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Radical Empathy Disrupts Depression: Review of Ratcliffe’s Experiences of Depression
Over the summer I have been catching up on my reading. Matthew Ratcliffe’s Experiences of Depression: A Study in Phenomenology (Oxford University
Press, 2015, 318 pp, (44.09 $US)) is an important and eye-opening book for anyone who engages with depression or who wants a deep dive into phenomenological method.
The strength of this book is that Ratcliffe begins by listening to what the first person accounts have to say. Though Ratcliffe does not even use the word “empathy” until late in the work, and then in a debate that leaves much to be clarified, Ratcliffe’s method is a highly empathic one. What does he get out of listening to what the diversity of first person accounts have to say?
What is going on when the depressed person complains that getting out of bed requires enormous effort, and brushing one’s teeth seem impossible because the tooth brush seems to weigh twenty pounds? What is possible for the ordinary person is not possible for the depressed person.
This is a simple-minded, though accurate, example. Now extend it to loss of energy (lethargy) for daily and professional projects, the breakdowns in relations to other people and to oneself, including rampant self-reproaches, physical symptoms such as disturbances of appetite, sleep, consciousness (inability to concentrate). What goes missing from the experience of the depressed person?
Where you and I see possibility – tomorrow is another (and better!) day – the depressed person does not see possibility. The depressed person’s tomorrow is going to be the same miserable day as today. This is not just a belief (though it may be that too); this is the depressed person’s way of being – his experience of the world. This is not just the loss of one possible project or even a series of projects. This is the loss of possibility itself. This is Ratcliffe’s fundamental idea: depression is the loss of the very possibility of possibility.
This idea – the loss of the possibility of possibility – open up the flood gates for the description and appropriation of the diversity (“heterogeneity”) of depressive symptoms. The depressed person does not experience the possible – does not experience the possible as possible. That is the disorder itself.
The disorder is that it is not possible to conceive that things will get better. One is left without hope. Hope is itself openness to a possible future that is better. One is left demoralized. One is left without a future. Guilt is the impossibility of undoing faults or mistakes in the past. One’s crime is irrevocable, impossible to fix or make reparations (or reinterpret). No possibility of forgiveness.
Meanwhile, the depressed person often gets influenza like symptoms – no energy, inability to concentrate, headaches, stomach distress – one takes to one’s bed. However, unlike the case of the flu, in which one feels miserable but knows if one just hangs in there one will get better in a few days, the depressed person cannot imagine things being otherwise. No possibility period.
The phenomenology? Backing up for a high level view based on the phenomenological methods of Husserl and Heidegger, the world is not a thing in the world. The world is the context for things in the world. The world is the space of possibilities. The world of the depressed person is different than the world of the ordinary person. The los of possibility has a domino effect, “taking down” practical significance, hope, and interpersonal connection. Nothing matters anymore. Lethargy, detachment, self-reproach, and flu like symptoms are pervasive.
Given that the audiences for this book, including psychiatrists and many analytic philosophers, have not read Husserl and Heidegger, Ratcliffe devotes significant time and effort providing background, marshaling evidence, and arguing “depression is the loss of possibility – not just one or a series of possibilities – the very possibility of possibility – the depress person cannot even conceive of [the] possibility [of taking action].”
This is as it should be, and the book contains many technical distinctions – e.g., noetic and noematic – and, in that respect, is not for the faint of heart. Still, I was persuaded, and I believe, you will be too. This is a powerful and important contribution, which should be, required study for anyone proposing to engage with persons who one customarily describes as depressed. It changes one’s listening and in a powerful and positive way.
Since this is not a softball review, this leads to the two-ton elephant in the room. So what? What is the guidance in overcoming depression? As I am a person who performs empathy consulting and psychotherapy, this reviewer asks: what are the action items or recommendations? How does one access the possibility of possibility, given that possibilities always present themselves as specific projects in the world? How does one jump-start the possibility of possibility when nothing seems possible?
In all fairness, addressing this may not be Ratcliffe’s job since he is doing phenomenological research, not clinical practice; but the question is almost unavoidable. Therefore, I am so bold as to engage in some “reading between the lines.”
Ratcliffe’s short answer to jump starting possibility is “radical empathy.” Radical empathy – unlike ordinary empathy (according to Ratcliffe) – does not presume that the two people trying to relate share the same space of possibilities (p. 242). Radical empathy is a kind of lever to open a space of possibilities of difference.
