the most of it. The provisioning of a virtual reality platform provides an “on ramp” to the virtual reality of a transference conversation in which displacement, symbolization, and interpretation can be marshaled above and beyond the VR scenarios.

Frankly, the most engaging scenario is one that Psious does not have available. As the result of the wars in Afghanistan and Iraq, the US and its allies has many soldiers suffering from diverse forms of post traumatic stress disorder. Worse yet, the diagnosis of PTSD does not even encompass the forms of moral trauma (see further the work of John Mundt, Ph.D., Jesse Brown, VA Center, Chicago) from which many service men and women are suffering. For example, In Iraq a car with four occupants is speeding towards a check point containing multiple passage, ignoring warnings to stop, zig sagging around the barriers. A suicide bomber? The sergeant orders the gunner to fire. The family was rushing to the hospital with a pregnant woman giving birth. One of the now orphaned children survives. The gunner cannot forgive himself, but this does not qualify as PTSD under current rules unless all the criteria are satisfied. The VR technology offers rich possibilities for reenacting the scenario with diverse outcomes, enabling an empowering conversation about what the soldier experienced, what it meant to him, and how to work through his suffering and guilt. Note at this point this is all “brain storming” and “blue sky,” but the possibilities are significant and deserve the urgent attention of software innovators, Veteran Affairs decision makers, politicians, psychotherapists, and survivors alike.

Issues include whether in what sense the hardware is a medical device. What sense, if any, does it make to certify it as health insurance compliant? There are so many rules and regulations around health care that I am not even clear that I know how to ask the right questions. Does a therapist using this device as an adjunct or augmenter to CBT or dynamic psychotherapy need to call it out in her or his coding of the insurance claim, and what sense would it make to try to do so? Presumably Psious will be engaging with these issues over the next year.

References: A selection of publications:

Chapman, L. K., & DeLapp, R. C. (2013). Nine session treatment of a blood–injection–injury phobia with manualized cognitive behavioural therapy: An adult case example. Clinical Case Studies. Retrieved October 26, 2014, from http://ccs.sagepub.com/content/early/2013/10/28/1534650113509304

Wiederhold, B.K., Mendoza, M., Nakatani, T. Bulinger, A.H. & Wiederhold, M.D. (2005). VR for blood-injection-injury phobia. Annual Review of CyberTherapy and Telemedicine, 3, 109-116.

Botella, C., Osma, J., García-Palacios, A., Quero, S. & Baños, R.M. (2004). Treatment of Flying Phobia using Virtual Reality: Data from a 1-Year Follow-up using a Multiple Baseline Design. Clinical Psychology & Psychotherapy, 11(5), 311-323.

Da Costa, R.T., Sardinha, A. & Nardi, A.E. (2008). Virtual reality exposure in the treatment of fear of flying. Aviation, Space, and Environmental Medicine, 79(9), 899-903.

Wallach, H.S. & Bar-Zvi, M. (2007). Virtual-reality-assisted treatment of flight phobia. Israel Journal of Psychiatry and Related Sciences, 44(1), 29-32.

Emmelkamp, P., Krijn, M., Hulsbosch, A. M., De Vries, S., Schuemie, M. J. & Van der Mast, C. (2002). Virtual reality treatment versus exposure in vivo: A comparative evaluation in acrophobia. Behaviour Research and Therapy. Vol. 40, 509-516.

Botella, C., García-Palacios, A., Villa, H., Baños, R., Quero, S., Alcañiz, M., & Riva, G. (n.d.). Virtual Reality Exposure In The Treatment Of Panic Disorder And Agoraphobia: A Controlled Study. Clinical Psychology & Psychotherapy, 164-175.

Cárdenas, G., Muñoz, S., González, M., & Uribarren, G. (n.d.). Virtual Reality Applications to Agoraphobia: A Protocol. CyberPsychology & Behavior, 248-250.

J., C. (n.d.). A Randomized Controlled Study of Virtual Reality Exposure Therapy and Cognitive-Behaviour Therapy in Panic Disorder with Agoraphobia. Frontiers in Neuroengineering.

Anderson, P.L., Price, M., Edwards, S.M., Obasaju, M.A., Mayowa, A., Schmertz, S.K., Zimand, E. & Calamaras, M.R. (2013). Virtual reality exposure therapy for social anxiety disorder: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 81(5), 751.760.

