Empathy: From Bench to Bedside, edited by Jean Decety. Cambrdige, MA: The MIT Press, 2012.

Short Review: Two thumbs Up.
Longer Review:
The thematic unity to this wide-ranging and diverse anthology on empathy is available in thinking of empathy as a stack of functions and capabilities. Neurology at the lowest level, sensorimotor functions one level up, intentionality and related issues in joint attention, social referencing in the context of community, and ultimately patient-doctor interactions in a rich setting such as medicine or psychoanalysis.

In a lead off article on philosophical and anthropological perspectives on empathy, Dan Zahavi and Søren Overgaard oppose a robustly phenomenological account of empathy to a widely distributed (if not widely know) account in the Handbook of Phenomenology and Cognitive Science by Frédérique de Vignemont. Zahavi and Overgaard argue the latter’s account is inadequate because it does not distinguish between empathy and emotional contagion and between empathy and sympathy. These lack of distinctions, in turn, leaves empathy detached from the foundation of interpersonal understanding to which they are committed. The authors properly parse and distinguish empathy from the complex issues entangling modern applications of empathy. On the radar are Theodore Lipps’s projective empathy in aesthetics, the intentional analysis of phenomenologists Edith Stein and Edmund Husserl, simulation, mind reading, and the role of mirror neurons in inner imitation. The authors take a strong stand for the immediate availability of the other [individual] through empathy – without succumbing to the fallacy of direct first person access. Still, de Vignemont is a suitable stalking horse; and he does not allow for a vicarious experience, so is unable to push back. Finally, by eliminating the criteria of isomorphism – “I know what you feel because I feel it too” (albeit not as a merger but as a vicarious experience) – the authors risk throwing out the empathic baby with the mistaken merger and over-intellectualization bathwater.

Allan Young is one of the most original thinkers on “Empathy, Evolution, and Human Nature” in our time, and it is hard to contain his innovative and conceptually disruptive contribution (in a positive sense) in a short precise such as this. Young provides a neo-Darwinian backstory of human evolutionary history including the great leap forward of reciprocal altruism, cooperation, and exchange. However, having solved one set of problems about living socially, another set of issues emerges. Cheaters, free riders, and self-deception emerge as a set of problems in evolutionary history. Punishment of cheaters does not make economic sense especially if those punished retaliate and new levels of cheating emerge as good reciprocators are unwilling to be enforcers. An evolutionary solution is suggested in which empathizing with the suffering of others is itself a reward. Empathic punishment includes a kind of shadenfreude (enjoyment in inflicting pain), under a Nietzschian interpretation or Freudian superego formulation. Punishment is its own reward – like virtue – through the vicarious experience of empathic cruelty. This should be read in relation to the last article in the anthology where empathy is treated by David Terman from a psychoanalytic perspective as including the demonization of the other in neg-empathy from a paranoid gestalt The imagination travels through time in fantasy to alternative versions of the present. Morality, religion, and art emerge as illusions in an alternative now, albeit comforting ones, in the face of life’s adversity and suffering.

In contrast to the darker side of empathy as exposed by Young, C. Daniel Batson is and remains the most celebrated proponent of the pro-social aspects of empathy. In a meta-analysis of more than thirty experiments in differentiating egoistic from altruistic behavior and motives, he marshals evidence that empathy contains within its core the kernel insight that we human are not always inherently egoistic. Empathic concern is a fundamental motivating factor in altruism. Arguably there is no contradiction between Batson’s position and alternatives such as Young’s deep history of empathy, for it is quite logically consistent that empathy could be used to motivate altruistic as well as cruel behavior under differing circumstances.

Stephanie Echols and Joshua Correll leverage research that suggests individuals reply on holistic processing of facial perceptions when engaging in-group members but used feature-based processing when viewing out-group members. A survey of research indicates that when perceives consider members of an out-group, empathic understanding is compromised. Empathic understanding is more likely to promote empathic concern and helping behavior for in-group members than out-group one. Ways of reducing the distance between out- and in-group include perspective taking, inducing empathic concern for a stigmatized target, and role playing exercises.

