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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 breadking 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

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Book Review: Susan Lanzoni’s Empathy: A History connects the dots between the many meanings of empathy

Short review: two thumbs up. Superb. Definitive. Well written and engaging. Innovative and even ground-breaking. Connects the dots between the different aspects and dimensions of empathy. Sets a new standard in empathy studies. The longer – much longer – review follows. Note also that since this is not a softball review, several criticisms, incompletenesses, and limitations are called out.

Susan Lanzoni’s comprehensive history of the concept of empathy – the concept, not the mere word – breaks new ground in our understanding of the distinction.  She

Cover art: Empathy: A History by Susan Lanzoni - showing the full spectrum of aspects of empathy from projection to receptivity in interpersonal relations

Cover art: Empathy: A History by Susan Lanzoni – showing the full spectrum of aspects of empathy from projection to receptivity in interpersonal relations

explores empathy’s significance for diverse aspects of our humanity, extending from art and advertising to race relations and talk therapy: Empathy: A History. New Haven: Yale University Press, 392 pp., $30 (US).

Just to be clear: Lanzoni’s is not a “how to” or self-help book; which does not mean that one cannot expand one’s empathy by engaging with empathy’s deep structure in this multi-dimensional, historical encounter. One can. However, the reader will not find explicit tips and techniques in applying empathy.

Lanzoni engages with empathy and: (1) natural beauty and art (2) the 19th century psychological laboratories of Wilhelm Wundt (1832–1920), Edward Bradford Titchener (1867–1927), and their rivals (3) theatre and modern dance (4) mental illness such as psychosis and schizophrenia (5) social work and psychotherapy (6) measurement using psychometric questionnaires (7) popular culture including advertising and the media (8) race relations (9) neuroscience.

Lanzoni begins by quoting the work of Ted Cohen (1939–2014) on metaphor in Thinking of Others: On the Talent for Metaphor(2009). Formulating a metaphor and imagining oneself in another person’s position point to a common twofold root, an art [Kunst] hidden in the depths of the human soul, whose true operations we can divine from nature and lay unveiled before our eyes only with difficulty, but whose depths we are unlikely to be able ever adequately to plumb. Lanzoni’s implies the art in question is precisely empathy and the translation it makes possible. Thus, we always honor the late Ted Cohen, whose predictably cutting, caustic and cynical wit, however, masked a deep and abiding empathy.

The narrative proper begins with Violet Paget (Vernon Lee (1856–1935)), who, with her partner and muse Clementina (Kit) Anstruther-Thomson, engaged in introspective personal journaling to detect and report the physiological effects of art and beauty on the human organism. Paget’s research crosses paths with that of Munich psychologist Theodor Lipps (1851–1914). Lanzoni reports that Lee and Lipps may have met in person in Rome at the Fifth International Congress of Psychology in 1905 (where both were on the program).

At the risk of over-simplification, Paget, Lipps, and Karl Groos (1861–1946) form a triumvirate of empathy innovators, who turn to motor mimicry, inner imitation, sympathetic muscular memory, and aspects of physiological resonance to account for the stimulating effects of artistic and natural beauty on human experience. Their analysis is the flip side of the implicit panpsychism, personification, anthropomorphism by which beautiful nature is animated with human expressions of the emotional life – for example, angrystorms in the ocean, melancholymists in the valley, a joyfulsunrise, a fearfuldarkness.

This remarkable feature of human experience: that we attribute emotions (and even intentions) to natural objects – angry storms, cheerful sunsets, and melancholy clouds. Magical, primitive thinking? An adaptive reflex? This review does not require that anyone, including Lanzoni, have solved this problem. However, some contemporary thinkers have speculated that it is a cognitive design defect of human nature to attribute intentionality (including emotional propositional contents) to otherness – whether human or physical – as an adaptive mechanism arising in the context of biological evolution.

 Theodor Lipps is the one who puts Einfühlung on the map between 1883 and 1914 (his death), and those who are contemporaries must explain how they differ from his position.

 Lipps’ position on empathy was already multidimensional, extending Einfühlung from the projection of feelings into objects to the perception of other people’s expressions of animate life. Lanzoni’s reading of Lipps is much more charitable than mine, and I find Lipps at loose ends and philosophically naïve as he tries to account for the first person’s access to the experiences of the second person by “an original innate association between the visual image and the kinesthetic image (1903: 116). Lipps thinks he has demolished the philosopher’s problem of other minds but unwittingly recreates it in his own terms (e.g., Agosta 2014: 62 – 63).

 Lanzoni engagingly (but briefly) references the critique of Lipps’ theory of projective empathy by the phenomenologists Edith Stein (1891–1942), Max Scheler (1874–1928), Edmund Husserl (1859–1938), Maurice Merleu-Ponty (1908–1961), and Martin Buber (1878–1965) (p. 37).

 Lanzoni notes Sigmund Freud’s (1856–1939) debt to Lipps based on transference as a kind of projection. For Lipps, psychological processes were performed, with few exceptions, beneath the threshold of consciousness, which is another factor that made Lipps’ positions attractive to Freud.

 Any thinker or author who used the term “Einfühlung” would inevitably also conjure up the image of Theodor Lipps, which limited the thinkers ability to use it without extensive argument or the risk of being mistaken as a follower of Lipps. This point is key: in his own time Lipps had in itself branded himself as the “go to guy” for all matters empathic. More on the significance of this dilemma below.)

 By the way, Lanzoni does not italicize the word “Einfühlung” unless it is used in a specifically German context. “Einfühlung” is now an English word!

 Johann Herder (1744–1803) also gets honorable mention at this point (p. 32) as a philosopher in the Romantic tradition. Herder is noteworthy as a proponent of empathy as a verb – sichhereinfühlen– to feel one’s way into. Herder was a fellow traveler of Goethe and actually “on staff” as the chief Lutheran prelate at Weimar, innovating in the historical development of language in a proto-evolutionary (and metaphysical) context. This points to an entire undeveloped paradigm of empathy not developed by Lanzoni. For example, for Herder empathy was required to feel one’s way into the world of Homer in order to produce an accurate translation of Homer’s Iliad.

 This paradigm of empathy as translation is arguably at the same level of generality as empathy as projection, but remained undeveloped until the rise of hermeneutics along a separate trajectory. And since Lanzoni seemingly unquestioningly accepts Rudolf Makkreel’s dismissal of the relevance of Einfühlung for Wilhelm Dilthey (granted he has little use for the word), this approach is not further explored.

 Yet the modern innovators of interpersonal empathy such as Carl Rogers (1902–1987) might be read as leap-frogging back to the original sense of entering the other’s world in order to translate it into the first person, subject’s own terms. Such Herderlike usages also fits well with what Gordon Allport (1897–1967) and Kenneth Clark (1903–1983) were doing in arraying empathy against racism and prejudice in expanding the boundaries of community by empathically translating between them (see Chapter Nine).

 An entire possible alternate history of empathy, as yet unwritten, opens up at this point – empathy as translation between subjects. (Granted that Rogers probably never heard of Herder, at least not in the context of empathy, so this is a conceptual nuance; but Rogers probably never heard of Lipps either.)