Moldovan, R. & David, D. (2014). One session treatment of cognitive and behavioral therapy and virtual reality for social and specific phobias. Preliminary results from a randomized clinical trial. Journal of Evidence-Based Psychotherapies, 14(1), 67-83.

Safir, M.P., Wallach, H.S. & Bar-Zvi, M. (2012). Virtual reality cognitive-behavior therapy for public speaking anxiety: One-year follow-Up. Behavior Modification, 36(2), 235-246.

Da Costa, R.T., de Carvalho, M.R. & Nardi, A.E. (2010). Virtual reality exposure therapy in the treatment of driving phobia. Psicologia: Teoria e Pesquisa, 26(1), 131-137.

Wald, J. & Taylor, S. (2000). Efficacy of virtual reality exposure therapy to treat driving phobia: A case study. Journal of Behaviour Therapy and Experimental Psychiatry, 31(3-4), 249-257.

Wald, J. & Taylor, S. (2003). Preliminary research on the efficacy of virtual reality exposure therapy to treat driving phobia. CyberPsychology & Behaviour, 6(5), 459-465.

Wald, J. (2004). Efficacy of virtual reality exposure therapy for driving phobia: A multiple baseline across-subjects design. Behaviour Therapy, 35(3), 621-635.

Botella, C.M., Juan, M.C., Baños, R.M., Alcañiz, M., Guillén, V. y Rey, B. (2005) Mixing Realities? An Application of Augmented Reality for the Treatment of Cockroach Phobia. Cyberpsychology and Behaviour, 8(2), 162-171.

Spira, J.L., Pyne, J.M., Wiederhold, B., Wiederhold, M., Graap, K. & Rizzo, A. (2006). Virtual reality and other experiential therapies for combat-related posttraumatic stress disorder. Primary Psychiatry, 13(3), 58-64. http://www.researchgate.net/profile/James_Spira/publication/228387636_Virtual_reality_and_other_experiential_therapies_for_combat-related_posttraumatic_stress_disorder/links/00463518c81d4ac9d1000000.pdf

(c) Lou Agosta, PhD

The Big Four Empathy Breakdowns and how to Transform Them into Breakthroughs…

 

Empathy breaks down into emotional contagion. Empathy breaks down in conformity and the closing off of possibilities for flourishing. Empathy breaks down in projection. Empathy breaks down in devaluing and cynical language, in which our humanity Slide1literally gets lost in translation. These are not the only ways that empathy fails, but they are the Big Four. How to overcome them?

Break throughs in empathy arise from working through the breakdowns of empathy. Empathic receptivity breaks down into emotional contagion, suggestibility, and being over-stimulated by the inbound communication of the other person’s strong feelings. If one stops in the analysis of empathy with the mere communication of feelings, then empathy collapses into emotional contagion. This and the other breakdowns of empathy are summarized in Figure: How empathy fails, breaks down, misfires.

These breakdowns (and how to overcome them) are considered in detail in Chapter Two of the book Empathy Lessons. To order the book click here: Empathy Lessons.) Read on for more details –

If one takes emotional contagion—basically the communication of emotions, feelings, affects, and experiences—as input to further empathic processing, then emotional contagion (communicability of affect) makes a contribution to empathic understanding.

A vicarious experience of emotion differs from emotional contagion in that one knows that the other person is the source of the emotion. That makes all the difference. I feel anxious or sad or high spirits, because I am with another person who is having such an experience, and I “pick it up” from him. I can then process the vicarious experience, unpacking it for what is so and what is possible in the relationship. This returns empathy to the positive path of empathic understanding, enabling a break through in “getting” what the other person is experiencing. Then the one person can contribute to the other person regulating and mastering the experience.

Or instead of empathic understanding grasping possibility for flourishing and relatedness, empathic understanding can break down in conformity. Humans live and flourish in possibilities; and empathic understanding breaks down as “no possibility,” “stuckness,” and the suffering of “no exit” (one definition of hell in a famous play of the same name by Sartre). One follows the crowd; one does what “one does”; one validates feelings and attitudes according to what “they say”; and, with apologies to Thoreau, lives the life of “quiet desperation” of the “modern mass of men.”

