PSYCHOLOGY OF EMOTIONS, MOTIVATIONS AND ACTIONS

PSYCHOLOGY AND NEUROBIOLOGY

OF EMPATHY

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 PSYCHOLOGY OF EMOTIONS,
MOTIVATIONS AND ACTIONS

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 PSYCHOLOGY OF EMOTIONS, MOTIVATIONS AND ACTIONS

PSYCHOLOGY AND NEUROBIOLOGY

OF EMPATHY

DOUGLAS F. WATT
AND
JAAK PANKSEPP
EDITORS

New York
Copyright © 2016 by Nova Science Publishers, Inc.

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Names: Watt, Douglas F., editor. | Panksepp, Jaak, 1943- editor.
Title: Psychology and neurobiology of empathy / editors, Douglas F. Watt, and
Jaak Panksepp.
Description: Hauppauge, New York : Nova Science Publishers, Inc., [2016] |
Series: Psychology of emotions, motivations and actions | Includes index.
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publisher; resource not viewed.
Identifiers: LCCN 2016004496 (print) | LCCN 2015048144 (ebook) | ISBN
9781634844826 () | ISBN 9781634844468 (hardcover)
Subjects: LCSH: Empathy.
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Published by Nova Science Publishers, Inc. † New York

 CONTENTS

Preface vii
Overviews of Empathy - Neurobiology, Evolution, Psychology 1
Chapter 1 Empathy and the Prosocial Brain: Integrating Cognitive
and Affective Perspectives in Human and Animal Models
of Empathy 3
Douglas F. Watt and Jaak Panksepp
Chapter 2 Evolutionary Origins of Empathy 37
Shigeru Watanabe
Chapter 3 The Positive (and Negative) Psychology of Empathy 63
Sara Konrath and Delphine Grynberg
Empathy Through the Lifecycle 109
Chapter 4 The Development of Empathy in Early Childhood 111
Maria Licata, Amanda Williams and Markus Paulus
Chapter 5 Empathy in Children: Theory and Assessment 149
María Cristina Richaud de Minzi,
Viviana Noemí Lemos and Laura Beatriz Oros
Chapter 6 Empathy in Adolescence: Familial Determinants and Peer
Relationship Outcomes 171
Holly Ruhl and Chong Man Chow
Chapter 7 Gender Roles, Not Anatomical Sex, Predict Social Cognitive
Capacities, Such as Empathy and Perspective-Taking 187
Jennifer Vonk, Patricia Mayhew and Virgil Zeigler-Hill
Chapter 8 Empathy and Aging: Mechanisms of Empathy
Throughout Adulthood 211
Tao Yang and Michael J. Banissy
vi Contents

Empathy in the Helping Professions 227

Chapter 9 Empathy in Medical Education 229
Geon Ho Bahn, Teckyoung Kwon
and Minha Hong
Chapter 10 Empathy: Angel or Devil? How Shared Emotions Can Help
or Hinder Nurses in Their Relationships with Patients 259
Anna Maria Meneghini, Laura Cunico and Riccardo Sartori
Chapter 11 Enhancing Empathy in the Helping Professions 297
Gail Kinman and Louise Grant
Empathy in Clinical Disorders 321
Chapter 12 Empathy Dysfunction: Deconstructing Social Functioning
in Autism Spectrum Disorders and Conduct Disorder 323
Sara Paloma Vilas Sanz, Amanda Ludlow
and Renate Reniers
Chapter 13 One But Not All Doors Closed to Empathy: Impaired Resonance
Induction in Patients with Huntington‘s Disease 349
Iris Trinkler
Chapter 14 Empathy and Mirror-Gazing 377
Giovanni B. Caputo
Chapter 15 Competing Factor Structures for the Toronto
Empathy Questionnaire 399
Carlo Chiorri
Epilogue 433
Chapter 16 Closing Neuroscientific Reflections and Cultural/Philosophical
Implications of Empathy Research 435
Douglas F. Watt and Jaak Panksepp
Editors' Contact Information 445
Index 449
 PREFACE