My take on radical empathy? Radical empathy consists in the would-be empathizer being committed enough to relating that he continues to try to do so even though logical reasons exist that empathy should fail. In this case, the depressed person is overwhelmed, experiencing being cut off from human relatedness, isolated, and disconnected. That is the disorder itself – along with the other symptoms.
Yet the would-be empathizer persists in his attempts to relate, vicariously experiencing the isolation and disconnectedness (or not) as a privative form of relatedness. The depressed person, even in his isolation, “gets it” that the empathizer is committed to the possibility of relating, even though the depressed person is frustrating the efforts. That’s it. That’s the moment something starts shifting.
Voila! The possibility of possibility is back in play. The depressed person’s “getting it” that the other is committed to the possibility of relating provides an Ariadne’s thread out of the labyrinth. That’s the empathic breakthrough.
This does not guarantee that radical empathy will succeed. Nor is there any guarantee that after trying ten times, the 11th try will be enough to do the trick. The depressed person may still be so cut off from possibility that suicide starts to look like a solution; but if one can acknowledge the possibility of a bad – very bad – solution (e.g., suicide), then one may be able to find a better solution – whether pharmacological, cognitive behavioral or empathy-based.
To cut to the chase, I am so bold as to suggest that all empathy is radical empathy (in Ratcliffe’s sense). Contrary to Ratcliffe’s assertion, ordinary empathy does notrequire a space of shared possibilities. Shared possibilities are a “nice to have,” but often a high bar. Possibilities might be shared, but often they are not. Given the state of the world, such a space of shared possibilities is rarer than any of us might wish. I assert: All empathy is a risk undertaken to create a space of shared possibilities when there was no shared context.
All the other would-be empathic mechanisms such as simulation, mindedness, sympathy, altruism, are examples of incomplete empathy or breakdowns of empathy into projection, emotional contagion, or conformity. If the breakdowns were clarified, then empathic connection would emerge out of the misunderstanding, restoring the integrity of the relationship.
Meanwhile, Ratcliffe acknowledges the usefulness of the Diagnostic and Statistical Manual (DSM) for aligning the conversation and assuring us that the researchers are talking about the same phenomena. He is respectful of the professional sensibilities of the medical and psychiatric establishment – perhaps too respectful in my opinion. Yet, then again, if one is going to speak truth to power, it is best to start with an agreeable word. The barber lathers a man before he shaves him.
Though not a contribution to the growing body of anti-DSM literature, Ratcliffe’s work is an antidote to the pervasive tendency to under-describe depression (and other psychiatric disorders). The DSM is a starting point. However, Ratcliffe’s work makes clear that the DSM, especially as regards depression, is a pragmatic conglomeration of overlapping traits, not a natural kind.
Arguably melancholy is a natural kind; mania is a natural kind; paranoia is a natural kind; inflammation is a natural kind (and here the cytokine theory of depression is called out); but major depressive order as defined by the DSM? Nope. Ratcliffe does not spend much time or effort on the matter of the social construction of the categories of mental illness, and if one had to summarize Ratcliffe’s approach it aligns with the genealogical approach of Ian Hacking (e.g., see Ian Hacking, (2002), Historical Ontology, Cambridge, MA: Harvard University Press), who was himself inspired by Foucault (in turn, inspired by Nietzsche).
In spite of his commitment to sustained phenomenological description of the things themselves, Ratcliffe quickly discovers that the phenomena bring forth a deep structure and background separable from any specific first person report. As usual, the way the researcher gets access to the phenomena significantly influences one’s description of the phenomena.
The data? The phenomena? Ratcliffe collects some 150 free form depression questionnaires in which sufferers and survivors of depression try to express and describe their experiences. Many of these contain lengthy feedback from the survivors on their experiences of depression. Ratcliffe also reviews many memoires of suicide and depression survivors, who try to express the ineffable nature of their experiences, such as Styron’s Darkness Visible. Many conditions and qualifications regarding the data are argued, limitations defined, and the richness of the experience plumbed for an expansive encounter with the enemy – depression.
Several things come out in the first person accounts that are not emphasized or are outright overlooked in the DSM. These include: the intimate relationship between depression and anxiety (“anxious distress” is called out in DSM-5, but unrelated to the whole); loss of hope and changes in bodily experience are briefly acknowledged in the DSM-5, but are critical path in the treatment; the altered experience of time is not mentioned at all (but the future seems to disappear as a positive, possible horizon); impaired social function is mentioned as a consequence whereas such loss of function is integral to the phenomena itself. This list goes on.
