Paul Bloom, in his recent book called Against Empathy, challenges us to question the role of empathy as a vital ingredient of goodness or morality. Bloom believes that kindness, guided by thoughtfulness, is the supreme guide to morality, while empathy is often morally neutral or even negative.
Bloom's definition of Empathy
By "empathy," Bloom is specifically referring to the phenomenon of experiencing and feeling what another person is experiencing and feeling. Many of us define empathy more broadly, so as to imply kind consideration for others' distress, a willingness to help, and an intellectual understanding of another person's problems. Even some of the researchers who study empathy are imprecise in their definition, leading them to include items about kindness or willingness to help on a symptom scale supposedly intended to measure empathy.
Bloom clearly is not talking about "understanding." He affirms that it is clearly and obviously important to strive towards understanding of another person's problems or situation, in order to be able to best act morally and helpfully. A variant of empathy, which we could call "cognitive empathy," refers to understanding, but not feeling, another person's emotional state. Bloom affirms that this cognitive empathy is important and positive as a social skill, but is not necessarily a guarantee of moral behaviour. With Bloom's specific, narrower definition of empathy (to feel what another person is feeling), he shows us the following:
Problems with Empathy
1) Empathy does not correlate with kindness. Many people who behave cruelly have a lot of empathy for their victims. In fact, sometimes the empathy for the victim causes a sadistic person to magnify their cruelty. A good fictional example is the character of O'Brien (the "Big Brother" agent) from Orwell's 1984, whose emotional and cognitive empathy guided him to personalize and maximize his torment of the main character.
Conversely, some people who behave with the most astounding kindness and altruism are not guided or motivated by empathy at all. People who perform daring rescues often do not empathize before they act. Having an empathic reaction in an emergency could delay a life-saving action.
One example is described of a person who chose to give his kidney to a stranger for a transplant, guided by a cooly mathematical observation of the needlessness of having two kidneys for health, while many people would face death without a single kidney. People, including young children, are usually motivated to do kind things not because of empathy, but because of a wish to be kind or helpful!
Empathy can actually deter people from behaving kindly, or from even being around suffering people, because the experience of feeling another's suffering is painful and aversive. A caregiver who is highly, reflexively empathic is at greater risk of burnout. Whole groups of people, such as those who identify as having autistic symptoms, may have much less "empathy" than average, but they are not at higher risk of causing anyone harm. Violent offenders do not necessarily have "low empathy"-- the psychological factors associated with violent behaviour have much more to do with low self-control than low empathy.
2) Empathy as a moral guide can cause us to behave in a biased or unfair manner. If we use only empathy to guide us to help a particular suffering person, it can guide us to help that person before helping someone else who needs the help more urgently. Furthermore, we empathize more easily with people who are more similar to ourselves, and who live closer. This may cause us to preferentially help others based on unjust factors (including age, race, ethnicity, etc.). It is easier to empathize with a suffering animal we find "cute" compared to a suffering animal (who may be in even greater need) who is less photogenic.
Bloom rightly critiques the tendency for empathy to be admired as a type of stellar quality, for all of us to emulate in a quest to become better people, better therapists, or better societies. He instead encourages us to strive towards kindness and understanding, with our actions guided by reason rather than the narrow, biased focus of emotional empathy alone. This view is supported by those considered some of the world's greatest altruists, such as the Dalai Lama--in this tradition, it is calm compassion, free of anger, which is felt to be the best guide for moral action, rather than the emotion-swept milieu generated by empathy.
My Thoughts
I see Bloom's thesis as an extension of Kahneman's insights about psychological biases. Our biases and emotional responses are an intrinsic part of being human, but they easily become experiences which fool us, and cause us to behave irrationally.
Empathy, in my opinion, is a quality similar to eyesight or one of the other senses: it does not, in itself, have a moral quality. It can have a narrow focus, which makes it prone to bias, and it can be easily fooled by illusions. Having highly developed empathy does not make you more moral any more than does having sharp eyesight. If you believe strongly that your sharp eyesight allows you to understand things better, you may be very prone to others taking advantage of your belief, and you may be very prone to being fooled by optical illusions. This does not mean we should not cultivate our senses, including eyesight or empathy. They are important talents and skills, and they deserve attention and practice. It is just that we should not rely on them by themselves as moral guides.