Karen Lewis and Sara Hodges produce a counter-intuitive result. While stereotypes can be depersonalizing and undermine empathy, that is not always so. Stereotypes contain a grain of truth – children of divorced parents blame themselves, chemotherapy patients miss their hair, widows mourn their spouses – and stereotypes give individuals access to the experiences of others is a short-handed, telegraphic way that enhances empathy.

The capuchin monkey prefers the token that rewards both itself and its fellow prisoner and the spontaneous consolation occurring among apes is so common that thousands of cases are documented. Though not engaged by de Waal in his incisive but brief inquiry is the issue of joint attentionality and social (in group) referencing which seems to be missing consistently in both monkeys and apes and lacking in at least some forms of the diseases of empathy in humans such as autism and psychopathy. Primate research is a source of significant insight into the evolutionary antecedents and most advanced forms of human empathy. According to Frans de Waal, a hard-wired socio-affective perception-action mechanism that can be observed in higher apes, elephants, and even rodents provides the foundation for advanced forms of sympathetic concern, consolation, perspective-taking, and targeted helping, Imagine a set of Russia dolls with an increasing self-other distinction as one works from the inside out towards a level at which we are hypothesized to be physiologically united as living organisms. The outer dolls in the stack enjoy an expanded and refined self-other distinction with the joint attentionality required for an appreciation of the other’s intentions. Synchronization responses extending from contagious yawning to the uncannily coordinated movements of masses of birds and fishes are reminders of the depth of the connectivity. Just as no man is an island, neither are there any absolutely isolated organisms.

Like a perfectly complimentary piece in a jigsaw puzzle, Sharee Light and Carolyn Zahn-Waxler collect reminders that basic joining attention and social referencing abilities are displayed by children even during the first year of life. This provides the basis for affective perspective-taking. The neural pathways and processes that underlie empathy in its various forms are made the target of hypothesis formulation that is acknowledged to be speculative. To their credit, the authors arrive at a level of engagement that conceptualized a vicarious experience of another individual’s emotions. The distinction between a vicarious experience and an original one loomed large in the phenomenological account of Max Scheler; and was independently developed in the psychoanalysis of Heinz Kohut (as accounted by David Termin in his article). However, while the neurology of mirror neurons is now well established and fMRI research – the editor, Jean Decty’s specialty – has succeed in identifying diverse neural correlates of consciousness (NCCs), such speculation has its risks. The history of neurology and physiology had early giants of the science such as Gustav Fechner, Johann Herbart, Theodor Meynert, and Moritz Benedikt describing elaborate brain functionality only to have it subsequently revealed to be “Gehirn Mythologie” – brain mythology. They made up an engaging narrative that failed to map to subsequent discoveries. This reviewer cannot help but feel we are getting some of that here only with updated brain slices.

Amrisha Vaish and Felix Warneken present findings that empathy-related, prosocial responses are already functional in early infant development. Surprisingly, the self-other distinction turns out not to be as fundamental as everyone had hypothesized. The correlation between autonomy and self-reliance with empathy does not hold up in South Asian cultures such as India with relational socialization goals and a tighter sense of community where jointly experiencing the other person’s distress is critical path to the emergence of empathic responding. Empathy works very well in cultures that are less individualistic and more commited to consensus and community.

Nancy Eisenberg, Snjezana Huerta, and Alison Edwards explore children who score well in empathy, sympathy or both, and tend to be socially competent and well liked by peers including high quality friendships. Especially significant is that such socially competent – empathic – individuals defend peers from bullies. This work deserves to receive wider circulation.

Jean Decety and Kalina Michalska focus on the neurological development of emotional regulation. As the child grows up, she sees a shift in empathic processing from bottom up regulation of affects to down reappraisal processing in which the perceiver’s motivations, intentions, and attitudes influence the empathic experience. Decety builds on his earlier work that provided evidence that the same neural circuits activated in the experience of physical pain are also involved in the perception or even the imagination of another individual in pain. We are all already connected and at a neurological level, albeit by action at a distance using a perception action mechanism. This is flatly and refreshingly contrary to philosophical thought experiments in which we need to be connected by imaginary radio transmitters in order to have a vicarious experience of another’s pain. Also promising is the search for mechanisms underlying empathy dysfunctions in children displaying conduct disorders and disruptive behavior disorders. Still, notwithstanding detailed fMRI studies, the research is incomplete and is being guided by lesion studies and gross accounts of major neurological malfunctions.