 As is by now well known, in part thanks to Lanzoni’s work, the word “empathy” itself comes into English thanks to Edward Bradford Titchener, the founder of a Wundtian style psychology lab at Cornell University (and translator of Wundt). However, what is less well known is the back-and-forth about the meaning of Einfühlung as explored in detail by Lanzoni.

I was impressed by the work of James Mark Baldwin (1861–1934), who contribution to empathy as semblance was interrupted and obscured as he had to leave town in a hurry – apparently for Paris – after being arrested in a raid on a Baltimore house of prostitution. Baldwin was innovating with empathy in terms of semblance – the “as if” of child’s play and the play of the artist.

 Lanzoni quotes in detail the devaluing remarks about “empathy” made by James and Alix Strachey, the translators of Freud, who call it a “vile word” (p. 67). Though Freud used variations of “Einfühlung” some 22 times in 24 volumes, the word is often paraphrased or mistranslated by the Stracheys, using synonyms such as “sympathetic understanding.”

 It is amazing how much empathy or lack thereof turns on a mistranslation. My take on it? Basically Freud did not use the word Einfühlung more often because he was not someone who could abide being a footnote to Lipps (who, as noted, virtually owned the distinction Einfühlungin German). There are other technical reasons Freud chose not to comment more extensively on empathy, including his dismissal of the philosophical uses of introspection as a function of the conscience (superego), whereas introspection and empathy are “joined at the hip” in a therapeutic context (see also Agosta 2014: 66 – 82).

 I hasten to add that Freud did say in his “Recommendations for Physicians Beginning Psychoanalytic Treatment” (1913) that if the would-be analysts start in any other way than with empathy, they are headed for trouble. But once again the reader has no idea of Freud’s true position, because “empathy” is mistranslated as “sympathetic understanding.” However, these observations are less critical to Lanzoni’s point, which is otherwise unexceptionally on target.

 Meanwhile, Titchener has numerous ideas (that we would today consider highly unconventional) about how images accompany word meanings, but his translation of “Einfühlung” as “empathy” sticks. In an otherwise comprehensive engagement (Lanzoni really does seem to have read everything!), she does not mention how empathy subsequently becomes embroiled in the disappearance of introspection controversy (behaviorists regard it as illusory) and ultimately is “taken down” by the behaviorists in their attack on all things relating to subjective consciousness and inwardness. However, all this lies ahead in the B.F. Skinnerian 1950s through 1980s, and the Chapter ends with Einfühlung being an intertwining of projection, aesthetic appreciation, and Baldwin’s “semblance.”

 But how does one get from a empathy that projects human emotions and mindedness onto objects in art and nature and an empathy as human understanding of another, second person who contains an emotional life and mind of his or her own distinct from that of the first person?

 Lanzoni skillfully navigates the challenge of engaging how the projective aesthetic empathy of Lipps et al get transformed, translated, and reconciled, with the interpersonal receptive empathy of talk therapy and personal counseling.

 One missing link comes in modern dance. The missing link is identified as to “live in the mind of the artist who designed it [the object]” (p. 97). At this moment in the text, the intentionality of the artist looms large. In effect, the regression (my word, not Lanzoni’s word) is back from the intentionality built into the artistic artifact or performance towards human subjectivity. Now intentionality is available to build a bridge between a projective empathy of the object and a receptive intersubjective empathy of the human subject.

 Both projective empathy and receptive empathy are ways (admittedly divergent) of dealing with and transforming otherness– the otherness of the object and the otherness of the human subject. This is why aesthetic empathy and interpersonal empathy belong to the same concept and are not merely the same homonymous word for different underlying concepts.

 Another missing link occurs in “Personality as Art.” Lanzoni gathers together the contributions of Herbert Langfeld (1879–1958), Wilhelm Worringer (1881–1965), Carl Gustav Jung (1875–1961), who expand the boundaries of aesthetic, projective empathy in the direction of the understanding of human beings. The study of the artistic self-expressions of psychotics incarcerated in mental asylums also deserves mention here as opening up the exchange between aesthetic projective empathy and interpersonal receptive empathy.

 Nowhere does any one (including Lanzoni) say, “Relate to the human being with the respect and interpretive finesse with which one relates to a work of art,” but that is the basic subtext here. In our own time, the late Richard Wollheim, a notorious free spirit, sometimes took such a position about art and its objects.

 The engagement with empathy as human understanding picks up speed. Whenever a breakdown occurs the possibility of a breakthrough also arises. Such is the case with schizophrenia. In apparently separate but overlapping and near simultaneous innovations, E. E. Southard (1876–1920), Roy G. Hoskins , Louis Stack Sullivan (1892–1949), Karl Jaspers (1883–1969), and C. G. Jung identified schizophrenia as a challenge to or a disorder of empathy. In short, it is hard to empathize – Jaspers maintained it was impossible – with people who were disordered in such a way that they displayed the cluster of symptoms we now group as schizophrenia including perceptual distortions, incoherent speech patterns, disordered thinking, lack of reality testing, bizarre ideas, emotional flatness, intermittent acute anxiety or paranoia, lack of motivation, lack of responsiveness, burn out, and (occasionally) lack of personal hygiene.

 Southard designed an “empathic index” (p. 101) guiding the psychiatrist through a series of questions such as: How far can you read or feel yourself into the patient? Thus the first, admittedly over-simplified, version of the schizophrenia test: Can you imagine experiencing what the patient reports he or she is experiencing? If not, then that counts as evidence they are on the equivalent of what we would today call the “schizophrenic spectrum.”

 We finally arrive at our present day folk definition of empathy: the ability to step into and walk in another person’s shoes and then to step back into one’s own shoes again, and, in so doing, to “feel along with, to understand, and to insinuate one’s self into the feelings of another person” (p. 124).  

 Lanzoni asserts: “[T]he psycho-therapeutic rendering of empathy traded self-projection for its opposite: one now had to bracket the self’s findings and judgments in order to more fully occupy the position of another” (p. 125). Thus, a coincidence of opposites in which the two extremes are perhaps counter-intuitively closer to one another than either point is to the middle.

 With Chapter Five on “Empathy in Social Work and Psychotherapy,” Lanzoni makes yet another decisive contribution to empathy scholarship.

 Carl Rogers famously puts empathy on the map in the 1950s, 60s, and beyond, as the foundation for psychotherapeutic action. Though it is an oversimplification, in client-centered Rogerian therapy, one gives the client a good listening – one gives the client empathy – and the client gets better.

 Lanzoni connects the empathy dots. They lead back into the empathy archives. They lead back from Carl Rogers to D. Elizabeth Davis, a student of Jessie Taft (1892 – 1960), a nurse and social worker, who, in turn, was strongly influenced in her conception of relational therapy by G. H. Mead’s (1863–1931) social behaviorism and Otto Rank (1884–1939). Rank belonged to Freud’s inner circle along with Ernest Jones (1879–1958), Karl Abraham (1877–1925), and Sándor Ferenczi (1873–1933).

