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​By Firas A. Nakshabandi, M.D.

Humanity is nearing a crossroads. The world is becoming increasingly hyperconnected. Information and people traverse incredible distances at amazing speeds with seemingly fewer boundaries as time moves forward. But the accelerated pace of this movement has spawned a counter movement. Emerging and re-emerging like the tide through it all are a number of antipodal ideas: nationalism vs. globalism. Introspection vs. extrospection. “me” vs. “we”. Lines are being drawn with varying degrees of inclusiveness, with the result being that humans are being grouped and categorized by themselves and by other humans. 

In a sense the fact that humans are being categorized is not surprising. After all, the human brain may be viewed as a “pattern recognition machine”. This is in fact how we learn, and by extension how we adapt to survive. The brain does however have a tendency towards being what has been termed a “cognitive miser”. That is to say, the brain tries to conserve its energy by conserving “processing power” using heuristics (i.e. taking “mental shortcuts”). Unfortunately, an increase in processing speed is usually error prone: while speed is gained, accuracy is lost. This is one theory as to how bias is generated.  Bias can be defined as an inclination to hold a partial perspective on a matter without consideration of an alternative point of view. In this sense bias may be viewed as the opposite of empathy. 

Interestingly, the term “cognitive distortions” used by cognitive behavioral therapists may be viewed as describing what are essentially either different kinds of biases or precursors to biases, as they interfere with one’s ability to hold a neutral point of view and result in “errors in judgment”. In this context, this bias is affected by both behavior and emotions. The cognitive distortions categorized as “jumping to conclusions” may be viewed as examples of how an attempt at heuristics may result in errors. It is worth specifically examining the cognitive distortion termed “mind reading” as it may relate to empathy, as this is an example of a failed attempt at inferring another’s emotions, thoughts or intentions from the other’s observed behavior or perceived emotions. Another term worth examining is the “hot-cold empathy gap”, which has been given to the tendency of people to underestimate their own attitudes or behaviors under the influence of “visceral drives”. Visceral drives here refer to things such as hunger, thirst, pain or strong emotions. This “empathy gap” has been used in studies into the cause of things like bullying and addiction, and posits that human understanding is “state-dependent”.  In this context, visceral drives put people in a “hot” state, the opposite of which is a “cold” state. 

 “Defense mechanisms” described by analysts may also be viewed as processes that results in bias. While the primary goal is to protect the ego from anxiety, this is achieved through different methods of “screening out” information, even if this does happen on a subconscious level. The result interferes with the ability to hold a neutral point of view, or one that aligns with reality. 

The idea of bias is of interest because it directly relates to concepts such as prejudice and stereotypes when expanding this conversation to groups of people and how they interact (i.e. group dynamics). In the wake of the atrocities committed during World War II, scientists became urgently invested in identifying the drives for such behavior. The infamous Milgram experiment on obedience to authority figures is perhaps the most well-known of these endeavors to understand those drives. But in addressing the question of conflict between groups social psychologists have come up with a number of different theories, including realistic conflict theory, social identity theory, social dominance theory and self-categorization theory.  

Realistic conflict theory posits that when two groups seek the same limited resource, this results in conflict, negative stereotypes and discrimination. On the other hand, it also posits stereotypes and conflict can be reduced in situations where groups seek to obtain a “superordinate goal”, that is, a mutually desirable goal that can only be obtained by the participation of both groups. Politicians and leaders have for centuries utilized this superordinate goal to consolidate power and strengthen the bonds within their own group by labeling an “out-group” as an enemy, with the superordinate goal being the defeat of this enemy. 

In stark contrast, social identity theory posits that conflict can arise simply by the act of categorizing oneself as belonging to one group while categorizing another as belonging to another group. The focus here is mostly on social identity as opposed to resources.

But how does any of this answer the question of how humans can go to such extremes as to rape, kill and torture millions of their own fellow humans? It seems reasonable to assume a process of group differentiation must take place prior to this. In the process of identifying “us” vs. “them”, a pattern of extreme categorization starts to develop: “good” vs. “evil” or even “human” vs “demon”. By dehumanizing the “other” and removing any sense of affiliation or belonging to the same group the way is paved for atrocities, and this transformation is produced through the suspension of empathy. 

The word empathy in the English language has been used to describe several related but likely separate phenomena. Different psychologists and neuroscientists have come up with different subdivisions, but at least two are worth considering here: cognitive empathy and affective empathy. 

Cognitive empathy describes the ability to “put oneself in someone else’s shoes”, and has been referenced when discussing “Theory of Mind”, as well as “mentalizing”. Affective empathy describes the ability to “be affected by another person’s emotions”, ideally with an appropriate emotional response. The term emotional contagion is used to describe this phenomenon, with mirror neurons being implicated. 

A study by Simon G et al suggested there were in fact two separate neuroanatomical systems responsible for each phenomenon; they found “Brodmann area 44 to be critical for emotional empathy while areas 11 and 10 were found necessary for cognitive empathy” 

This subdivision is also important when observing different psychiatric disorders. Atypical empathic responses have been observed in autism, various personality disorders, schizophrenia and bipolar disorders to name a few. During a manic episode one might observe a decrease in cognitive empathy but an increase in affective empathy. In antisocial personality disorder, cognitive empathy may be intact and in fact employed manipulatively to further the afflicted person’s own goal, with a lack of emotional empathy likely contributing to a lack of remorse. 

When discussing empathy, the hormone oxytocin will invariably come up. This hormone is secreted during activities such as breast feeding and hugging, and is crucial in establishing a feeling of connectedness. The importance of skin to skin contact and a sense of security in early childhood development has been well established and is essential for both physical and mental health. While it may be attractive to think of oxytocin as a “Love Hormone” that holds the key to empathy, studies have shown mixed results when examining the administration of oxytocin as an intervention. Interestingly, while oxytocin is viewed as being important for pair bonding in females, in males it appears the structurally-similar hormone vasopressin may be more important.  