Abigail Marsh confesses that intact functioning of neural structure is a necessary condition for empathy, but it is certainly not sufficient. Provocatively, the author cites evidence of the role of dynamic social behaviors such as eye gaze in responding to fearful facial expressions. Redirecting attention to distress cues around the eyes may be an effective means of social engagement in individuals with psychopathic traits. Insert here the narrative about the amygdal’s role in fear recognition. Connecting the dots between the two is a work in progress, but a promising one.

Precisely along those lines, Jamil Zaki and Kevin Ochsner propose to align two systems that coincidently correspond to the two major competing models of simulation theory and theory of mind. The shared representation system (SRS) enables vicariously experiencing or sharing experiences of another. The mental state attribution (MSA) system enables mentalizing and a theory of mind. Thus, empathy fragments into two forms of computations – experience sharing and mental state attribution. In autism spectrum disorders, failures in responding to social cues – failure to initiative or appreciate subtle micro-expressions of the face – correspond to the misfiring in the first (SRS) system; whereas misfirings in the second correlate with failures accurately to ascribe complex mental states to others using the second system (MSA).

Jodi Halpern mounts a sustained questioning of the traditional medical model that advocates empathy with the patient as “detached concern,” acknowledging the emotion of the other individual without experiencing it oneself. How one can access the other’s experience without experiencing it is left unclarified by the advocates of detached concern. In the background is the fundamental given that human beings are naturally empathic and will, as a matter of course, empathize with our fellow creatures unless trained not to do so. Always the diplomat working within the system, Halpern does not wax polemical (as this review is about to do), there are ample publications in her bibliography citing the fact that medical students score less empathic when surveyed in their 4th year than their 2nd year of medical school. Whatever the explicit curriculum, students are in fact being trained to inhibit their empathy. Her proposed new model for clinical empathy is careful to distinguish that empathy requires having a trace affect of the other’s experience without merging or over-identifying with the other. Empathy requires a trial, partial identification that delivers a sample of the other individual’s experience without over-identifying with her. Though Halpern does not fully connect the dots and leaves it a provocative and open question, numerous articles are cited that assert that getting empathy right actually reduces rather than aggravates burn out (“compassion fatigue”).

Ezequiel Gleichgerecht and Jean Decety document the “down regulation” of empathy” that comes with expertise in medical settings. There is nothing wrong with that, since the alternative is over-stimulating negative emotional arousal; yet there is something missing. The authors document that empathy suffers erosion during medical school. Yes, unfortunately it does. Doctors are in survival mode from the hectic reality of clinics, overly demanding and unappreciative patients, lack of tort (malpractice) reform, expanding regulatory guidelines and generally not being omniscient. In short, what is missing is expanded empathy.

Charles Figley develops a flow chart of compassion stress/fatigue. Variables that help to eliminate or reduce compassion fatigue include limiting exposure to vicarious trauma; being assertive to supervisors; venting with colleagues, regular supervision and coaching, socializing, effective self-soothing and stress management methods. The recommendation? Training in resilience. Unfortunately, Dr. Figley may have been stressed when preparing the manuscript since he makes three typos in two sentences (p. 264). He misspells the German word for empathy (should be: “Einfuehlung”); misspells the name of Theodor Lipps, who was responsible for popularizing the term in Germany; and misspells the name of the Cornell University psychologist who coined the term “empathy” in English, Edward Bradford Titchner. Other than not including an article by me, this is the low point of the text of an otherwise admirable collection.

The honors for the most empathic (and felicitous) turn of phrase goes to Johanna Shapiro who speaks of the “vicarious voice of the physician.” As the patient gets drowned in the complexities of medical technology or is in the process of succumbing to her or his illness, the patient ends up on the periphery of the medical chart and the physician must become the patient’s vicarious voice. In the most polemical quotation in the book Shapiro cites Coulehan and Williams o the effect that the emperor has no clothes: “North American medical education favors an explicit commitment to traditional values of empathy, compassion, and altruism – and a tacit commitment to an ethic of detachment, self-interest and objectivity” (p. 276). Shapiro makes the point that medical students, as well rounded human beings, have natural human impulses towards identifying with others. Students are naturally empathic unless these impulses are “stifled and repressed in the existing medical culture” (p. 281). Shapiro herself becomes a voice crying in the wilderness of the reductive positivism of the sciences of evidence-based everything. Still, her voice and article are an individual expression of truth to the powers-that-be; nor is the ability of an individual to make a difference to be underestimated.