 Not a medical man or even a scientist, Otto Rank met Freud in 1905 when he presented Freud with his innovative work on the artist as inspired by Freud’s theories. Something clicked between them. In 1905 Freud was less isolated, but still hungry for recognition and fellow travelers. Think: father son transference.

 Rank eventually completed a PhD dissertation at the University of Vienna on literature (the Lohingrin Saga), in part thanks to the financial generosity of Freud. Freud paid him to be the recording secretary of the Psychoanalytic Association. The literary dimension is of the essence, and, in our own time, we have a renewed appreciation that studying literary fiction expands one’s empathy.  This too  strengthens the case for the overlap of the aesthetic and interpersonal dimensions of empathy.

 As was often the case with Freud and his “sons” – Jung, Ferenczi, Adler – the seemingly inevitable “falling out” between Rank and the Freudian establishment was especially bitter. Ultimately Louis Stack Sullivan made the parliamentary motion to expel Rank from the American Psychoanalytic Association. With friends like these … Rank formed his own separate Association and continued to innovate and earn Greenbacks.

 Carl Rogers learns of Rank’s work through one of his colleagues, who is being analyzed by Rank, now residing in the States. Rogers invites Rank to speak at a three-day seminar (circa 1936), lecturing to forty-five social workers and educators. Rogers later notes that it was in this context “that I first got the notion of responding almost entirely to the feeling being expressed” (p. 144). Voila! Mark the historical moment: Client-centered therapy is conceived.

 Mine is a bare bones outline of how Lanzoni connects the dots. The dynamics and the personalities, which Lanzoni richly narrates, make for fascinating story telling in themselves. Fast forward to the 1930s as Jessie Taft, a nurse and social worker separately innovating in empathic relatedness, is translating Rank’s Will Therapyfrom the German. There is still research to be done to follow the threads into Rank’s work, whose literary skills in mining myth and fiction are used in elaborating an approach to the emotions that transgresses the relatively narrow definition of Freudian libido (desire).

 Though Lanzoni does not get so far, I do not believe that Rank had the specific distinction of Einfühlung, but worked with the communication and understanding of the emotions in such a way as to produce psychological transformation. Rank uses the word “love” in the way of an empathy-like “unconditional positive regard.”

 By the time Rogers is fully engaged with Einfühlung, “empathy” does notmean agreement with the other or mere mirroring. The therapy client may usefully be self-expressed about the emotions with which he or she is struggling. These emotions, in turn, are thereby brought to the surface, acknowledged, worked through, and able to be transformed. The therapist helps the client to metabolize the emotional congestion and gives back to the client the client’s own experience in a form that the client recognizes, hypothetically opening up a reorganization of psychic structure.

 Lanzoni also gives a “shout out” to Heinz Kohut, MD (1913–1981), but just barely. Kohut was the innovator who puts empathy on the map in psychoanalysis (then the dominant paradigm in psychiatry) starting in 1959 with his celebrated article “Introspection, empathy, and Psychoanalysis.”

 Kohut was very circumspect about his sources relating to empathy and regarding those who inspired him in his work on empathy. Chronically under-appreciated (and sometimes even under attack) by the prevailing orthodoxy of Freudian ego psychology, Kohut’s footnotes about empathy as such are few and far between. Surely knowing the fate of Adler, Jung, Ferenczi, and Rank, not even to mention Jeffrey Masson, Kohut pushed back against the unfriendly accusation that Kohut’s emerging Self Psychology was distinct from Freudian psychoanalysis, even as Self Psychology seemed increasingly to be so.

 It is likely Kohut was influenced by Sándor Ferenczi and Michael Balint (Lunbeck 2011). Speaking personally, I have never seen a shred of evidence that Kohut read Rank, who was by that time devalued as yet another notorious “bad boy” and psychoanalytic heretic. Of course, that does not mean that Kohut did not do so – and it is also possible that I just need to get out more. Kohut and Rogers seemed to have inhabited parallel but wholly distinct universes.

 My take? And not necessarily Lanzoni’s: Kohut was sui generis– and wherever he first got the word “empathy” itself (Kohut, though a Austrian, German-speaking refugee, was by 1959 writing in English), his definition of empathy as “vicarious introspection” is a wholly original contribution.

 One problem is that as soon as one engages Kohut’s The Analysis of the Self(1971), arguably a work of incomparable genius, discovering as it does new forms of transference, relations to the other, and possibilities for humanization, the reader is hit by a tidal wave of terms such as “cathexis,” “archaic object,” and “repressed infantile libidinal urges.” These make the reading a hard slog for most civilians.

 The force of historical empathy is strong with Lanzoni as she engages “Popular Empathy.” She describes how in the post World War II world “empathy” breaks out of its narrow academic context into the American cultural milieu at large.

For example, the then-popular radio (and eventually TV) personality Arthur Godfrey was featured on the February 1950 cover of Time magazine, asserting “He has empathy” (p. 208). The notorious quiz show scandals of the late 1950s were apparently a function of mis-guided empathy, giving contestants answers to build audience empathy for the contestants. Advertisers “got it”: help the audience empathize with the brand and the person using the brand – give the customer empathy, they buy the product. Even if it was never quite so simple, the Boston Globe(July 3, 1964) quotes the Harvard Business Review:  Empathy is “the ability feel as the other fellow feels – without becoming sympathetic” (p. 210).

 Meanwhile, Carl Rogers has an existential encounter with Martin Buber (celebrated author of I and Thou) at the University of Michigan (1956). Rogers is profiled in Timemagazine in 1957 as practicing a psychotherapy that uses empathy in contrast with the then-prevailing paradigm of psychoanalysis, which uses – what? Insert the caricature of an authoritarian analysis of the Oedipus complex.

 In an eye-opening Chapter on “Empathy, Race, and Politics,” Lanzoni documents the role of empathy in the movement for civil rights in the 1950s and 1960s in America. Both Kenneth B. Clark and Gordon Allport provided examples of (social) psychologists who were committed to social justice. They were committed to overcoming the one dimensional, trivial and convenient issues of academic research (still ongoing) instead engaging with urgent social realities such as prejudice, racism, poverty, and inequality.

 According to Lanzoni, Allport drew on the tradition of Einfühlung to describe empathy as a means of grasping the human personality holistically, thus breaking down the barrier between aesthetic and interpersonal empathy. Clark used empathy as the basis for arguing for equality under the law: “to see in one man all men; and in all men the self” (p. 217). Sounds like empathy to me.

 In 1944 Allport taught an eight-hour course to Boston police officers to tune down racial tensions. Allport encountered and faced what he called an “abusive torrent of released hostility.” In response Allport deployed the technique of nondirective or “unemotional listening,” learned from Carl Rogers. Once again, sounds like empathy. By the end of the session, the officers reportedly became bored by their own complaints. One who had “at first railed against the Jews tried in later remarks to make amends.” But empathy remained a two-edged sword, capable of eliciting searing anger when others thought they had not been given the dignity they deserved as well as dialing down narcissistic rage once it had been called forth (pp. 220 – 221).