The scientific study of empathy has exploded in the past decade. Practically all of the
relevant sciences — from various neuroscientific, psychological and sociological perspectives
— are now vigorously participating in the emerging conversations about the nature of this
essential, pro-social process. Empathy is also emerging as a critical topic in medical
education and practice, in terms of its essential relevance for not only the patient – physician
relationship and bed-side practice, but also for diverse psychiatric problems and syndromes
that demonstrate a fundamental disordering of empathy, particularly conduct disorder
/sociopathy and autistic spectrum disorders. Consistent with these multidisciplinary trends
and interests, this volume reflects contributions from many disciplines and summarizes the
impact of diverse empathy studies. It also discusses the perspectives of individuals
participating in the scientific discussion and scholarship about this critical frontier topic.
Contributions in the present volume range from detailed neuroscientific reviews of empathy
concepts and processes, to a diversity of evolutionary and developmental perspectives looking
at empathy in both phylogeny and ontogeny. Likewise, an examination of how helping and
medical disciplines are impacted by such issues are included — a wide ranging and
comprehensive list of topics that are typically not covered elsewhere in a single volume.
In summary, this book covers diverse but related approaches to understanding empathy
from evolutionary, developmental, sociological and clinical viewpoints across the life cycle.
Various contributors from around the world merge scientific and practical viewpoints in depth
to provide readers a comprehensive picture of this emerging field, ranging from basic
scientific knowledge to practical medical perspectives. This book should be a valuable
resource to those interested in the diverse facets of empathy, from advanced students in
psychology and related fields, to educators, to various medical and healthcare professionals. It
may appeal to anyone interested not only in scientific studies of empathy, but also those
curious about how a deeper understanding of empathy might inform and illuminate problems
related to our daily human social interactions and their vicissitudes.
Chapter 1 – Empathy is multidimensional concept with many possible definitions, but in
this review we focus on more affective conceptions of empathy, which require a basic
affective resonance, and we view empathy as a prosocial process essential for the mitigation
of suffering. As an essential part of a pro-social brain, empathy helps promote both the
creation and long-term stability of social bonds, and appears to have emerged in tandem with
the evolution with social bonding and attachment. Although increasingly a focus of intensive
study after decades of neglect, models of empathy emerging from cognitive and affective
viii Douglas F. Watt and Jaak Panksepp

neuroscience still demonstrate a fundamental bifurcation in the division of empathy into

cognitive and affective ‗forms‘ or perhaps cognitive and affective components, but with still
rather limited understanding of the constitutive neural substrates and possible functional and
developmental relationships between these two components, namely how their functional
integration is instantiated in living brains. Although there has been a history of neglect of
affective contagion (‗proto-empathy‘), it presumably appeared well before the more cognitive
and deliberative variants of empathy emerged in evolution, but such capacities for affective
resonance may be essential for sensitive social-learning to emerge. Emotional contagion has
attracted intensive research in recent cross-species studies, allowing substantive causal work
to be undertaken, especially at the instinctual (‗primary-process‘) level. It seems likely that
most ‗real-world‘ social empathy in humans typically reflects variable admixtures of more
primitive affective resonance mechanisms (basic emotional contagion), melded with
developmentally later-arriving theory of mind, emotion understanding/identification and
acquired thoughtful perspective-taking operations, conjoined with affective concern for
others‘ suffering. This suggests that what we call ‗empathy‘ in the real world is a complex
composite of more ancient and more evolved processes. Human empathy, in its more
affective forms, probably requires positive attitudes of stable concern towards related others
(and thus is likely augmented by more primal affective attachments among individuals), along
with capacities for affective regulation (such that the empathizer is not flooded by the
suffering of others, and hence immobilized). Empathy thus involves a stable valuing of other
sentient creatures, suggesting intrinsic ties between empathy and basic attachment processes.
We thus argue that a primal sort of empathic capacity was presumably selected as part and
parcel of the trajectory into a highly social brain in our vertebrate and mammalian phylogeny,
with the importance of social attachments perhaps even augmented further in hominid
evolution.
Chapter 2 – Empathy is an intrinsic emotional response to the emotional expression of
others. Darwin believed that infrahuman animals have a sense of empathy and wrote, ―Many
animals certainly sympathize with each other‘s distress or danger.‖ Empathy for positive
emotions occurs when the positive fortune of others generates similar positive emotions in the
observer, and empathy for negative emotions occurs when observing the distress of others
activates similar distress in the observer. These emotional responses are considered to be
potentially adaptive for the observer, because the good fortune of others may signal positive
fortune for the observer while the misfortune of others may signal danger for the observer.
Empathy for positive emotion results in social facilitation and empathy for negative emotion
can result in rescue or helping behavior that potentially serves to alleviate both the observer‘s
and the subject‘s distress. In both forms of empathy, emotions are generally state-matched
between the demonstrator and the observer. ‗Reversed empathy,‘ or envy, occurs when
distress results from observing the fortune of others. This emotional response may be a
contributing basis for the sense of fairness. Schadenfreude occurs when pleasure is derived
from the misfortune of others. Reversed empathy and Schadenfreude are forms of non-state-
matched empathy, and were previously thought to be unique to humans. However, recent
animal experiments have suggested that non-human animals also exhibit non-state-matched
empathy, pointing to an earlier evolutionary origin of these phenomena. In this chapter,
experimental evidence for the four types of empathy in animals is presented, and the
evolutionary origin and biological function of empathy is discussed.
 Preface ix

