Sunday, November 28, 2021

Is Empathy Therapeutic?

Something about the current rage for empathy keeps coming up stupid. It becomes even worse when medical professionals try their hand at a bit of psycho theorizing. Such is the case with Dr. Richard Friedman who tries to address the problem of patients who believe that they can only be treated by someone who has felt their pain.

Nowhere in the annals of medicine, as Dr. Friedman knows well, has anyone ever suggested that a physician cannot treat cancer if he has never had cancer. The same applies to setting a broken bone. Do you, sitting in pain in the ER, want a physician who has broken a bone or a physician who knows how to set a broken bone?

Somehow or other psychiatry has been reduced to this kind of mental drool. It is no longer about how best to treat a mental illness. The issue now concerns whether your lived experience correlates with that of your patient.

One understands that this all began as a marketing campaign for female therapists. At a time, several decades ago, as more and more women were entering the mental health field, they started explaining that no male therapist or even psychiatrist could ever understand how it felt to be a woman. Ergo, women should exchange their male therapists for female therapists and bask in the warm glow of empathy. They could have the soul rousing experience of hearing a therapist echo the immortal words of Bill Clinton: “I feel your pain.” 

If this makes anyone feel better, good for them. And yet, nowadays the mental health profession is more likely to veer toward cognitive treatments than touchy-feely psycho-silliness. After all, in Great Britain, the National Health Service will not longer pay for any treatment that is not cognitive or behavioral. They do not much care whether therapists feel their patients’ pain. They are more concerned with what works.

In America that does not seem to be the case. It’s empathy uber alles. Patients are insisting that they can only relate to someone who has the same life experience. Might this not be a flagrant manifestation of a culture of narcissism? While therapists are wringing their crying towels about how much narcissism is out there, they might consider the off chance that they are manufacturing it.

So, Dr. Friedman shares an experience:

I’ve received many phone calls in recent years from patients in the outpatient clinic where I supervise residents in psychiatry, all asking to change therapists. One gay man in his 30s told me that, although his new female therapist seemed okay, he’d be more comfortable being treated by another gay man. An elderly White woman with depression who had recently lost her husband said there was no way her 20-something resident therapist had enough life experience to understand her.

This assumes, dare we mention it, that therapy is about understanding someone’s life experience. How about solving someone’s problems? Isn’t treatment more about solving problems, setting one’s life on track, learning how to function as an adult in the world? So what if your therapist has never menstruated? Do you really think that this makes him (or her) unqualified to help you with that difficult managerial decision?

Apparently, Dr. Friedman has been struggling with this issue. He treats people who are severely depressed, and yet, would you believe it, he has never been seriously depressed himself. Does this mean that he should immediately retire and send all his patients to therapists who have been severely depressed. Will they feel better knowing that their therapist has suffered the same condition?

Beneath her question is a larger one: How well can we understand people whose life experiences — or identities — are vastly different from our own?

As a clinician, I’ve struggled with this dilemma for years. I’m an expert in treating severe treatment-resistant depression. What do I know about depression? On a personal level, nothing. I’ve never been clinically depressed, and I’m a relentlessly cheerful optimist.

And yet, somehow or other the good doctor feels the right feelings. Of course, he just told us that he is relentlessly cheerful, so one wonders how deeply he can feel despair. Besides, if his patients feel that nothing can be done and he feels their feelings, doesn’t that mean that he will feel that there is nothing that can be done. If he thinks that something can be done, does that mean that he is denying their life experience.

As I have occasionally noted, using empathy as a guidepost tends to make people less than intelligent:

But my lack of shared experience has never stopped me from bonding with or helping my patients. That’s because I don’t need to experience suicidal thoughts or feelings myself to recognize how disturbing, and dangerous, they are to my patients. Psychiatric training teaches that empathy — the ability to imagine the mind of others — is critical to being an effective therapist. Empathy is really theory of mind in action: It allows us to understand people whose life experiences are very different from our own, which is probably most of our patients, and most people out in the world.

If empathy is shared hopelessness, then it is surely not a useful arrow in the psychiatrist’s quiver. He would do better to examine his patient’s situation objectively and draw up a plan of action for dealing with it. Isn’t that what cognitive treatment offers. Strange to see that a senior New York psychiatrists acts as though cognitive treatment does not exist.

And, let us not forget that empathy does serve a useful purpose-- in mothers of infants. As Dutch researcher Elseline Hoekzema has discovered through the brain scans of pregnant women, pregnancy causes their empathy circuits to expand. After all, when you are dealing with an infant you do better to be able to read variations in mood. By definition, infants cannot tell their mothers what they need or want.

This tells us that the best way to enhance your capacity for empathy is to get pregnant. If you cannot get pregnant, you are out of luck.

The other slightly surprising conclusion I would draw is quite simple. If a therapist is treating his patient with empathy he is effectively babying and infantilizing him. 