Clark was so impressed by psychoanalyst Alfred Adler’s (1870–1937) power dynamics in the context of society that he shifted his major from neurophysiology to psychology. In 1946, Clark and his wife, Mamie Clark (PhD, Columbia) established the Northside treatment Center in Harlem to expand education, counseling, and psychological service for youth in Harlem.

 In July 1953 Clark wrote to Allport, asking help in preparing a document for the upcoming Supreme Court deliberations on desegregation in the Brown v. Board of Education case. Allport responded quickly. The rest, as they say, is history.

 Gunnar Myrdal (author of the celebrated American Dilemma, demonstrating that the history of the US isthe history of race relations (1944)) said of Clark’s work, especially Dark Ghetto(1965): a demand for “human empathy and even compassion of the part of as many as possible of those who can read, think, and feel in free prosperous white America” (p. 241). Just so.

 Instead of becoming ever more cynical and resigned in the face of prejudice that seemed baked into the neo-liberal, market-oriented vision of American society, Clark calls forth empathy. Clark’s calls for empathy became more insistent. What happens when Clark and empathy speak truth to power? Empathic reason? Rational empathy? One can only wish that Clark had lived to see the people of this great country elect Barak Obama as President of these United States. We do not know if this was an anomalous moment, a beacon in the current fog of fake everything, or a kind of liberal purgatory – one step forward, one step backward – to call forth further struggle. From the perspective of Q2 2019 as I write this review, such events seem like a dream. Breakdowns are hard but inevitably point the way to the next breakthrough.

 Lanzoni demonstrates that society’s interest in empathy had continuously been at the level of at least a steady simmer in the popular and social justice communities in the 1950s through 1970s even as professional psychology was lost and wandering through the wasteland of Skinnerian behaviorism.

 That which really brings the conversation about empathy to a rolling boil in the final chapter is the discovery of mirror neurons in the macaque monkeys by the group of brain scientists in Parma, Italy including V. Gallese,, L. Gadiga, L. Gogassi, and G. Rizzolatti.

 Mirror neurons are neurons are activated both when a subject takes an action and similarly when the subject watches another subject doing the same thing. For example, the set  of neurons in the premotor cortex of the monkey is activated when it drinks from a cup. Okay, fine. The astonishing finding is that these same neurons are activated when the monkey watches another monkey (or any one) drink from the cup. Could this be the underlying basis of the motor mimicry, inner imitation, felt resonance, with which thinkers such as Violet Paget, Theodor Lipps, and Karl Groos remarked? Could this be the neural infrastructure for Kohut’s vicarious engaged, or Roger’s felt sense of participating in the other’s experience? The infrastructure for Mark Davis or Alvin Goldman on perspective taking and simulation?

  The battle is joined.

 Lanzoni covers the explosion of theories, studies, and amazing results that have occurred since the identification of alleged mirror neurons. Bottom up, affective empathy is combined with top down, cognitive empathy to complete the picture of empathic relatedness.

 The author of Emotional Intelligence, Daniel Goleman, weighs in with a follow up on Social Intelligence– that is, empathy.  Victorio Gallese’s shared manifold hypothesis makes the case for a multi-person virtual manifold of experience that can be vicariously sensed by each partner in empathic resonance. Jean Decety’s seminal architectural definition of empathy paves the way for social neuroscience and functional magnetic imaging research (fMRI) that visualizes other people’s pain. Marco Iacoboni Mirroring Peopleargues that we have no need to use inference to understand other people. We use mirror neurons. Disorders of empathy are identified: Simon Baron-Cohen’s breakthrough work on Mindblindness(1995) identifies possible interventions for autism spectrum disorders.

 On a less positive note, the colonization by neural science of the humanities and social sciences has proceeded apace with neuroaesthetics, neurolaw, neurohistory, neurophilosophy, neuropsychoanalysis, neurozoology,and so on,  drawing provocative but, in many cases, highly questionable conclusions from what areas of people’s brains “light up” as they lay back in the fMRI apparatus and are shown diverse pictures or videos of people’s fingers being painfully impacted by blunt force.

 Lanzoni reports on the neuro-hype that accompanies the discovery of mirror neurons in monkeys: “Cells That Read Minds.” Hmmm. The backlash is predictable if not inevitable. Greg Hickok’s The Myth of Mirror Neuronsraises disturbing questions about voodoo correlations in fMRI research. Other than a single report from 2010 of human mirror neurons allegedly identified in epileptic patients undergoing surgery, there is no evidence of the existence of human mirror neurons.

 Lanzoni is an equal opportunity debunker: The fMRI research, while engaging and provocative, provides evidence of diverse brain functions that include thousands of neurons, not individual ones, whose blood oxygenation level data (BOLD) is captured by the fMRI. Correlation is not causation. The brain lights up! Believe me, if I doesn’t you are in trouble.

 Still, the neuro-everything trend has traction (and its merits). Even if human mirror neurons do not exist, it is highly probable that some neurological system is available that enables us humans – and perhaps us mammals – to resonate together at the level of the animate expressions of life.

 If there is a myth, it is that we are unrelated. On the contrary, we humans are all related – biologically, socially, personally. You know that coworker or boss you can’t stand? You are related. You know that politician you regard with contempt? You are related. You know that in-law or neighbor who gets your goat? You are related – intimately related, because we all share the same cognitive, affective, and neural mechanisms – and defects – designed in from when we were that band of hominids fighting off large predators and hostile neighbors in the environment of evolutionary origin.

 Since this is not a softball review, as noted, I call out the limitations and incompletenesses of Lanzoni’s impressive contribution. One of the challenges is that the history of the concept empathy is not limited to the word “empathy” or Einfühlung. Indeed prior to Lanzoni’s work, some entirely reasonable individuals had concluded that Lipps projective empathy and Roger’s interpersonal empathy were entirely distinct concepts. We now know that they belong together in a kind of coincidences of opposites because empathic animation of the work of art or beautiful nature and empathic receptivity to other human beings are related, but diverse, ways of engaging with otherness. 

 First incompleteness: Prior to Titchener’s invention of the word “empathy” as a translation of the German “Einfühlung” the main word in English was “sympathy.” Now it is a common place today to say that “sympathy” means a reactive emotion such as pity in contrast with “empathy” that captures a vicarious experience of the other’s experience or takes a sample or trace affect of the other’s experience. And that remains true today. David Hume (1711–1776) and Adam Smith (1723–1790) get barely a shout out.

 However, if one goes back as recently as David Hume’s Treatise of Human Nature(1731) one can find at least four different senses of sympathy – emotional contagion, the power of suggestion, a vicarious experience such as one has in the theatre, the conjoining of an idea and impression of another’s expression of emotion with the idea of the other [which starts sounding like our notion of interpersonal empathy].

 In addition, if one looks at Hume’s aesthetic writings, one finds the distinction of a delicacy of sympathy and of taste. If your delicacy of sympathy and taste is more refined than mine, then you may experience a fine-grained impression that is more granular than mine. For example, you perceive sadness behind a person’s outburst of temper whereas I only perceive the obvious anger. Your delicacy of sympathy and taste is superior to mine. In our own modern language, you empathy is more discriminating.