Taming Empathy
I do believe that empathy is important, however. It just needs to be "tamed." I can think of many clinical situations in which an empathic moment--even to the point where I might shed a tear--has helped with my patient feeling a sense of connection and trust. A therapist who shows no emotional response to a patient's suffering could be experienced as detached, aloof, and cold. Also, many therapists have a reflexive suppression of their own affect, which is felt to be a part of professionalism, yet which causes an unnecessary and obstructive detachment. A therapist's practice of allowing their own emotions to flow empathically, and to manifest in the session, can be an aspect of fostering connection and demonstrating sensitivity. But if this empathy would lead to the therapist suffering with sadness or panic through the hour, at the same time as the patient, then this clearly would not be helpful! It would probably frighten or disturb the patient, and would also lead to burnout in the therapist. A brief moment of deep empathy can be very therapeutic, but after that point, therapy moves away from pure empathy towards cognitive understanding and gentle problem-solving.
Empathy can also be a joy of life to experience, provided it is not understood to be a moral guide. Empathy can and should be practiced and savoured, just as you would cultivate your other senses--but it should not be granted power as an arbiter of moral decisions.
Empathy for the Therapist!
Bloom makes a nice point that in a good therapeutic environment, sometimes empathy is most beneficial in the opposite direction: if the therapist is gently attuned and understanding, but calm and at peace, then the patient's empathy for the therapist may help the patient to attain calm and peacefulness in the midst of painful emotions.
Empathy could work this way in therapy as an example of social learning therapy combined with CBT: if the patient would see the therapist briefly having a deep empathic moment of "co-suffering," but would then see the therapist gently step back, in a thoughtful, compassionate calm state, this could be an in-the-moment example for the patient to follow...in this way the therapist would truly be an emotional guide. I think this effect should not be overstated, as the therapist's helping role may usually be much more modest and subtle.
The Importance of Listening and Showing Understanding
I believe it is very important to emphasize that we have been talking about Bloom's very focused definition of empathy. I usually use the term empathy in a broader sense. When people are meeting with a therapist or a friend, they often greatly desire to simply be with someone who will listen. Many people do not desire to have advice or reassurance in response to what they are sharing, at least not right away. And they may be frustrated if the other person starts to discuss their own similar problems. It is often very appreciated if the listener at times reflects back what has been said, to convey respectful understanding, of both the situation and the emotions involved. This reflection and demonstrated understanding is what I mean by empathy, most of the time. A typical example could be saying something like, "you had an exhausting day..." When giving this reflection, I would not normally feel exhausted myself! Sometimes a more elaborate or detailed reflection could be good, but sometimes prolonging these responses for more than a brief sentence can interrupt the person's experience of being gently listened to.
Wednesday, February 1, 2017
Tuesday, January 17, 2017
Hallucinogens in mental health
Hallucinogenic drugs such as LSD, psilocybin, and ayahuasca have been used to treat depression and addictions, and to help with the psychological well-being of patients suffering advanced stages of cancer.
Terminally Ill Patients
Jan Hoffman's article, published on December 1, 2016 in The New York Times, describes some of the research supporting the use of psilocybin for treating psychological suffering in cancer patients.*
The most recent major study supporting this was published by Stephen Ross et al. in the December 2016 edition of The Journal of Psychopharmacology. In this study, 29 cancer patients suffering from anxiety and depressive symptoms were given either 0.3 mg/kg of psilocybin, or an active placebo of niacin. They received only one single dose! There were no serious side effects. The psilocybin doses led to large, sustained relief of anxiety and depression symptoms, following an immediate hallucinogenic, mystical effect which lasted about 6-7 hours. Response and remission rates for depression and anxiety symptom scores were significantly larger, compared to placebo, than what we would typically see for most other established therapeutic modalities, such as conventional psychotherapy or antidepressants. And these beneficial effects appeared to persist for up to 8 months.