Chapter 3 – The current chapter summarizes research on empathy in terms of its benefits
and costs. The majority of research on empathy finds desirable correlates. For example, high
empathy is associated with more prosocial behaviors and stronger relationships with others.
Yet, excessive empathy can also be problematic in a variety of ways. Taken together, the
positives and negatives of empathy can best be understood within an evolutionary framework
in which empathy evolved to address issues of survival and reproduction. Empathy seems to
facilitate caregiving behavior to close others, at the expense of outgroups and society at
larger, and sometimes (but not always), at the expense of the self.
Chapter 4 – Recent research employing a variety of different measures has shed new light
on the developmental origins of empathy. Beyond basic behavioral observations, current
studies also rely on neurophysiological and psychophysiological assessments to examine
empathic reactions and their correlates in young children. In this review, we first examine
classical models of empathy. We then present in greater detail recent findings on empathic
behavior in young children, focusing both on issues such as the neural basis of early empathic
behavior, the role of the parent-child relationship as well as cognitive and social factors in
children‘s empathy development. We conclude our review by reporting training effects on
empathy.
Chapter 5 – Empathy is the ability to perceive, share, and understand the emotional states
of others, and it is crucial to succeeding in society. This social and emotional competence
underlies some of the most significant human interactions from the first bonds between
mother and child all the way to more complex forms of prosocial behavior, all of which may
even be essential for survival. Empathy is critical to social bonds, especially mother and
child. The field of child mental health is especially focused on emotional development.
Therefore, the neuropsychological understanding of attachment and empathy may create a
more accurate and comprehensive model of the normal development of the human body,
brain, and mind in the early stages of development and, consequently, lead to more accurate
definitions of the adaptive basis for mental health of children. Most models of empathy
emphasize that helping behavior is motivated by emotional states activated by the emotional
states of others, a capacity which develops in the context of parental care and other social
bonds. The resulting sense of security that leads children to adopt a more empathic attitude
not only in intimate relationships but also toward others with whom they do not have such
close relationships. Despite the importance of empathy as a basic socioemotional
development process, it has been difficult to develop a theory that integrates its emotional and
cognitive aspects as well as to create adequate operational definitions in order to test theories
more empirically. This challenge is especially evident when trying to assess empathy in
children through self-reports that provide a multidimensional measurement. This chapter will
discuss the different theoretical perspectives of empathy and its manifestation in children and
will introduce a multidimensional empathy questionnaire developed for children between 9
and 12 years of age that is based on models proposed by social cognitive neuroscience. This
questionnaire integrates four aspects of empathy: a) emotional contagion, which is an
affective reaction to another person that typically involves sharing the emotional state of that
person; b) self-consciousness, which protects the boundary between self and other despite a
transient identification with that person; c) perspective taking, which implies the cognitive
ability to put oneself in the place of the other; and d) emotional self-regulation, which occurs
through self-regulatory and control mechanisms that regulate and modulate personal
emotional states.
x Douglas F. Watt and Jaak Panksepp

Chapter 6 – During the past 30 years, research has explored the determinants and
outcomes of empathy in adolescence. In this chapter, we adopt a socialization perspective and
extend the dialogue on adolescent empathy with the hope of highlighting the familial factors
that contribute to the emergence of empathic capability. We also review the body of literature
that establishes a connection between empathy and relational competence and functioning in
adolescent peer relationships. The overarching theoretical model that guides the current
chapter is presented in Figure 1. Taken as a whole, this model shows that specific factors
influence adolescent empathy and social outcomes of empathy in adolescent friendships and
romantic relationships. Specifically, empathy is impacted by familial factors, such as the
intergenerational transmission of empathy, parenting styles, and parent-child relationship
quality. Adolescent empathy leads to social competences, such as intimacy skills, the ability
to manage and resolve conflicts with peers, and prosocial behaviors. In general, these
competences lead to more positive peer relations, including better friendship quality, higher
status within peer networks, and better romantic functioning. In addition to the core model,
we will also discuss the ―dark side‖ of empathy—the potential for empathy to have
deleterious psychological and social outcomes during adolescence. Finally, a summary of the
literature and future directions for research on adolescent empathy are discussed.
Chapter 7 – Sex differences have not been examined thoroughly with regard to cognitive
skills of typically-developed adults in both social and non-social domains. Furthermore,
studies that do examine the effects of anatomical sex rarely simultaneously examine the
possible role of psychological gender role orientation. This gap in the literature exists despite
commonly held notions about possible sex differences in perspective-taking, empathy, and
causal reasoning. We examined the associations between sex, gender roles, and self-esteem,
and aspects of social and non-social cognition (e.g., perspective-taking, empathy, emotional
intelligence, social and physical causal reasoning, systemizing) in two college student
samples. These indicators of social and non-social cognition were more closely associated
with masculine and feminine gender roles than anatomical sex. Undifferentiated individuals
(i.e., those with low levels of both masculinity and femininity) displayed deficits in social and
non-social cognition. In addition, men with low levels of masculinity showed decreased
perspective-taking and increased personal distress. These findings support the idea that the
influence of psychological gender roles extends beyond anatomical sex with regard to social
cognitive abilities.
Chapter 8 – In recent years, there has been growing interest in age-related differences in
social cognitive functions across the adult life span, such as emotion perception and theory of
mind. Empathy, the ability to both understand and share another person‘s feelings, involves
emotional and cognitive processes and is a fundamental aspect of social interactions and
relationships. However, systematic knowledge about the development of empathy across the
lifecycle is limited, including changes through adulthood. Several questionnaire and
behavioral studies have suggested that in typical aging, late adulthood and advanced age is
associated with reduced capacity for cognitive empathy, but the developmental trajectory of
empathy throughout adulthood remains a topic of debate. Here, we summarize the latest
results in this growing area of study, and discuss potential neurocognitive mechanisms that
might contribute to changes in empathy throughout adulthood.
Chapter 9 – Empathy is an important tool for interpersonal relationships and a better
social life. Especially for healthcare professionals, it is essential to establish a good doctor-
patient relationship in addition to possessing the requisite medical knowledge. According to
 Preface xi