 A second incompleteness is in the treatment of the phenomenologist’s – Edith Stein (1891–1942), Max Scheler (1874–1928), Edmund Husserl (1859–1938), Maurice Merleu-Ponty (1908–1961), who receive honorable mention in a cursory nod to their diverse engagements with Einfühlung. For example, in a footnote, Scheler’s eight distinctions of sympathy and empathy are called out in a footnote (p. 360n40): Miteinanderfühlung[reciprocal feeling], Gefühlsansteckung[infectious feeling], Einsfühlung[feeling at one], Nachfühlung[vicarious feeling], Mitgefühl[compassion], Menschenliebe[love of mankind], akosmischtishe Person- und Gottesliebe[acosmic love of persons and God], und Einfühlung[empathy]. Well and good.

 Leaving aside purely practical considerations of editorial constraints on word count and that the phenomenological material may have been covered elsewhere [e.g., see Agosta 2014, especially Chapters 4 – 6]: the reason that the additional phenomenological chapter was not provided is a breakdown in an otherwise astute historical empathy. 

 In particular, today hardly anyone has heard of Theodor Lipps (granted that Lanzoni’s work is changing that). However, in his own day Lipps was famous – celebrated as the proponent of a theory of Einfühlungthat provided the substructure for aesthetics and grasping the expressions of animate life of other people. It was as if Lipps was an Antonio Salieri to would-be Mozarts such as Freud or Husserl (once again, except for the play (and movie) Amadeus). Using modern terms, it was as if in his own day Lipps was branded in the marketing sense as “the empathy guy.”

 Between roughly 1886 and 1914 (the date of Lipps’ death) no philosopher, psychologist, or psychoanalyst could use the word “Einfühlung” without being regarded as a follower – or at least a fellow traveller – of Lipps.

 In the case of the phenomenologist, the result is a sustained attack on Lipps. Edith Stein quotes Max Scheler against Lipps’ theory of “projective empathy.” Her contribution becomes a candidate deep structure of Husserl’s 5thCartesian Meditation. Husserl attempts to overcome the accusation of solipsism [there is nothing in the universe except my own consciousness] without using empathy as a mere psychological mechanism. Yet Husserl dismisses empathy, using a Kantian idiom, and “kicks it upstairs”: “The theory of experiencing someone else, the theory of so-called ‘empathy,’ belongs in the first story above our ‘transcendental aesthetics’ ” (1929/31: 146[173]). “Transcendental aesthetics” is a form of receptivity – such as receptivity to another subject. But then Husserl has to reinvent empathy in other terms calling it “pairing” and “analogical apperception.”

 One thing is certain: in Husserl’s Nachlass(posthumous writings) he makes extensive use of Einfühlungin building an account of intersubjectivity. Empathy is the window into the sphere of ownness of the other individual subject. Empathy is what gives us access to the Other, with a capital “O.” Empathy enacts a “communalization” with the other. Key term: communalization (Vergemeinschaftung).

 In his published writings Husserl was exceedingly circumspect in his use of the term “Einfühlung,” virtually abandoning it between Ideas(1913) and the Cartesian Meditations(1929/31).  But in Husserl’s work behind the scenes empathy was moving from the periphery to the center of his account of intersubjectivity. The Nachlassvolumes corresponding the Cartesian Meditations contain hundreds of references to Einfühlung, in which it is doing the work of forming a community of subjects. The anxiety of influence? The influence of Lipps? Quite likely.

 I would not blame anyone – including Lanzoni – for not wanting to try to disentangle this complex of distinctions and influences of empathy in the context of phenomenology. It is not for the faint of heart.

 As of this date (Q2 2019), Lipps is not translated from the German so far as I know. There is a reason for that – Lipps falls through the crack between Immanuel Kant and Wilhelm Wundt. If ever there were someone of historical interest, it is Lipps.

 Lipps provides an elaborate rewrite of rational psychology using a quasi-Kantian idiom without any of the empirical aspects of Wundt. Still, Lipps enjoyed considerable celebrity in his own time. So far as I know, no one has commented on the fact that Lipps in effect substitutes the term “Einfühlung” for “taste” in his aesthetics. Those wishing to engage further may usefully see Agosta 2014: “From a Rumor of Empathy to a Scandal of Empathy in Lipps in A Rumor of Empathy: Rewriting Empathy in the Context of Philosophy: pp. 53 – 65: DOI: 10.1057/978113746534.0007.)

 A third incompleteness is the role of empathy in psychoanalysis proper, which was perhaps a wilderness too desolate to reward proper scholarly engagement. Lanzoni notes: “There were also handful of psychoanalysts, trained, not surprisingly, in Vienna, who ventured to explain empathy to a popular audience. Analyst and writer Theodor Reik published Listening with the Third Ear in 1948 [….] Empathy worked like wireless telegraphy to allow one to tune in to the inchoate messages of another’s unconscious” (p. 208). Empathy as receptivity andbroadcast of messages. However, Reik was not a medical doctor, and the American Psychoanalytic Association declined to validate his credentials, leaving him as yet another voice crying in the wilderness.

 Lanzoni gives Kohut another “shout out,” noting that empathy was an observational act that led the analyst to a scientific appraisal of the other person rather than one of the “sentimentalizing perversions of psychotherapy” (p. 207). Of course, Kohut moved steadily in the direction of asserting that empathy itself could be curative, though, in contrast to Rogers, mainly in a process of optimal breakdown, being ruptured and restored. Empathy breaks down, the attuned therapist acknowledges and cleans up the misunderstanding, empathy is restored, psychic (personality) structure is shifted and strengthened – thenthe patient gets better.

 A fourth incompleteness is the missing paradigm of empathy as translation between different individuals and the worlds in which the individuals inhabit. Once again, this is not a criticism of Lanzoni, but simply to note that, substantial though Lanzoni’s contribution is, there is more work still to be done.

 Herder was working on a complex interpretive problem of empathy, creating an entire world in all its contingencies and details in order adequately to translate a text from attic Greek into German or understand a work of art in its ancient context. Herder’s project envisions no trivial translation, and, if anything, is an application of empathy broader and bolder than what is being proposed here or in any reconstruction of Kant. According to Herder, in order to deliver an adequate translation, the translator must think and feel himself into – empathize into [sichhineinfühlen] – the world of the author or historical figure. The translator is transformed into a Hebrew, e.g., Moses, among Hebrews, a poet among bards, in order to “feel with” and “feel around” the world of the text (e.g., Herder as cited in Sauder 2009: 319):

 Feeling is the first, the most profound, and almost the only sense of mankind; the source of most of our concepts and sensations; the true, and the first, organ of the soul for gathering representations from outside it . . . . The soul feels itself into the world [sichhineinfühlen] (1768/69: VIII: 104 (Studien und Entwürfe zur Plastik)) (cited in Morton 2006: 147-148).