In another study published in the same edition of this journal, by Griffiths et al., 51 anxious or depressed participants with life-threatening cancer received a low dose (~.01 mg/kg) and a high dose (~0.3 mg/kg) of psilocybin, 5 weeks apart. The authors found that the higher dose led to significant relief of anxiety and depression symptoms (final symptom scores were about 30% of the initial scores), which persisted over 6 months of follow-up. Interestingly, reports outside of the usual depressive symptom score domain also changed in a positive way; for example, there were substantial increases in "positive attitudes about life." A majority of subjects considered the experience with this therapy to have been very meaningful and significant. The amount of symptom improvement was correlated with the intensity of the experience on the dosage day. Once again, there were no severe side effect problems. Blood pressure increases of up to 20 mm Hg could be expected.
Treatment-Resistant Depression
Here is a reference to another study published in the prestigious journal Lancet Psychiatry by Carhart-Harris et al. in July 2016: **** This was an open-label study of 12 people with severe, treatment resistant depression. They received a first dose of 10 mg psilocybin, followed by a second dose of 25 mg one week later. They did not receive any further doses! They were followed after this for 3 months. Remarkably, there was a substantial reduction in depression severity scores which persisted at all follow-up points. 58% of the patients showed a response, and 42% of the patients showed full remission after 3 months.
Microdoses
Others have used so-called "microdoses" of hallucinogens on a more regular basis, typically about 10% of a typical recreational dose every 4 days (e.g. an LSD microdose would be about 10 micrograms). This is too low to produce a dramatic subjective hallucinogenic effect, but anecdotally can lead to a sustained relief of depression. Here is a reference to Alex Williams' January 7, 2017 article in The New York Times describing a case example of this practice: **
Addictions
Hallucinogens have also been used to treat addictions. Here is a reference to a study showing very good long-term abstinence rates (67% after 1 year) in smokers treated with 2-3 doses of psilocybin (0.3 - 0.4 mg/kg) in combination with CBT: ***
In another small study, two doses of psilocybin were given, 4 weeks apart (0.3 mg/kg, then 0.4 mg/kg) to patients with alcohol dependence. ***** The patients were followed for 36 weeks, and had a dramatic, sustained reduction in heavy drinking days (reduction from 40% to about 10-15%).
Conclusion
Hallucinogens remain illegal in most places. The quality and dose of hallucinogens available on the street might be very uncertain.
I have seen people whose experience with these agents appears to have helped them substantially.
But I have also seen people over the years who have used hallucinogens periodically, yet still suffer from a variety of psychological problems, including depression, anxiety, and addictions.
While the studies mentioned above have been very reassuring about toxicity risks and side effect problems, it would of course be very important to understand better any of the possible risks associated with this type of approach. Patients with bipolar or psychotic symptoms might be at particular risk of harm from hallucinogens, though I would be interested to see better evidence of such risks.
If hallucinogens do have a role in treating various types of psychological suffering, I think it is likely that they would have to be used with great care, probably in combination with a very safe, gentle, supportive milieu, and in combination with psychotherapy. Arguably, some aspects of the benefit might be due to a "catalytic" effect when used in a safe, therapeutic setting, or as an augmentation to psychotherapy.
I would be interested to see more carefully conducted, randomized controlled studies of hallucinogens, so we could understand this issue better. I think there is some urgency to get going with these studies, since the preliminary evidence seems so very promising. The most likely dosing schedule for hallucinogens would be very infrequent, which would cause such treatments to be economically very inexpensive. But as a result, we would not be seeing large-scale corporate funding for research into this! Also, parts of the research community may have quite orthodox beliefs about non-standard treatment regimes such as this, which might cause delays in setting up good studies quickly.
Terminally Ill Patients
Jan Hoffman's article, published on December 1, 2016 in The New York Times, describes some of the research supporting the use of psilocybin for treating psychological suffering in cancer patients.*
The most recent major study supporting this was published by Stephen Ross et al. in the December 2016 edition of The Journal of Psychopharmacology. In this study, 29 cancer patients suffering from anxiety and depressive symptoms were given either 0.3 mg/kg of psilocybin, or an active placebo of niacin. They received only one single dose! There were no serious side effects. The psilocybin doses led to large, sustained relief of anxiety and depression symptoms, following an immediate hallucinogenic, mystical effect which lasted about 6-7 hours. Response and remission rates for depression and anxiety symptom scores were significantly larger, compared to placebo, than what we would typically see for most other established therapeutic modalities, such as conventional psychotherapy or antidepressants. And these beneficial effects appeared to persist for up to 8 months.