Almost inevitably, when someone is stuck, experiencing shame, guilt, upset, emotional disequilibrium, and so on, the person is fooling himself—has a blind spot—about what is possible. This does not mean that it is easy to be in the person’s situation or for the person to see what is missing. Far from it. But we live in possibilities that we allow to define our constraints and limitations—for example, see the above-cited friend who was married and divorced three times. At the risk of being simple-minded, dear friend, have you considered the alternative—cohabitation? Though this might not be a “silver bullet,” it points to a break through in empathic understanding. If one acknowledges that the things that get in the way of our relatedness are the very rules we make up about our relationships and what is possible within them, then we get freedom to relate to the rules and possibilities precisely as possibilities, not absolute “shoulds.” We stop “shoulding” on ourselves.

For example, if cohabitation is unacceptable due to personal or community standards, then let’s have a conversation for possibility about that (and so on). This brings us to the next break down—the break down in empathic interpretation.

This is the aspect of empathy that corresponds most exactly to the folk definition of empathy—taking a walk in the other person’s shoes. But in the break down of empathic interpretation, one takes that walk with one’s own foot size. This is also called “projection.” Now that can sometimes tell you something useful, because human beings have many things in common; but most times—and especially with most of the tough cases—empathy is going to run off the path. Imaginatively elaborating the metaphor, the other person is literally flat footed, whereas I have a high arch on my foot; the other person is an amputee, a “blade runner” with a high tech prosthesis—a different kind of “feet.” I am a “duck” and have webbed, duck feet; the other person is a “rabbit” and has furry, rabbit feet.

The recommendation? Own your projections. Take back the attributions of your own inner conflicts onto other people. One gets one’s power back along with one’s projections. Stop making up meaning about what is going on with the other person; or, since one probably cannot stop, at least distinguish the meaning—split it off, quarantine it, take distance from it, so that its influence is limited. Absent a sustained conversation with the other person, be humble that you have any idea what is going on with the other person.

Having worked through vicarious experiences, possibilities for overcoming conformity and stuckness, and taken back one’s projections, one is ready to attempt to communicate to the other person one’s sense of their experience. One is going to try to say to the other what one gets from what they told you, giving back to the other one’s sense of their experience. And what happens? Sometimes it works; but other times something gets “lost in translation.”

The breakdown of empathic response occurs within language as one fails to express oneself satisfactorily. I believed that I empathized perfectly with the other person’s struggle and effort, but (in this example) I failed completely to communicate to the other person what I got from listening to her. My empathy remains a tree in the forest that falls without anyone being there. My empathy remains silent, inarticulate, uncommunicative. I get credit for a nice empathic try (assuming that I really have tried); but the relatedness between the persons is not an empathic one. If the other person is willing, then go back to the start and iterate. Learn from one’s mistakes. Try again.

The fact that one failed does not mean that the commitment to empathy is any less strong; just that one did not succeed this time; and one needs to keep trying. It takes practice. Empathy lessons are useful. The exchange in questions was one of them. Learn from one’s mistakes.

Often understanding emerges out of misunderstanding. What I say is clumsy and creates a misunderstanding (in a given context). But when the misunderstanding is clarified and cleaned up, then empathy occurs. In a world that is lacking in empathy, the empathic person is a non-conformist. Be a non-conformist. Break throughs in empathy emerge out of breakdowns. So whenever a breakdown in empathy shows up, do not be discouraged; rather be glad, for a break through is near.

Bibliography / Further Readings on Empathy by Lou Agosta

Click here to order: A Rumor of Empathy: Resistance, Narrative and Recovery in Psychotherapy

Those interested in the history of empathy – the distinction, not just the word – will want to check out:

Click here to order: A Rumor of Empathy: Rewriting Empathy in the Context of Philosophy

Those into a Heideggerian account of empathy with further work in Searle’s speech act approach, Husserl, and Kohut will want to check out:

Click here to order: Empathy in the Context of Philosophy

In empathy one person is quite simply in the presence of another human being. Empathy is supposedly like apple pie and motherhood. What’s not to like? Yet being empathic can be confronting and anxiety inspiring because one has to dispense with evaluations, filters, diagnostic labels, and egocentrism and be with the other person as a way of being. Empathy arouses subtle and pervasive resistances. A Rumor of Empathy engages such resistances to overcome them. People are naturally empathic and given half a chance empathy will come forth, but it is inhibited by limited natural endowment, individual deprivations, and organizational conformity. Classic interventions can themselves represent resistances to empathy, such as the unexamined life; over-medication, and the application of devaluing diagnostic labels to expressions of suffering. Agosta explores how empathy is distinguished as a unified multidimensional clinical engagement, encompassing receptivity, understanding, interpretation and narrative. When all the resistances have been engaged, defenses analyzed, diagnostic categories applied, prescriptions written, and interpretive circles spun out, in empathy one is quite simply in the presence of another human being.