Prior to the discovery of mirror neuron in the mid-1990s and the work of Johann Gottfried Herder in the later 1790s, the individual most responsible for stimulating interest in empathy was the psychoanalyst Heinz Kohut (1959, 1971, 1977, 1984). Kohut argued that empathy was a method of data gathering targeting the emotional life of other human beings, which Kohut characterized as “vicarious introspection”. We do not have direct access to the first person experience of the other; but sustained listening with empathy can provide a powerful, vicarious access to the inner life of the other. As such, empathy became the foundation for a psychology of the self, which, arguably, stood Freud’s classic drive theory of its head. When the self fragments in an unempathic environment lacking human responses to the individual’s humanity, the result is classic Freudian body parts – breasts and penises (or envy of them) and oral and anal sphincters. Hence, neurosis or worse. psychosis. The author of the last article, David Termin, lines up Kohut’s work on empathy with Decety’s functional architecture of empathy (including three key distinctions between self and other, shared (vicarious) representations, and emotional regulation) in a way that validates the work of Kohut and self psychology. The neurophysiology Decety has work so hard to validate maps to psychoanalysis in detail. In turn, the clinical experiences of psychoanalysis enrich social neuroscience (as Decety sometimes calls his interdisciplinary work) that are critical path in regulating affect, doing and undoing symptomatic behavior, and transforming rigid personality defenses into humor, wisdom, and expanded empathy for others. Getting in the last word, Termin makes the case for the advantages psychoanalysis enjoys over neuroscience in moving beyond the isolated mind and in generating a field of empathic data that is of another (“higher”) order of complexity. Strong agreement on this point. David Termin was a student and eventual colleague of Heinz Kohut and subsequently the Director of the Chicago Institute for Psychoanalysis. He has separately made significant contributions to integrating self psychology with an expanded version of the classic approaches to psychoanalysis and (for example) whether there is a separate or unified developmental trajectory for the Oedipus complex. It is a scandal – whether major or minor depends on who you talk to – that Kohut made significant use of Termin’s work without proper attribution. Homer nods? Still, it is good to see the tail wagging the dog, and psychoanalysis reaching for the credit it deserves. The question left unaddressed here – perhaps because there is no answer – is what happened to psychoanalysis since the early 1980s when self psychology and its program of empathy had traction, psychoanalysts headed every major department of psychiatry and today’s shrinking prospects. True in 1992 Peter Kramer published Listening to Prozac, knocking the legs out from under many forms of talk therapy (with psychoanalysis being the “jewel in the crown”). What happened? Today the offices at the Institutes are quiet, the waiting rooms nearly empty, and the couches cold. Candidates applying for analytic training are few and far between (lucky to get five prospects a year per program); and those that do apply, far from being welcomed empathically (and with apologies to Melanie Klein), are treated to a dose of the paranoid position in such a way as to pathologize their professional uncertainties and ambivalences. Department heads at major teaching departments of medicine (psychiatry) are psycho-pharmacologists or would-be clinical psychology specialists in cognitive behavioral therapy (CBT). Nothing wrong with CBT but research by David Orlinski (separately documented) indicates that CBT works best only in so far as it employs psychoanalytic empathy in the background. As the market for Talk Therapy in its many forms continues to fail to flourish, and notwithstanding occasional spikes in a long downward cycle, those psychoanalysts still using the couch (between cynically writing prescriptions for SSRI’s when they are MDs) seem to cling ever more tightly to the small piece of turf that they still control, generating barriers to entry to younger would-be colleagues and competitors in an anti-empathic death spiral of the market. Not exactly what is needed to promote the natural unfolding of empathy. That question of what happened between then and now, however, has no easy response and is left for another day.

(c) Lou Agosta, Ph.D.

Categories: Empathy, empathy consulting, fMRI, Jean Decety book review, Neurology

Tags: Empathy, fMRI, Jean Decety book review, Neurology