In another study published in the same edition of this journal, by Griffiths et al., 51 anxious or depressed participants with life-threatening cancer received a low dose (~.01 mg/kg) and a high dose (~0.3 mg/kg) of psilocybin, 5 weeks apart. The authors found that the higher dose led to significant relief of anxiety and depression symptoms (final symptom scores were about 30% of the initial scores), which persisted over 6 months of follow-up. Interestingly, reports outside of the usual depressive symptom score domain also changed in a positive way; for example, there were substantial increases in "positive attitudes about life." A majority of subjects considered the experience with this therapy to have been very meaningful and significant. The amount of symptom improvement was correlated with the intensity of the experience on the dosage day. Once again, there were no severe side effect problems. Blood pressure increases of up to 20 mm Hg could be expected.
Treatment-Resistant Depression
Here is a reference to another study published in the prestigious journal Lancet Psychiatry by Carhart-Harris et al. in July 2016: **** This was an open-label study of 12 people with severe, treatment resistant depression. They received a first dose of 10 mg psilocybin, followed by a second dose of 25 mg one week later. They did not receive any further doses! They were followed after this for 3 months. Remarkably, there was a substantial reduction in depression severity scores which persisted at all follow-up points. 58% of the patients showed a response, and 42% of the patients showed full remission after 3 months.
Microdoses
Others have used so-called "microdoses" of hallucinogens on a more regular basis, typically about 10% of a typical recreational dose every 4 days (e.g. an LSD microdose would be about 10 micrograms). This is too low to produce a dramatic subjective hallucinogenic effect, but anecdotally can lead to a sustained relief of depression. Here is a reference to Alex Williams' January 7, 2017 article in The New York Times describing a case example of this practice: **
Addictions
Hallucinogens have also been used to treat addictions. Here is a reference to a study showing very good long-term abstinence rates (67% after 1 year) in smokers treated with 2-3 doses of psilocybin (0.3 - 0.4 mg/kg) in combination with CBT: ***
In another small study, two doses of psilocybin were given, 4 weeks apart (0.3 mg/kg, then 0.4 mg/kg) to patients with alcohol dependence. ***** The patients were followed for 36 weeks, and had a dramatic, sustained reduction in heavy drinking days (reduction from 40% to about 10-15%).
Conclusion
Hallucinogens remain illegal in most places. The quality and dose of hallucinogens available on the street might be very uncertain.
I have seen people whose experience with these agents appears to have helped them substantially.
But I have also seen people over the years who have used hallucinogens periodically, yet still suffer from a variety of psychological problems, including depression, anxiety, and addictions.
While the studies mentioned above have been very reassuring about toxicity risks and side effect problems, it would of course be very important to understand better any of the possible risks associated with this type of approach. Patients with bipolar or psychotic symptoms might be at particular risk of harm from hallucinogens, though I would be interested to see better evidence of such risks.
If hallucinogens do have a role in treating various types of psychological suffering, I think it is likely that they would have to be used with great care, probably in combination with a very safe, gentle, supportive milieu, and in combination with psychotherapy. Arguably, some aspects of the benefit might be due to a "catalytic" effect when used in a safe, therapeutic setting, or as an augmentation to psychotherapy.
I would be interested to see more carefully conducted, randomized controlled studies of hallucinogens, so we could understand this issue better. I think there is some urgency to get going with these studies, since the preliminary evidence seems so very promising. The most likely dosing schedule for hallucinogens would be very infrequent, which would cause such treatments to be economically very inexpensive. But as a result, we would not be seeing large-scale corporate funding for research into this! Also, parts of the research community may have quite orthodox beliefs about non-standard treatment regimes such as this, which might cause delays in setting up good studies quickly.
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