Lou Agosta, Ph.D., is one of the premier empathy consultants, psychotherapists, and educators in the community. He is the author of three books on empathy including the book that is the subject of this announcement and A Rumor of Empathy: Rewriting Empathy in the Context of Philosophy (Palgrave 2014), a short history of empathy in Hume, Kant, Lipps, Freud, Scheler, and Husserl; Empathy in the Context of Philosophy (Palgrave 2010), a Heideggerian interpretation of empathy with follow on results in Searle, Husserl, and Kohut. For further details on empathy therapy, consulting, and education see www.aRumorOfEmpathy.com

(c) Lou Agosta, Ph.D. and the Chicago Empathy Project

What to look for in selecting a psychotherapist…

Three criteria are front and center in selecting a psychotherapist: cost, schedule, and empathy. These are not the only variables. For example, academic degrees and diplomas, professional certifications or equivalent publications and experience, insurance benefits, location, and Internet reputation (say, on  Facebook or LinkedIn) are also criteria. Okay, I am just kidding about Facebook; but don’t laugh too hard, we are heading in that direction. In addition, it is increasingly common for psychotherapists to call out the therapeutic agreement explicitly, sometimes in writing, managing the expectations and defining the boundaries of the situation. In general, not a bad thing if it is handled with care – and empathy. The challenge faced by most prospective patients or clients, who are searching for a therapist, is that once they are in an emotional emergency, there is no time to interview several prospective psychotherapists to find a good fit. This is a case for having a periodic emotional check up just as one would have a physical check up in order to establish a relationship against a possible future crisis. However, this level of planning rarely occurs. From a negotiating perspective, the individual seeking help is “one down” in terms of leverage. Of course, reputable professionals will bend over backwards to be accommodating. In any case, the patient/client is still responsible for making his or her own best case and being a powerful self-advocate. Once again, no easy answer here if your issue is low self esteem and loss of power. Still, while acknowledging that the variables of negotiating flexibility, schedule, and cost are on the critical path, they are not the focus of this article. That leaves the criteria of empathy. Without empathy, nothing else works.

The short definition of empathy is that it is the capacity to know what an other individual is experiencing because (speaking in the first person for emphasis) I experience it too, not as a merger but as a trace affect or experience that samples the other’s experience. Thus, if one is overwhelmed by the other’s trauma and re-traumatized, one is not using one’s empathy properly. Simply stated, you are doing it wrong. Optimally, I experience a trace, a sample, a virtual vicarious representation of the other’s experience of suffering or joy or indifference so that I “get it” experientially and emotionally as well as cognitively. The boundary between self and other is firmly maintained, but the boundary is permeable in one limited sector, the communicability of affect, sensation, experience. In a larger context, empathy is the capacity that enables the other person to humanize the one by recognizing and acknowledging the possibilities for growth, transformation, and recovery in the one.

Empathy is different than interpersonal chemistry – that certain something = X that just clicks between two people such that they know they can work together. Yet empathy is the basis for this chemistry and fans out into multiple forms of relatedness and possibilities of understanding. As the author of three professional books on empathy, I work with behavioral (mental) health professionals on burnout, compassion fatigue, and related dis-orders of empathy in their lives and practices, and my own client interactions benefit from this depth of expertise and experience.