One of the first things that occurred to me as I sat down to read this book was: Am I going to get depressed – not necessarily in the full clinical sense; but is it going to cause an upset? My experience was that such a negative outcome was not the case. I suspect that was because, as an author who “gets” and uses empathy, Ratcliffe knows how to regulate the empathy in the space of possibilities to prevent empathic distress.
However, before turning to Ratcliffe’s breakthrough notion of radical empathy, the text engages with the issue of how empathy maps to the theory of mind debate in which empathy as simulation is arrayed against a theory of mindedness that enable persons to perceive others as sources of intentionality. The details of this debate are technical and at times Ratcliffe seems to forget the insight with which he began the book: “I argue that human experience incorporates an ordinarily pre-reflective sense of belonging to a shared world’, which is altered in depression” (p. 2).
Once one disconnects the subject from its environment – the subject’s belonging to a shared world of people, neither simulation theory nor theory of mindedness can ever quite connect them again. It is a myth that we human beings are unrelated. We are all related. Human beings are already related to one another – biologically, psychologically, and in our very way of being (ontologically). Ratcliffe gets this. There is nothing wrong. Yet there is something missing.
Ratcliffe conceptualizes empathy as an attitude that does not include the communication of affect. Therefore, he overlooks several breakdowns in empathy – such as emotional contagion, projection, conformity – that if clarified provide the breakthrough to “radical empathy” (Ratcliffe’s key term) that is need to give traction to treatment options. There is indeed such a thing as an empathic attitude; but I disagree with Ratcliffe that a congruence of feeling (whether partial or complete) is to be ruled-out.
Ratcliffe (and his argument) are troubled by the notion that if one empathizes with a depressed person, then one may end up feeling quite depressed. This seems to be an invalidation of empathy and an obstacle to using it in treatment. Neither needs to be the case. First, in an admittedly extreme case, if one talks to eight depressed people in a row in the course of a treatment day, then one is very likely going to feel down – at least sub-clinically depressed – by the end of the day, regardless of the quality of one’s empathy. Is this empathy or a breakdown of empathy?
Look at the phenomena. Phenomenologically, there is no other plausible way to describe this than to say that the feelings and emotions have been communicated from one person to another. Once again, is this empathy? No – according to Ratcliffe, empathy is an attitude, not a congruence of feelings.
I suggest this answer is incomplete. It is not an “either or” choice. One must integrate empathic receptivity (openness), empathic understanding, empathic interpretation, and empathic responsiveness.
The answer is still “No,” but because the communication of feeling, the congruence of feeling – one paradigm case of which is vicarious experience – is not complete empathy. It is merely phase one of empathy.
If one stops with the mere communication of feeling, then one gets emotional contagion (as Ratcliffe properly notes). This is a breakdown of empathy, but Ratcliffe does not describe it in such a way. However, do not be so hasty to dismiss empathy. That empathy breaks down does notmean empathy is invalid or must be abandoned.
The would-be empathizer may [must?] take this vicarious experience of the other’s distress and process it further through empathic understanding, empathic interpretation, and empathic responsiveness in order to make it useable in relating to the other person as a possibility or a breakdown of possibility.
Likewise with compassion fatigue, which is likely in the background of Ratcliffe’s insistence that empathy is an attitude, not a congruence of feeling. Though compassion fatigue is not an issue Ratcliffe engages, it is common to acknowledge that the helping professions are at risk of burn out, empathic distress, and compassion fatigue. (Note that burn out itself is a kind of loss of the possibility of possibility. “Depression”?)
Those who engage with depressed people are particularly at risk of such an outcome. Empathy reportedly peaks in the third year of medical school, and, unless specific interventions such as further training are undertaken, it is downhill from thereon (see Hojat, Mohammadreza, et al. (2009). The devil is in the third year: A longitudinal study of erosion of empathy in medical school, Academic Medicine84 (9): 1182–1191). What to do about it?
Once again, Ratcliffe may not see this as his job – and the book is already over 300 pages of dense descriptions of depression – but one may offer a couple of thoughts. We usually think of empathy as an “on off” switch. Turn it on for the “in group” – patients, clients, friends, family – turn it off for the competition, the opposing team, people who talk foreign languages or have unfamiliar customs or the “out group.” Rather, the training is to regard empathy as more like a dial or tuner – dial empathy up or down by regulating one’s receptivity – one’s openness (Ratcliffe’s term) – to the experiences of other persons.