 Thinking from the point of view of everyone else is not to be confused with empathy in the Romantic idea of empathy where empathy is a truncated caricature of itself and summarily dismissed as merger, projection, or mystical pan-psychism. Nor is it clear that Herder, always the sophisticated student of hermeneutics, ever envisioned such a caricature of empathy. In any case, empathy is not restricted to the limitations of a Romantic misunderstanding of empathy as merger. Empathy as creating a context within which a translation – an empathic response – can occur stands on its own as an undeveloped paradigm (see also Agosta 2014: 36–37 (from which this text is quoted)).

 Among the many strengths of Lanzoni’s book is her engagement with the many women researchers and scholars who contributed to the history of empathy: Violet Paget (Vernon Lee), who was there are the beginning with the physiological, mirroring effect of empathy in inner imitation; Edith Stein, research assistant (along with Martin Heidegger) to Edmund Husserl and her dissertation The Problem of Empathy(1917), which was influenced by and, in turn, informed Husserl’s ambivalence about making Einfühlungthe foundation of intersubjectivity (community); Jessie Taft, who developed an entire model of psychotherapy, relational therapy, combining element of G. H. Mead’s social behaviorism and Otto Rank’s psychoanalytically informed approach to the emotions, which, in turn, decisively influenced Carl Rogers. All this and more does Lanzoni truly deliver.

 References and Further Reading

 Jean Decety (ed.). (2012).  Empathy From Bench to Bedside(2012). Cambridge, MA: MIT Press.

 Jean Decety and P.L. Jackson. (2004). “The functional architecture of human empathy,” Behavioral and Cognitive Neuroscience Reviews, Vol 3, No. 2, June 2004: 71-100.

Sigmund Freud. (1913). “Further recommendations: On beginning the treatment.” Standard Edition, Volume 12: 121-144.

Victorio Gallese. (2001). “The shared manifold hypothesis: embodied simulation and its role in empathy and social cognition.” In Empathy and Mental Illness, T. Farrow and P. Woodruff (eds.), Cambridge, UK: Cambridge University Press, 2007: 448-472.

Edmund Husserl. (1905/20). Zur Phänomenologie der Intersubjectivität: Texte aus dem Nachlass: Erster Teil: 1905-1920,I. Kern (ed.). HusserlianaXIII. The Hague: Martinus Nijhoff, 1973.

 ______________. (1913). Ideas: General Introduction to Pure Phenomenology, tr. W. R. Boyce Gibson. New York: Collier Books, 1972.

 _____________. (1918). Ideas Pertaining to a Pure Phenomenological Philosophy: Second Book, tr. R. Rojcewicz and A. Schuwer. Dordrecht: Kluwer Academic Publishers, 1989.

 ______________. (1921/28).  Zur Phänomenologie der Intersubjectivität: Texte aus dem Nachlass: Zweiter Teil: 1921-1928I. Kern (ed.). HusserlianaXIV. The Hague: Martinus Nijhoff, 1973.

 ______________. (1929/31). Cartesian Meditations, tr. D. Cairns. Hague: Nijhoff, 1970.

 _____________. (1929/35).Zur Phänomenologie der Intersubjectivität: Texte aus dem Nachlass: Dritter Teil: 1929-1935, I. Kern (ed.). HusserlianaXV. The Hague: Martinus Nijhoff, 1973. 

 Marco Iacoboni. (2007). “Existential empathy: the intimacy of self and other.” In Empathy and Mental Illness, Tom Farrow and Peter Woodruff (eds.), Cambridge, UK: Cambridge University Press, 2007: 310-21.

L. Jackson, A. N. Meltzoff, and J. Decety. (2005). “How do we perceive the pain of others? A window into the neural processes involved in empathy,” Neuroimage24 (2005): 771-779.

G. Jung. (1921). Psychological Types, tr. R. F. C. Hull. Princeton: Princeton University Press, 1971.

Susan Lanzoni. (2012). “Empathy in translation: Movement and image in the psychology laboratory,” Science in Context, vol. 25, 03 (September 2012): 301-327.

Vernon Lee [Violet Paget]. (1912). Beauty and Ugliness and Other Studies in Psychological Aesthetics. New York: John Lane, Co.

 Theodor Lipps. (1883). Grundtatsachen des Seelenlebens. Bonn: Verlag des Max Cohen und Sohns.

 _____________. (1897). “Der Begriff der Unbewussten in der Psychologie.” In Dritter internationaler Congress für Psychologie in München vom 4. bis 7 August 1896. München Verlag von J.F. Lehmann, 1897: 146-163.

 _____________. (1909). Leitfaden der Psychologie. Leipzig: Wilhelm Engelman Verlag.

 _____________. (1903). Aesthetik. Volume I. Hamburg: Leopold Voss.

 Lou Agosta. (2014). “From a Rumor of Empathy to a Scandal of Empathy in Lipps in A Rumor of Empathy: Rewriting Empathy in the Context of Philosophy: pp. 53 – 65: DOI: 10.1057/978113746534.0007.

 ____________. (2014). A Rumor of Empathy: Rewriting Empathy in the Context of Philosophy. New York: Palgrave Pivot.

Elizabeth Lunbeck. (2011). “Empathy as a Psychoanalytic Mode of Observation: Between Sentiment and Science,” in Histories of Scientific Observation, ed. Lorraine Daston and E. Lunbeck. Chicago: University of Chicago Press.

George H. Mead. (1922). “A Behavioristic account of the significant symbol,” Journal of Philosophy, 19 (1922): 157-63.

 Michael Morton. (2006). ‪Herder and the Poetics of Thought: Unity and Diversity in On Diligence in Several Learned Languages. London and University Park: Penn State University Press.

Lou Agosta, PhD and the Chicago Empathy Project

 

 

 

 

 

Review: Narrative Exposure Therapy – and empathy

Narrative Exposure Therapy (NET) was originally designed as a treatment for victims of war, persecution, and torture. Civil wars (e.g., Rwanda, Burundi, DR Congo, Iraq) often target civilians and include widespread atrocities and human

Narrative Exposure Therapy (NET) by Schauer, Neuner and Elbert

Narrative Exposure Therapy (NET) by Schauer, Neuner and Elbert

rights violations. For example, the widespread use of rape as a weapon of war and the recruitment of child soldiers in the civil wars of east Africa have left entire populations traumatized even after the cessation of hostilities.

Engaging with these survivors is not for the faint of heart. Therapists are at risk of compassion fatigue and burn out. Many survivors have had to run the gauntlet of multiple, complex traumas, requiring a raid on the inarticulate even to bring their suffering to language. NET is such a raid on the inarticulate.  

The colleagues at the Universities of Konstanz and Bielefeld have innovated in the matter of an intervention that aims at restoring the survivor’s humanity, does not leave the therapist overwhelmed, is scalable, is relatively brief, indirectly gathers data to pursue justice against the perpetrations, and is evidence-based in reducing the symptoms of post traumatic stress disorder (PTSD) even in populations with limited resources.

In a Grand Rounds session on NET at Rush Medical Center, Chicago, in March (2019), I raised the issue of empathy and the risk of burn out with Dani Meyer-Parlapanis Doctor of Psychology, University of Konstanz). Dr Dani is notone of the authors of the text under review here. However, she trains NET practitioners and is providing leadership in extending NET to other applications, including girls and women who embrace violence. I said to her: “If this is not empathy, I would not know it: Empathy LIVEs in NET and in the work you-all are doing. You are engaging with child soldiers and really tough cases. What about it?”