research on the empathy of medical students and doctors carried out in the US, the duration of
education and empathic capacity have a negative correlation, and females have a better
capacity of expressing empathy than men. It is ironic that the erosion of empathy occurs
during a time when the curriculum is shifting toward patient-care activities, for which
empathy is most essential. On the contrary, some reports applying the same or similar
empathy scales, conducted with respect to Asian medical students or doctors, including
Korea, Japan, or China, revealed that the education years and empathy have a positive
correlation. A few studies have shown that gender differences do not play any role in those
reports. Students from Okayama University Medical School, Japan, showed a specific
increase of the mean empathy score in each of the six successive years of medical education.
In addition to U.S.A. and Asian studies, research conducted in Iran and New Zealand reported
that medical students‘ capacity for empathy decreased with each successive year. However,
similar research in Ethiopian and Portuguese medical schools showed an improvement of
empathy as the years of medical education continued. Interestingly, the empathy scores of
beginning Asian medical students are lower than those of U.S. students, as shown by in a
study conducted at Jefferson Medical College. Some of these differences may simply arise
from cultural differences in defining and interpreting the concept of empathy. When
configuring programs to improve the capacity for realizing empathy, medical professionals
should reflect on those cultural characteristics. Nonetheless, in light of the conflicting data
about empathy in medical education, educators should consider developing programs to
enhance and sustain empathy. Indeed, better education in the humanities and narrative arts
has been found to raise awareness of empathy. Such interventions may improve physician
skills by promoting the capacity to express empathy among future medical practitioners.
Chapter 10 – From the standpoint of the discipline of psychology, empathy is a construct,
that is to say a concept used to describe a specific psychological activity or a pattern of
activity that is believed to occur or exist but cannot be directly observed or measured. One
popular and widely referenced definition might be: ―We empathize with others when we have
(a) an affective state that (b) is isomorphic to another person‘s affective state and (c) was
elicited by observing or imagining another person‘s affective state, and (d) when we know
that the other person‘s affective state is the source of our own affective state‖. This is a
working or basic definition shared by such scholars as Eisenberg et al. (1994), de Vignemont
and Singer (2006), Gallese (2007) and Decety et al. (2012) among others (but see discussion
of empathy definitions in first chapter by Watt and Panksepp in this volume). It implies that
empathy involves sharing the same emotional state as someone else and does not refer to a
situation in which the observer feels different or fundamentally incongruent emotions.
Regarding studies that have attempted to clarify the mechanisms underlying empathic
processes, Decety et al. (2012, p. 44) have recently argued that the ―development of human
empathy has been elaborated through the integration of other abstract and domain-general
high-level cognitive abilities such as executive functions, language, and theory of mind,
underpinned by the prefrontal cortex, which expand the range of situations that can elicit
empathy and the range of behaviors that can be driven by empathy.‖ Therefore, in this review,
we will assume that empathy is mainly an emotional phenomenon (―suffering with another
person‖ as suggested by the basic etymology of the word; see Watt, 2005, 2007) and that
certain cognitive aspects (e.g., perspective taking and theory of mind) are probably closely
related (typically conjoined with more affective responses including contagion/affective
resonance) in empathizers, but these cognitive aspects are probably not fundamental to more
xii Douglas F. Watt and Jaak Panksepp