If one is over-whelmed by the other person’s depression one is doing it wrong. Properly deployed by experienced practitioners, empathy is a method of providing a sample or trace of the other person’s experience. Max Scheler (who Ratcliffe approvingly cites) calls this a “vicarious experience” (Nacherlebnis) – rather like an after image of another person’s feeling. As noted, this trace or sample of the other’s experience has to be further processed by the understanding of possibilities to be useful in shifting out of stuckness. (See Max Scheler, (1913/1922). The Nature of Sympathy, tr. Peter Heath. Hamden: CN: Archon Books, 1970)).
Of course, expanding one’s empathy does not come naturally to most people, which is why training and practice are needed. But experience shows that if one works at it, one can expand one’s empathic capabilities and the results one gets in trying to be empathic. (See Zaki, Jamil and Mina Ciskara. (2015). Addressing empathic failures, Current Directions in Psychological Science,December 2015, Vol. 24, No. 6: 471–476. DOI: 10.1177/0963721415599978).
The antidote? A radical proposal – in addition to radical empathy. If one is experiencing compassion fatigue, maybe one is being too compassionate. Now compassion is different from empathy. In compassion, one’s strong feeling – passion – motivates one to get involved, take action, and intervene to help the other. (Nor is anyone saying be hard-hearted or indifferent, but know when to dial it down a bit.) In contract, empathy in the full sense of the term, of which Ratcliffe’s radical empathy is a subset, is a method of data gathering about the experience of the other person. It consists in being open to the experiences of the other person, having a vicarious experience of the other’s experience, and further processing it in empathic understanding, empathic interpretation, and empathic responsiveness.
It is ironic that the phenomenology of depression misses the key phenomenological distinction – vicarious experience – in the account of trying to empathize with depression. In relating to a depressed person, I can be open to a vicarious experience of melancholy or stress or anger or irritability or discordant mood or whatever the other person is experiencing – without succumbing to a merger with them. This vicarious experience gets processed further in understanding who the person is, where he is at, what he “gets” as possible for himself in the moment. Through interpretation and responsiveness, this may open up other possibilities. Now we are back in the realm of jump-starting the possibility of possibility.
Ratcliffe finds inspiration in, but puts his own definitive spin on, Jonathan Lear’s Radical Hope, a narrative of the struggles of the Native American Crow people. After the buffalo went away (were killed off), the indigenous Crow people, experienced world collapse. Hunting ceased. Demonstrating courage in tribal warfare became impossible. Culture and customs lost significance and ceased to make a difference. Nothing changed – i.e., in effect, time stopped. All hope was lost and – at the risk of a caricature – the only possibilities were the self-destructive non-possibilities of alcoholism and inadequate, dignity-destroying government handouts.
However, even amid this world collapse – analogous to the depressive person’s loss of the possibility of possibility – a wise Crow elder put forth a prophecy that an event, something = x, would happen that would enable a the rebirth of possibility of the true people. This was radical hope – “to hope against hope until hope creates from its own wreck the thing it contemplates” as the poet Shelley put it.
The prophesized event turned out to be World War II, a conflict in which the Crow were able to draw on their warrior tradition and make a contribution to the defeat of the enemy.
Ratcliffe’s radical empathy is analogous to radical hope here. The therapist keeps alive the possibility of possibility and gives expression to it while the depressed person is unable to do so for himself. The therapist keeps blowing on the embers – and may indeed get short of breath doing so – until the spark rekindles the fire of neuronal activity in the depressed person’s consciousness.
In conclusion, Ratcliffe “gets it” – while simulation and theory of mindedness go round-and-round about whether feelings are congruent or perspective interchangeable, psychiatric disorders across the spectrum, from mood disorders to thought disorder, are especially challenging to anyone’s empathy. Most psychiatric disorders – not just autism or psychopathy – involve a breakdown of empathy (as Ratcliffe points out elsewhere), leaving the person feeling disconnected, isolated, not “gotten.” Ordinary empathy is already radical in so far as one person is able to understand another in his or her humanity. Such a commitment – call it an “attitude” or a “method” – is not easy or trivial. Yet the commitment to relating to the other’s humanity is what calls forth the humanity back into possibility.
(c) Lou Agosta, PhD and the Chicago Empathy Project