Dr Dani of course acknowledged that compassion fatigue (“burn out”) was a significant risk in engaging with large numbers of survivors of complex trauma, so the NET trainers, are, in effect, counseling the lay counselors notto go into unnecessary detail at first (or words to that effect). Just get the time-line and a label for what happened. But then acknowledging full well that the work was precisely to go into the details she said: “The idea is to be like an investigative reporter.” Though acknowledging the matter may be controversial, I took that to mean empathy in the sense of data gathering and sampling the survivor’s experience, not immersing oneself in it. The investigative reporter is not hard-hearted, but in tune with what the survivor is experiencing. That indeed is the heart of the investigation.

Thus, “empathy” is distinct from compassion. Empathy targets a form of data gathering about what the other person experienced, a sampling of the other’s experience. Such empathy is in tune with the boundaries between self and other and leaves each individual whole and complete in a context of acceptance and toleration. I believe the definition of empathy of Heinz Kohut (1959) as vicarious introspection aligns remarkably well with that employed in NET.

 In the face of compassion fatigue, dial empathy up or down by simulating the role of an investigative reporter. If one can say exactly what happens, the trauma begins to shift, lose power, and shrink, typically by being reintegrated in the context of everyday life and experience. In this case, the investigative reporter also uses vicarious introspection. Easier said than done; but necessarily both said and done.  

The reader in Chicago may say that’s fine, but what has it got to do with the situation here in the USA? We do not have child soldiers or wide spread traumatized populations.

Think again. Gangs are recruiting children of tender age not only as messengers but also as triggermen, because they know youngsters will face a different criminal justice system and process, generally more lenient, than adults.

 After two wars, stretching back to the consequences of the 2001 terrorists attacks, the population is peppered with wounded warriors, both men and women, with a diversity of untreated symptoms from subclinical substance abuse to PTSD, thought disorders, and depression. Violence against (and abuse of) women is no longer an issue in the inner city, but is acknowledged to be a challenge from Hollywood to corporations and the US Supreme Court. 

So, while NET has not received much application in the USA (or the first world), the unmet need is great and it deserves consideration. Hence, the value of this overview.

In some four to fourteen sessions of 90–120 minutes each, the therapist and client create an autobiographical time-line that names the events that have stimulated the most affective arousal in the person’s life. These include traumatic events such as aggression, sexual boundary violations, deaths of loved ones, becoming a refugee, and so on. Positive events are also included on the time-line such as births, marriages, graduations, and life successes. Fast forwarding through the process, the client is handed a copy documenting the narrative at the end of the sessions and a copy is retained just in case the client wishes/agrees to submit the report to the authorities for judicial, prosecutorial follow up.

One of the innovations and most challenging aspects of the narrative in working with former child soldiers (who have grown up in the interim) is to create a context of acceptance and tolerations. Naturally the therapist must employ empathy, but he or she does so as an investigative reporter gathering data about what happened. To become a child solider the survivor is generally required to commit an atrocity such as kill a member of his or her family. Issues of shame and guilt along with the deadening loss of one’s own humanity are powerfully present and evoked.

The first session begins. Diagnosis and psycho-education occur up front. The client may not even know what is PTSD. The client may be living a basically resigned and hopeless existence, and she or he must be enrolled in the possibility of recovery. The education includes information on symptoms, what is involved in the therapy, as well as a statement about the universality of human rights.

An initial pass through the client’s autobiography occurs. A time-line, the life span history, is completed during the second session. The task is to name or label the event in the course of one 90–120 minute session without calling forth the details and hot emotional impact of the traumatic incident. A rope line is used with a variety of stones for traumas, flowers for positive events, and sticks for when the client perpetrated a dignity violation against another. The subsequent work of sessions three through fourteen is to engage sequentially with the events. The work at hand is to find words to express what has previously been unexpressible.

The narrative work consists of going through the events of the time-line. When? Where? And what? The five senses are invoked. Hot memory, sensation, cognition, and emotion are called forth.  What did the background look like? What were the people wearing. Small, cold details call forth powerful hot emotions.

The idea is to put into words and capture verbally the hot affect and experience. The session is not over until the client (often with the support of the therapist) is able to describe what happened in words – that is the narrative.

Now “what a person made it mean” also starts to emerge at this time, and those meanings will naturally be compared with reasonable (or unreasonable) assessments of what to expect of children or people literally with a gun or machete to their necks.

Talking about what happened in the course of the traumatic events calls forth the hot experiences. Talking about what happened following the traumatic events put the hot events back into the context of cold experience. Talking about what happened following the trauma enables the client to reintegrate the trauma into the all-encompassing, greater life narrative. The client is reoriented in time and space to the present, the trauma is contextually situated as to emotional meaning. Before the session ends, the therapist verifies and validates that the client’s arousal has subsided to standard levels and is oriented to the present.

Cognitive restructuring occurs automatically in the days after the story telling. The client may return to the next session with new insights, meanings, and understanding of her or his own behavior in the trauma. Formerly inaccessible details (memories) may emerge and should be included in the narrative. 

For example, one child soldier reported that he killed his sister by cutting her neck with a machete as part of the initiation, for which he bore a great emotional and moral burden; but he subsequently remembered that one of the paramilitaries hit his sister in the head with his rifle butt, a fatal blow, prior to his own action. Therefore, though he did in fact cut his sister, he did not kill her. Small comfort; and not a choice anyone should have to make; yet a significant step in recovering this individual’s dignity and humanity.

In the final session, the client is given a document of her or his narrative lifeline with the details filled in. Where appropriate, the client is asked if he wants to forward the data to the authorities for prosecution of the high level authorities and perpetrators who organized the war crimes. Follow up occurs at six months and a year, often documenting further improvement in symptom reduction, acquisition of life skills, and accomplishments.

NET is trauma focused but unlike many trauma focused therapies that require the survivor to identify thetrauma or select the worst trauma (“good luck with that”), NET acknowledges that survivors of war, torture, and persecution have encountered a sequence of traumas. This is call a “life span” approach.

Granted NET evokes a grim calculus, the number of traumatic event types – beating, rape, killing, torture, branding, amputation, witnessing these, destruction of home by paramilitaries, domestic violence and/or substance abuse by family member, perpetrating or participating in these, and so on – predicts the symptoms of PTSD over and above the actual number of traumatic events.

The results? Studies showing the effectiveness of NET have been independently conducted (Hijazi et al 2014, Zang et al 2013). Centrum 45 in the Netherlands and the Center for Victims of Torture in Minnesota use NET in treating survivors and refugees. NET manuals are now available in English, Dutch, French, Italian, Slovakian, Korean, and Japanese and are also available from the authors in Spanish and Farsi.