affective empathy. However, the typically highly conjoined nature of affective

empathy/contagion and theory of mind/perspective taking operations has led many authors to
talk about empathy as having both more cognitive as well as more affective dimensions.
Thus, we refer to emotional empathy as the vicarious experience of the emotional states of
other people, i.e., feeling and sharing how another person feels. As emphasized by Watt
(2007) and discussed in the chapter by Watt and Panksepp in this volume, most empathy
concepts probably sit on the emotion/cognition border, a location that no doubt contributes to
the significant terminological confusion that surrounds empathy concepts.
Chapter 11 – Human empathy is generally considered to be an extension of more ancient
mammalian emotional contagion which enables one person to perceive, understand and share
some of the emotional and mental states of another person. The demonstration of empathy is a
pre-requisite for ―helping‖ professionals, such as nurses, social workers, psychotherapists and
physicians, as it underpins authentic person-centred care. Nonetheless, the negative
implications of ―uncontrolled‖ empathy have been highlighted. This chapter explores the
empathy construct in helping contexts and discusses the implications of over- or under-
identification with patients and clients for the well-being and performance of helping
professionals. Particular focus is placed on the concept of ―accurate‖ empathy which refers to
the requirement for helping professionals to forge empathic and authentic connections with
patients and clients whilst maintaining clear personal and emotional boundaries. The
advantages of utilising extended models of empathy that encompass competencies such as
reflective ability, emotional literacy and social competence are discussed. Also considered are
ways in which empathic skills can be developed in order to manage the emotional demands
inherent in helping professions more effectively.
Chapter 12 – Empathy is a multidimensional construct that can be understood as the
ability to be perceptive of and vicariously experience the feelings of other people (affective
components of empathy), while at the same time being able to build a working model of their
emotional states (cognitive components of empathy). The ability to empathize has critical
social functions in that it helps us to respond appropriately to perceived feelings of others,
thereby facilitating successful social interaction. The importance of empathy is particularly
apparent in disorders on the autism spectrum, where the ability to form social relationships
and communicate with others is impaired. In addition, empathy is considered to be equally
crucial in conduct disorder, which is characterized by reduced responsiveness to the distress
of others in association with callous-unemotional traits. While both disorders are thought to
be characterized by problems in empathy, social interaction and adaptation, these disorders
reflect distinct problems in relationship to others within a social milieu. Individuals with
either condition can appear uncaring and poorly attuned towards others, suggesting that
empathy dysfunction should be considered one of the hallmarks to both conditions. It has
been suggested that individuals with autism spectrum disorders show more difficulties with
cognitive empathy but less so with affective empathy. In clear contrast, it has been argued
that individuals diagnosed with conduct disorder demonstrate low affective empathy and
normal levels of cognitive empathy in that they show relatively preserved ability to
understand other people‘s states of mind but do not share or care about these feelings. This
chapter addresses empathy dysfunction observed in disorders on the autism spectrum and
conduct disorder. Mechanisms associated with empathy dysfunction are discussed and
common and differentiating factors between the disorders are identified. In particular, four
mechanisms vital for an appropriate empathetic experience are treated: shared affect, emotion
 Preface xiii

recognition, perspective taking and self-other differentiation. Implications for social

functioning of these individuals are discussed.
Chapter 13 – Patients with Huntington‘s Disease (HD), a rare, inherited neurological
disorder, causing motor, cognitive and emotional dysfunctions, are impaired at recognizing
emotional facial expressions. I will argue that this impairment closes one important door to
empathy for them. If they cannot decipher other‘s emotional expressions correctly, they can
no longer resonate normally with other‘s emotional states. However, all doors to empathy
might not be motor, and other ways of affect sharing might be spared. In a series of
experiments it is shown that the representation of an emotional gesture appears to be lesioned
in HD. As a consequence, recognition of an emotion expression in another individual is
impaired, as well as voluntary emotional expressivity, and micro-mimicry of facial
expressions. Importantly however, these impairments do not go along with affect
understanding in self, and/or with affect sharing on purely verbal-communicative and
cognitive levels. Indeed, HD patients perform normally on empathy and alexithymia
questionnaires. Such a differential view is essential to guide patients and caregivers in finding
and strengthening their tools for affect sharing and communication.
Chapter 14 – A relationship between empathy and self-directed behaviour during mirror-
gazing has been hypothesized by some authors. Nevertheless, how these concepts may be
connected is still an argument of debate. Previous research on mirror self-recognition may not
completely account for the fascination produced by mirror-gazing. In fact, gazing at one‘s
own face in the mirror for a few minutes, at a low illumination level, can produce the
perception of bodily dysmorphic visual illusions of strange-faces. Strange-face illusions may
be the ‗projection‘ of the subject‘s unconscious contents into mirror image on the basis of
somatic/motor mimicry and contagion. Motor mimicry and emotional contagion can operate
through the feedback produced by the mirror within the observed/observing subject. The
‗projection‘ of unconscious content can characterize empathy, according to early ideas of
Einfühlung. Empirical research shows correlations between susceptibility to strange-face
illusions and both the Fantasy and Empathic-concern subscales of Interpersonal Reactivity
Index (IRI).
Chapter 15 – The Toronto Empathy Questionnaire has been proposed as a short but
comprehensive measure of empathy, with sound psychometric properties such as internal
consistency, test-retest reliability, construct validity and unidimensionality. This chapter
presents four studies that assessed the psychometric properties of the Italian version of the
TEQ. In general, results supported the reliability (both as internal consistency and temporal
stability) and construct validity of the scale, as found in previous studies, but not its
unidimensionality. Results from exploratory factor analysis showed that a two-factor solution
accounted for a substantially higher proportion of variance and provided a neat simple
structure (Study 1). The two factors clustered straight and reverse items (Empathy and
Callousness) and in Study 2 fifteen confirmatory factor analysis models specifying either two
substantively important trait factors, one trait factor and ephemeral method artifacts
associated with straight and reverse items or one trait factor and stable response-style method
factors associated with item wording were tested. Results supported the findings of Study 1,
since a model with two (moderately) correlated factors defined by straight and reverse items
had an excellent fit to observed data. Results of Study 3 supported the discriminant validity of
the two constructs, since the Empathy score was significantly more associated than the
Callousness score with a measure of appraisal and perception of emotions (a facet of trait
xiv Douglas F. Watt and Jaak Panksepp