To cut to the chase, look for a psychotherapist that is genuine and authentic in relating, providing a gracious and generous – that is, empathic – listening. If the individual you are talking with does not provide the empathy you require, keep looking. Absent a warm, empathic listening, the process of psychotherapy is indistinguishable from dental work. It can be painful, granted that many individuals seeking a therapist are already suffering from significant emotional pain. Even in the best of situations, it is not that there are zero challenges even with empathy. The process does not work unless one goes up to the edge of one’s comfort zone and goes through the boundary, pressing beyond it. That takes courage – going forward in spite of being afraid (“anxious”).The more the therapist can be authentic in the relationship, the more powerful he (or she) can be in facilitating transformation in the direction of health and well-being on the part of the patient. This is true even when the attitudes that the therapist experiences are not ones that he would endorse if he lived up to all his ideals. A simple example: if I am approached for services by a person with self-esteem issue [low] who is also obese, my attitude towards the perceived extra weight is going to be front and center. Since the person struggling with low self-esteem and an (un)related weigh issue may not endorse such a view himself, it is important to recognize that there is nothing wrong with people coming in all shapes and sizes. Even if I would not endorse such an admittedly edgy slogan as “fat is beautiful”, it is still essential to be in touch with my own ambivalence (given that such exists). It is essential for the therapist to be intimately in touch with his own feelings and attitudes, generally as a result of his own work in psychotherapy or psychoanalysis as a patient. He must be willing to make the call – “the chemistry is just [not] right here and it is me” – otherwise, it just will not work out. The point is that none of this will work without a deep empathy for the experience of the world of the other individual.

What to look for is a therapist who can provide the kind of empathic relatedness that recognizes the humanity of the other, even amidst the effort and struggle of dealing with unattractive, challenging symptoms, not all of which the patient is even willing to share at first due to doubt, shame, or previous unhappy experiences and outcomes. Sometimes it is necessary for a prospective patient to “burn through” several therapists until he finds someone that he can trust. This doesn’t means that the other therapists were “wrong and bad,” though it might mean the mismatch between patient expectations and therapists’ services took awhile to converge on market availability. In short, look for a therapist who can provide the kind of relationship that the patient/client is able to use to overcome obstacles, jump start growth, and facilitate transformation in the direction of positive possibilities.

The key term here is actually “usability,” not in the sense of mis-use but in the proper and powerful sense of a means to guide the person back to naturally occurring development. The differentiator between use and mis-use is – you guessed it – empathy. The more the patient recognizes the therapist’s empathy, the more the patient will naturally restart the process of growth away from rigid, fixed, apathetic, shut down emotional functioning toward a way of being that is alive, vital, dynamic, full of feeling, engaged for better or worse with the issues that promise to provide satisfaction and fulfillment. Full disclosure: as I write this, I do so as someone who has been on both sides of the therapist/patient interface as well as the therapist/client one. It is going to sound a tad like bragging here at the backend but … additional qualifications for commenting on what to look for is that my works on empathy are footnotes in Goldberg, Wolf, and Basch (see bibliography below).  This list of what to look for is not complete nor is my knowledge and experience; all the usual disclaimers apply; so your feedback, criticism, experiences, impertinent remarks, and comments are hereby requested. Please let me hear from you.

Bibliography

Agosta, Lou. (2010). Empathy in the Context of Philosophy.London: Palgrave/ Macmillan.

__________. (1984). “Empathy and intersubjectivity,” Empathy I, ed. J. Lichtenberg et al.Hillsdale,NJ: Lawrence Erlbaum Press.

__________. (1980). “The recovery of feelings in a folktale,” Journal of Religion and Health, Vol. 19, No. 4, Winter 1980: 287-97.

__________. (1976). “Intersecting language in psychoanalysis and philosophy,” International Journal of Psychoanalytic Psychotherapy, Vol. 5, 1976: 507-34.

Basch, Michael F. (1983). “Empathic understanding: a review of the concept and some theoretical considerations,” Journal of the American Psychoanalytic Association, Vol. 31, No. 1: 101-126. (See p. 114.) .

Gehrie, Mark (2011). “From archaic narcissism to empathy for the self: the evolution of new capacities in psychoanalysis,” Journal of the American Psychoanalytic Association, Vol. 59, No. 2: 313-333.

Goldberg, Arnold. (2011). “The enduring presence of Heinz Kohut: empathy and its vicissitudes,” Journal of the American Psychoanalytic Association, Vol. 59, No. 2: 289-311. (See  pp. 296, 309.) .

Kohut, Heinz. (1984). How Does Analysis Cure? Chicago: University of Chicago Press.

Wolf, Ernest S. (1988). Treating the Self.New York: TheGuilford Press. (See pp. 17, 171.)

This post and all contents of this site (c) Lou Agosta, Ph.D. and the Chicago Empathy Project