There has been an explosion of research on empathy across multiple disciplines, yet it appears to be scarcely mentioned in the field of psychiatry. My personal opinion as a psychiatrist is that our training has been severely lacking in exposure to the concept of empathy, not only as an academic focus but also practically within the training programs themselves. My emerging interest in the effects of stress on empathy and bias was born while navigating the demands of being a physician on call who had to manage not only the stress of patients but often also that of the staff and of the administration. A practical lack of empathy within training programs is frequently and ironically a complaint of many a psychiatry resident during their intense years of training. The expectation is to be fully present and engaged in addressing a patient’s needs, while also addressing the needs of staff in the emergency units or on the inpatient units. Virtually no one is interested in the amount of stress placed on the resident or how this might affect his ability to care for a patient, again mostly due to a failure of empathy. 

What starts to materialize from all that has been discussed, however, is that at the core of these experiences and the aforementioned theories across multiple disciplines, three “elemental”, continuously interacting concepts emerge: stress, bias and empathy. This realization has led me to formulate what I have termed the “empathy-distress cycle”.

To put it simply, a vicious cycle is born out of stress, which both inhibits empathy and promotes bias, this leads to an increase in errors, resulting in more conflict and more stress.  I use the term empathy-distress to emphasize a need to “rescue” empathy in order to break this cycle. This may at first glance seem like an oversimplification, especially since there are times when an increase in empathy might potentially lead to more stress as well. Specifically, too much empathic concern for others can be distressing to the point where if not appropriately managed the result may be an urge to protect or defend a person we feel empathic towards by violating the rights of the perceived offending third party who has wronged the target of our empathy. The conflict in the Middle East is a prime example of how the perception of one group being wronged can trigger a member of another group to feel the need to act, even if the member of the group is not directly affected; it is enough that the member has identified himself as belonging to one group or the other. However, if we apply what we have learned so far about groups it is obvious the problem here again remains the categorization of “us” vs. “them”. This is why in the strongest sense I argue that empathy must be expanded to include all of humanity, and not just the selective groups we identify with in the moment of the perceived stress. 

To further break down this relationship and in light of what we have reviewed so far I would like to posit that most humans are constantly swinging between two extremes on a continuum. On the one hand (and I would like to think at “baseline”) most humans are empathic creatures, in a state driven by the “mammalian” brain, oxytocin, the prefrontal cortex and the parasympathetic system, most humans are able to engage in both cognitive as well as affective empathy. Prosocial and altruistic behavior dominates here. 

On the other extreme, when there is a real or perceived “stressor”, there is a shift towards a state that is primarily concerned with self-preservation in the moment. A “reptilian” brain, amygdala, HPA axis and sympathetic nervous system driven state concerned only with the self takes over. It should come as no surprise that in this state of “fight or flight” the brain shifts to a stance that calls for a need for instant categorization: “friend or foe”? Bias is maximized and errors are frequent, but the errors tend to occur in favor of survival of the individual, and an over classification of others as “enemy or threat” can occur. This biased state is again the polar opposite of an empathic state, where the primary concern in the extreme shrinks down to the individual being the sole member of his group. 

I would like to posit that perhaps in between these extremes the “circle of trust” or circle of inclusiveness of the in-group shrinks proportionally to the amount of perceived stress. This can again be seen in conflicts such as civil wars where two members of separate religious groups may have been happily married prior to a conflict, but once war breaks out the members are forced into alignment with the groups in conflict.  The “national” grouping here is dissolved, and alignment shrinks to include members of one religious affiliation or another. 

The need to decrease stress will not be over emphasized here as it has been rigorously studied. The effects of stress on both mental and physical health on developing children has been well established in the “Adverse Child Event (ACE) Study”. Chronic stress has been theorized to cause mental illness through a variety of mechanisms including its effects on inflammation and delta wave sleep. Interestingly, it appears that oxytocin also decreases inflammation. 

The need for meaningful human relationships has also been firmly established in the longest study on happiness ever undertaken: The Grant study of adult development. Empathy is the gateway to reaching these relationships. Early childhood trauma has also been well established in affecting the ability to empathize. When employing empathy to imagine the schema of abused or neglected children, it is not very difficult to see why said children would be primarily focused on their own wellbeing as opposed to that of those around them. They would have learned early on that the world is a dangerous place, and have little capacity to self soothe. 

Lastly, empathy is also the gateway to altruism. There is an abundance of research into the positive effects of altruism in alleviating mental suffering, including depression, anxiety and somatization.  

In conclusion, stress both promotes bias and inhibits empathy. While this relationship may seem easy enough to appreciate superficially, the challenge is being consistently mindful of it to the point where this knowledge is practically useful in everyday life. A deeper understanding of this relationship and why it is practically helpful could be taught to children at school, or in short courses or workshops to adults across various disciplines. Exercises in mindfulness, role-playing and how to consistently re-examine our own biases would need to be a focus. Skills could be taught from an early age by parental modeling as well.

Increased inter-group contact and co-dependence as well as open communication has applications extending from the classroom to international relations, and a shift to a more universally inclusive view of humans as all belonging to the same group regardless of the nationalities and religions they are born into with no say in the matter is paramount.

This understanding is crucial to what it is to be human. The implications extend from our individual everyday interactions to global politics and how we relate to each other as a species. Hopefully this undertaking may play a role in preparing the next generation on how to better handle any real or perceived stresses presenting a challenge to our beautifully diverse human race.

On Empathy, Stress, Bias & Humanity:
The Empathy-Distress Cycle