emotional intelligence that includes empathy), whereas Study 4 provided evidence of test-
retest reliability of total and subscale scores. Taken together, the results presented in this
chapter seem to advise against the use of a single TEQ score and to suggest the computation
of two subscale scores for the straight and the reverse items, although further research is
needed to investigate the replicability and generalizability of these findings in other cultural
contexts.
Chapter 16 Empathy remains a challenging and confusing concept in terms of current
neuropsychological investigation and theorizing. However, increasing evidence suggests that
a proto-empathy, constituted by highly resonant socio-emotional feelings, must be a
fundamental foundation for more complex forms of human empathy, and is shared across
most mammalian species but is not a primarily a cognitive function organized by human
neocortex. Indeed, this subcortical locus of control for affective urges is true for all the primal
emotional systems of the brain, albeit mature empathic urges in humans surely reflect
contributions from higher neurocognitive processes as well. Still, we argue that the
fundamental mammalian core of empathy is founded on a process of basic emotional
contagion, and although contagion is surely modified by cognitive development and affective
regulation, it remains a fundamental mechanism upon which human empathy is built.
Although most of the relevant animal work has been done with FEAR, which is not usually
thought of as a prosocial emotion, the most fundamental mammalian prototype affective
system with the greatest relevance for more complex and cognized human empathy is the
system for mammalian maternal CARE (as outlined in Panksepp, 1998). This prototype
emotional system for maternal devotion constitutes a distinguishing but still poorly mapped
feature of the mammalian genome. A second prototype system with special relevance for
empathy (and with close ties to this system for maternal CARE) is the system driving infant
separation calls (primal PANIC responses) which directly mobilize maternal care and help
focus maternal attention towards infants that are lost, injured or otherwise distressed. A final
consideration is that maternal attachment to offspring is surely energized in part by the
mother‘s own separation distress circuitry. Thus, a proto-empathy capacity as a basic
mammalian endowment may emerge from the concerted functioning of several of these
primary affective systems.
 OVERVIEWS OF EMPATHY -
NEUROBIOLOGY, EVOLUTION, PSYCHOLOGY
In: Psychology and Neurobiology of Empathy ISBN: 978-1-63484-446-8
Editors: Douglas F. Watt and Jaak Panksepp © 2016 Nova Science Publishers, Inc.

Chapter 1

EMPATHY AND THE PROSOCIAL BRAIN:

INTEGRATING COGNITIVE AND AFFECTIVE
PERSPECTIVES IN HUMAN
AND ANIMAL MODELS OF EMPATHY

Douglas F Watt1 and Jaak Panksepp2

1
Cambridge City Hospital, Harvard Medical School, Clinic for Cognitive Disorders
Quincy Medical Center, Boston University School of Medicine, MA, US
2
Baily Endowed Chair for Animal, Well-Being Science
Department of Integrative Physiology and Neuroscience
Washington State University, Pullman, WA, US

―Sympathy is founded upon special adaptation of the receptive side of each of the
principal instinctive dispositions that renders each instinct capable of being excited on the
perception of the bodily expressions of the excitement of the same instinct in
other persons.‖
McDougall, 1908

―Where there are two, one cannot be wretched and one not.‖
Euripides

Sympathy is a phylogenetically continuous phenomenon.

Charles Darwin, 1871

ABSTRACT
Empathy is multidimensional concept with many possible definitions, but in this
review we focus on more affective conceptions of empathy, which require a basic
affective resonance, and we view empathy as a prosocial process essential for the
mitigation of suffering. As an essential part of a pro-social brain, empathy helps promote
4 Douglas F. Watt and Jaak Panksepp

both the creation and long-term stability of social bonds, and appears to have emerged in
tandem with the evolution with social bonding and attachment. Although increasingly a
focus of intensive study after decades of neglect, models of empathy emerging from
cognitive and affective neuroscience still demonstrate a fundamental bifurcation in the
division of empathy into cognitive and affective ‗forms‘ or perhaps cognitive and
affective components, but with still rather limited understanding of the constitutive neural
substrates and possible functional and developmental relationships between these two
components, namely how their functional integration is instantiated in living brains.
Although there has been a history of neglect of affective contagion (‗proto-empathy‘), it
presumably appeared well before the more cognitive and deliberative variants of empathy
emerged in evolution, but such capacities for affective resonance may be essential for
sensitive social-learning to emerge. Emotional contagion has attracted intensive research
in recent cross-species studies, allowing substantive causal work to be undertaken,
especially at the instinctual (‗primary-process‘) level.
It seems likely that most ‗real-world‘ social empathy in humans typically reflects
variable admixtures of more primitive affective resonance mechanisms (basic emotional
contagion), melded with developmentally later-arriving theory of mind, emotion
understanding/identification and acquired thoughtful perspective-taking operations,
conjoined with affective concern for others‘ suffering. This suggests that what we call
‗empathy‘ in the real world is a complex composite of more ancient and more evolved
processes. Human empathy, in its more affective forms, probably requires positive
attitudes of stable concern towards related others (and thus is likely augmented by more
primal affective attachments among individuals), along with capacities for affective
regulation (such that the empathizer is not flooded by the suffering of others, and hence
immobilized). Empathy thus involves a stable valuing of other sentient creatures,
suggesting intrinsic ties between empathy and basic attachment processes. We thus argue
that a primal sort of empathic capacity was presumably selected as part and parcel of the
trajectory into a highly social brain in our vertebrate and mammalian phylogeny, with the
importance of social attachments perhaps even augmented further in hominid evolution.