Dare we say that the current psycho wisdom about empathy has very little to do with empathy. Friedman says that you can enhance your capacity for empathy by considering both sides of an argument. That is, if you put together reasons why someone might believe something that you do not believe. Obviously, this has nothing to do with empathy. It has to do be with being liberal minded and even rational, as the old saying goes:

Here’s an exercise that might boost your empathy: Listen carefully to someone you want to communicate with better, and choose something they said or did that you don’t like or agree with. Now imagine at least two reasons why they might have said or done that thing. Then ask the person to tell you about their experience — and don’t react emotionally to what they say. This is about opening your mind to someone else’s and learning all that you can. Get the data and withhold what you think and feel for later. Now, can you imagine why this person thinks or behaves as they do?

Not only that, but the exercise resembles a practice that was coined by cognitive therapists decades ago. When facing a negative self-deprecating thought, Aaron Beck recommended that patients do home work exercises where they write down any evidence that would affirm the self-deprecating thought and any evidence that would refute it. This is certainly a useful mental exercise. It has nothing whatever to do with empathy.

Apparently, different people from different backgrounds have different experiences. Our multicultural world tells us that this must be true. And yet, should we seek to emphasize differences or should we try to find common ground. In our multicultural mania we assume that people have different experiences and that these experiences, and most especially the pain that attends to belonging to a victim group, are the most valid part of their psyches.

Just as psychiatrists don’t need to share personal experiences to be able to help their patients, many of us could better understand others, including those from other backgrounds, if we put some effort into it.

And then, do we really want to validate violent traumas. We recall that Helen Epstein wrote a book called Children of the Holocaust.  Therein she described the recovery process of two different groups of holocaust survivors in Montreal. She discovered that the group that tried to forget about what had happened had done much better in life than the group that clung to the experience and let it define who they were. 

Encouraging patients to share their pain, to allow their pain to define them and to pretend to belong to the same victim cult does not seem to be therapeutic.

Some life experiences, such as violent traumas, can make it understandably hard to open our minds to others who are different — and of course we would not want to retraumatize a victim by insisting that they do. But there are many situations in which people would do well to consider the potential benefits of connecting with someone outside their particular group.

So, Friedman does not seem to understand that empathy is an emotional reaction. The word itself derives from a Greek root that means-- feeling with. To say that pathos does not involve emotion shows a poor grasp of the concept:

Empathy offers a pass out of our seemingly intractable conflicts; consider, say, your friend who refuses to get vaccinated against the coronavirus. Unlike sympathy, which is feeling pity or sorrow for another’s misfortune, empathy doesn’t require an emotional response. Nor does it mean that you have to agree with or even like the person you were trying to communicate with. You just have to be open and curious enough to get a sense of another’s mind. Note that empathy can even be abused: Some people can use empathy to exploit grievances or weaponize anger in others.

Then again, what does he mean when he says that most people want to be understood. Do they want their pain to be validated? Do they want their pain to define them? Do they feel better when they discover a therapist who shares their pain?

Or does understanding require that they deal with clinicians who do not believe that trauma defines them and who are more concerned with helping them to get over whatever they need to get over and less concerned with affirming their status as victims.


Anonymous said...

There is always the fact that the patient must feel that the therapist can relate (at least somewhat) to their thoughts and circumstances. The bond of trust must be more than just, "Well I'm trained for this". I've been profoundly uncomfortable discussing certain issues with an older female therapist. I'm sure she's good at what she does and has heard it all before, but there is a certain level of intimacy involved in discussing some things, and if you are a younger male, and the doctor is older and female, some things just never get said.
So, some level of congruency must exist.
(An issue the V.A. never wants to acknowledge)

markedup2 said...

I'm not going to read the original, but based on your excerpts, it seems that Freidman is mixing feeling and reasoning together. One can certainly imagine circumstances that cause someone else to act or believe in a certain way. That has nothing to do with how one feels.

I can _understand_ why a woman goes back to the man who beats her. She needs to get out of that situation. Feeling her pain, confusion, and fear doesn't change anything, one way or the other.

You point this out, then let it slip away. Freidman misusing the word "empathy" seems to the root of the problem with his stance.

Making a list of reasons is also a waste of time. The boundary between a "reason" and a "justification" is very difficult discern, especially from the inside. The point of two lists is generally to compare them. Ask any alcoholic for a reason to have a drink. We can rattle them off by the dozen for any given circumstance. There is only one reason not to: It leads down a nasty slippery slope. Comparing those two lists, the alcoholic should have the drink.

What a stupid therapy technique - especially for someone who is depressed and has a litany of reasons why that is so. No one in therapy is going to say, "I have no reasons, just justifications and excuses." If one knows that, one does not need therapy.

IamDevo said...

Let us extrapolate from psychiatry/psychology to, say, cardiac surgery. So the next time you have a heart attack, seek out a surgeon who has had a heart attack so he can empathize with you as he cracks your chest. Guaranteed he'll do much better than the surgeon who has cracked a thousand chests and knows the insides of the heart and its attendant vessels like he knows the back of his hand, but exhibits a detached, professional demeanor. Any takers?

markedup2 said...

I don't have enough information to decide: Which surgeon is the oppressed minority?