Further detailed evidence of the effectiveness of NET is at hand. Reorganizing traumatic memories seems to be inherently stress reducing. Chronic stress causes a weakening of the body’s resilience and defenses against disease and emotional disorder. Reducing stress improves one’s health and well-being. “Morath, Gola et al. (2014) showed that symptom improvements caused by NET were mirrored in an increase in the originally reduced proportion of regulatory T cells in the NET group at a one-year follow-up.” “These cells are critical for maintaining balance in the immune system and regulating the immune response to infection without autoimmune problems. This finding fits with the observation that NET reduces the frequencies of cough, diarrhea, and fever for refugees living in a refugee settlement (Neuner et al. 2008, Neuner et al 2018).”

NET works. NET produces positive results for those suffering from PTSD. This brings us to the question: Why does it work? Thereby hangs a tale – and a theory.

NET conceptualizes PTSD and related disorders as disorders of memory.

For example, hot memories include the sounds of people screaming for help, the sight of dead or wounded persons, the smell of the perpetrator pressing his body against the victim, the taste of one’s own vomit, the experience of being unable to move and helplessness, and so on. These are “hot memories.” These occur or occurred in a context of coldmemories of place, time, and standard activities.

For example: “We were working in the garden behind the house when the paramilitaries drove up in a truck.”  In the case of an individual trauma or series of traumas of the same type, as a defensive measure to preserve the integrity of one’s personal experience, the individual may take himself out of the situation in thought automatically, watching and experiencing the situation as if he was an observing third party. How this occurs is not well understood, but it seems to support survival of the organism in extreme situations.

This disconnects the “hot” and “cold” contexts. In the case of an individual surviving multiple trauma types, beating, rape, loss of home, the cumulative traumatic load causes the traumas to be grouped into a network disconnected from the standard, cold context of everyday life. Fear generalizes forming a fear network. Emotional, sensory, cognitive and physiological representations interconnection with the excitatory force of hot memories. Ordinary, random events become triggers of this network.

The trauma LIVEs. It takes on a life of its own as the fear network. PTSD survivors learn to avoid triggers that act as activators of hot memories. The client isolates. He or she has difficulties with the cold context of autobiographical memory. A negative cascade of experiences is mobilized as symptoms suck the life out of the individual, leaving him or her as an emotional zombie. “Shut down” replaces intrusive thoughts and hyper-arousal with passive avoidance and disassociation.

The effectiveness of NET consists in reestablishing the connections between hot and cold memories, the hot traumatic events and the cold, everyday occurrences that situate them in place and time. In a context of acceptance and toleration (i.e., non-judgment and empathy), the client is supported in reliving the details of what happened by putting them into words without losing the connection to the here and now. If one can say what happened, the emotion is called forth and reintegrated into the context of the person’s life. The trauma starts to shrink.

The imagined exposure to the traumatic event is maintained long enough for the affect, especially the fear, to be called forth and allowed to begin to fade in intensity. The narrative is essential. Absent words, retraumatization – invoking the trauma in an uncontrolled way – is the risk to the client. Even if time is running short, the session must not end until the client (with the help of the therapist (as appropriate)) has found some words to describe what happened. (If the trauma involves organized or domestic violence, the testimony may be recorded or documented for forensic purposes.) 

Two of the strengths of NET are the low drop out rate and the scalability due to building a network of lay therapists. Lay therapists?

The World Health Organization endorses this approach for those communities with limited resources (Jordans, Tol 2012). Given the limited resources of third world countries or even many communities in the USA due to the monopoly-like rents being collected by healthcare insurance providers, NET embraces “task shifting.” “Task shifting” consists in training lay therapists to perform the intervention.

Regarding the training and use of lay therapists to deliver NET, it is scalable, affordable, and workable. It is also controversial. In the State of Illinois (USA) one needs a license to cut hair. However, so far as I know, one does not need a license to have a structured conversation for possibility with another human being about what they had to survive. No doubt the graduates of PsyD programs may have an opinion about that; but personally having taught in two PsyD programs, I know the dedication, commitment, and hard work of the students and teachers; and I also know that one cannot take a course entitled (or with the content of) “empathy lessons” or with “empathy training” in any of these programs. I know because I proposed to do so, but it simply did not get approval due to other priorities. 

NET offers significant potential not only to treat PTSD survivors of violence and trauma. Anxiety and panic disorders, depression, eating and substance abuse disorders, borderline personality disorder (BPD), all report intrusive memories filled with upsetting content but lacking cold memory context.

One final thought. Those suffering from PTSD are suffering from reminiscences –  disorganized, toxic memories. The astute reader may recall this is what Freud said, in slogan-like sound byte, about hysteria (Breuer, Freud 1893). Each memory has to be transformed into words, into a narrative. Each memory has to be expressed in speech so that the body no longer has to function as the corporeal narrator in flashbacks, startle response, panic attacks, intrusive ideas, emotional numbing and overstimulation. Narrative exposure therapy gives new meaning to the phrase “the talking cure,” and it is one. How shall I put it delicately? My “French” fails me: The more things change, the more they stay the same.

 REFERENCES

Breuer, Josef and Freud, Sigmund. (1893). Studies on Hysteria. Translated from the German and edited by James Strachey. (The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. II.) Hogarth Press, London 1955.

Hijazi, A. M., Lumley, M. A., Ziadni, M. S., Haddad, L., Rapport, L. J., & Arnetz, B. B. (2014).Brief narrative exposure therapy for posttraumatic stress in Iraqi refugees: A preliminary randomized clinical trial. Journal of Traumatic Stress, 27(3), 314–322. https://doi.org/10.1002/jts.21922

Jordans, M. J., & Tol, W. A. (2012). Mental health in humanitarian settings: Shifting focus to care systems. International Health, 5(1), 9–10.

Kohut, Heinz. (1959). Introspection, empathy, and psychoanalysis. Journal of the American Psychoanalytic Association7. (July 1959): 459–407.

Morath, J., Gola, H., Sommershof, A., Hamuni, G., Kolassa, S., Catani, C., … Elbert, T. (2014).

The effect of trauma-focused therapy on the altered T cell distribution in individuals with PTSD: Evidence from a randomized controlled trial. Journal of Psychiatric Research, 54, 1–10. https://doi.org/10.1016/j.jpsychires.2014.03.016

Neuner, F., Onyut, P. L., Ertl, V., Odenwald, M., Schauer, E., & Elbert, T. (2008). Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 76(4), 686–694. https://doi.org/10.1037/0022-006X.76.4.686

Neuner, Frank, Elbert, Thomas, Schauer, Maggie. (2011).Narrative Exposure Therapy: A Short-Term Treatment for Traumatic Stress Disorders, 2ndEdition, Göttingen, Germany: Hofgrefe Verlag.

Neuner, Frank, Elbert, Thomas, Schauer, Maggie. (2018).Narrative Exposure Therapy (NET) as a Treatment for Traumatized Refugees and Post-conflict Populations: Theory, Research and Clinical Practice. 10.1007/978-3-319-97046-2_9.

Zang, Y., Hunt, N., & Cox, T. (2013). A randomised controlled pilot study: The effectiveness of narrative exposure therapy with adult survivors of the Sichuan earthquake. BMC Psychiatry13(1), 41. https://doi.org/10.1186/1471-244X-13-41

 (c) Lou Agosta, PhD 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