Overall Perspective: Animal models and detailed experimental studies of proto-empathy

– emphasizing basic affective contagion – have markedly increased in the last decade, and
have strongly confirmed that fundamental precursors of more cognized and complex human
empathy are well represented in mammalian lines. We still understand relatively little about
how these primal affective resonance induction/contagion mechanisms, centrally involved in
attachment and appearing relatively early in human ontogeny, connect to developmentally
later-arriving cognitive theory of mind abilities (including affective theory of mind and
emotion identification). Mature ‗cognized‘ human empathy surely requires, over and above
any affective resonance, the capacity for complex perspective taking, namely ‗standing in
another‘s shoes‘ from more cognitive standpoints, but also concern for another‘s suffering
and motivation to reduce it. A developmental bridge from affective contagion to more
cognitive forms of empathy and perspective taking may be that contagion guarantees and
energizes a fundamental interest in the minds and affects of others, given the capacity of
those affects to influence our own internal feeling states directly and powerfully, thereby
priming and motivating a more cognitive interest and concern with their mental and affective
experience. The perspective developed in this review is that before we can represent another‘s
experience cognitively – indeed perhaps before we are even interested in it as a phenomenon
outside ourselves – we may first have to feel a version of it affectively inside ourselves. In
other words, affective contagion may help to energize a critical developmental interest in
others and their emotions and thus kindle an eventual cognitive understanding of the
 Empathy and the Prosocial Brain 5

emotions in other‘s minds, enlivening affectively-regulated learning and memory processes.

Accordingly, we suggest that such critical developmental questions about how cognitive and
affective components of empathy are linked is critical for deepening our neuroscientific
understanding of empathy. Clarification of the potential relationships between contagion and
an emerging ‗theory of mind‘, including an affective ‗theory of mind‘, and other forms of
adaptive social cognition thus remains an important research frontier for a slowly maturing
empathy science.

INTRODUCTION
During the past two decades there has been a veritable explosion of interest in empathy,
progressing rapidly in the past decade from benign neglect to emergence as a robust empirical
focus in both psychology and neuroscience, and related applied medical disciplines,
especially psychiatry. This is a refreshing change from the preceding century of comparative
neglect. In 1998, when the second author published his exhaustive summary of affective
neuroscience, there was minimal brain research literature on empathy, and only a modest
empirical literature on the related topic of altruism, which was receiving attention under the
rubric of ―kin selection‖ in the emerging discipline of evolutionary psychology (Panksepp,
1989/1999) which has changed only modestly since then (Kurban, 2014). Meanwhile the
empirical literature on empathy has exploded, and investigators have recently confirmed that
in altruistic individuals, compassionate and empathic tendencies are strong (FeldmanHall, et
al., 2015; Haas, et al., 2015). While it has long been recognized that in humans the traits of
altruism and compassion/empathy go hand in hand, in animal models only the proto-empathic
(emotionally contagious) behavior patterns have been studied so far, although one can
presume that with more sophisticated behavioral tests, perhaps even animalian forms of
altruism and compassion may eventually be addressed. As recently as 2005-7, when the first
author completed his second review paper on the subject of empathy (see Watt, 2005; 2007),
there were a few dozen review papers and perhaps less than two dozen or so imaging studies
probing empathy concepts and processes, while a more recent search (June 10th, 2014) on
Medline demonstrates just under a staggering 10,000 discrete references with empathy as a
keyword or a title word in the virtual avalanche of more recent work, involving both many
hundreds of empirical studies and dozens and dozens of review articles. These empirical
studies range from functional imaging probes in both children and adults in several popular
empathy paradigms, along with many different types of psychological studies examining
empathy across the lifecycle, as well as probes of empathy in various social and relationship
paradigms. The literature now also includes many more recent animal model studies
examining affective contagion, and many studies on empathy in the helping professions (as
reviewed in several chapters in this volume), along with the systematic examination of
empathy deficits in a multiplicity of psychiatric conditions, especially antisocial and
borderline personality disorders, autism, depression, schizophrenia, and PTSD. In other
words, we have gone from a relatively systematic, ideological neglect of the subject (long
encouraged and supported by behaviorist prejudices) to a virtual flood of information, with
only the beginnings of an emergent theoretical coherence and integration. The sprawling,
heterogeneous and rapidly expanding literature poses many challenges to reviewers
6 Douglas F. Watt and Jaak Panksepp

attempting to provide coherent views of empathy, not the least of which is simply specifying
what the term ‗empathy‘ might mean.

THE PROBLEM OF DEFINING EMPATHY –

CONTINUING TERMINOLOGICAL CONTROVERSIES?
The term empathy was originally translated by Titchener in 1909 from the German term
‗Einfühlung,‘ a term from aesthetics meaning ‗projecting yourself into what you observe‘.
The many emerging literatures on empathy offer significantly different and even conflicting
definitions, with variability typically pivoting around more cognitive vs. more affective
emphases; some suggest that perhaps we should consider empathy broadly defined as coming
in two forms, one more related to theory of mind and one more related to affective contagion.
One cluster of literatures emphasizes a more cognitive dimension of empathy as involving
perception of affective states, theory of mind (including recent appreciation for an ‗affective
theory of mind‘), a more conscious/deliberative imitation of facial and emotional expression
as paradigmatic in empathy (Iacoboni et al., 2005), and perspective taking (Gallagher and
Frith, 2003), while another group of literatures emphasizes the centrality of affective
activation in the empathizing subject, in resonance with the affects of another party (such as
work by Decety, 2010 and Singer, 2006). But these apparent terminological disagreements
are clearly multidimensional and extend well beyond cognitive versus more affective
emphases: 1) whether empathy should be considered synonymous with or as discriminable
from ‗sympathy‘ and from notions of ‗compassion‘ or ‗tenderness‘; 2) how much and how
intensely the witnessed person‘s emotional state is fully and completely shared versus how
much a strict personal boundary is maintained (and by implication, perhaps a less intense
version of shared affect is experienced), and 3) the depth, accuracy and degree of cognitive
representations of the witnessed person‘s emotional state. For a more extended and thorough
review of these definitional issues and semantic controversies see treatments by Batson
(2009), and Cuff et al., (2015).
Cuff et al., (2015) note a total of at least 43 distinct (albeit variably overlapping)
definitions in the literature, and at present it seems unlikely that any more specific definition
is going to satisfy all theorists, researchers, or for that matter, even students new to the
literature struggling to understand such a confusing diversity of terms. However, several
major and more recent overviews of empathy (Decety and Svetlova, 2012; Singer (2006),
Decety, Norman, Berntson, and Cacioppo (2012), have argued that the term ‗empathy‘ should
be restricted to situations in which there is some degree of affective resonance – in other
words, that the term empathy should be reserved for more affective or emotional processes
that reflect what others are feeling (at least some degree of ‗isomorphism‘ or shared affect in
other words), and not applied solely to theory of mind, and perspective-taking operations.
These neural systems for cognitive versus affective forms of ‗mind reading‘ (in other words,
more cognitive theory of mind versus more affective forms of empathy) appear to be doubly
dissociated in lesion studies, suggesting different neural substrates. More affective forms of
empathy appear to load on paralimbic networks involving anterior cingulate and insula while
more cognitive theory of mind and perspective taking load on several heteromodal cortical
 Empathy and the Prosocial Brain 7

regions (Shamay-Tsoory et al., 2009), a network discrimination perhaps supporting various

reviewers attempting to validate the more affective definitions and emphases.
Thus despite all the confusion and differing meanings for the term ‗empathy,‘ there may
be an emerging ‗soft‘ consensus that the term empathy is perhaps best reserved for processes
that have certain basic emotional components, particularly some form of affective resonance
or affectively ‗congruent‘ internal states (again see Cuff et al., 2015 for extended treatment),
although the question of exactly how ‗isomorphic‘ the shared emotional states need to be
between subject and empathic witness remains poorly defined. As noted above, there is a
similar confusion about how much boundaries might be allowed to overlap in empathy versus
how much the witness needs to maintain a clear self/other distinction (as emphasized in
definitions offered by de Vignemont and Singer, 2006). Lastly, there is still divided opinion
on whether empathy properly requires a stance of ‗affective concern‘ and a motivation to
reduce suffering, or whether simply some version of shared affects emerging from affective
resonance is sufficient, and several authors (notably Singer (2006) argue that empathy is
confined to an affective resonance/isomorphism while motivation to reduce suffering implies
‗compassion‘ or ‗sympathy‘. Thus, the expanding field of empathy science still struggles with
a confusing diversity of meanings for the term, and empathy remains a complex and
multidimensional construct, very much like the larger problem of emotion itself (Panksepp,
1998, 2011).
As noted above, one of the most important and confusing of these terminological/
conceptual controversies remains unsettled: distinguishing vs. identifying ‗empathy‘ in
relationship to ‗compassion‘ and ‗sympathy‘. While many authors (see Jackson and Decety
2004), treat these as rough synonyms, other authors, notably Singer (2006), argue that these
terms index substantially different processes, with sympathy in Singer‘s estimation putatively
lacking the required fundamental affective resonance (see Eisenberg et al., 1991 and Hein and
Singer, 2008 for details of this debate about whether empathy means ‗feeling as‘ versus
‗feeling for‘ another). According to Singer‘s usage, a sympathetic reaction to sadness
involves concern for the subject‘s suffering, while an empathetic reaction creates an actual
sadness in the observer. One might readily question however if these fine distinctions
between ‗feeling with someone‘ vs. ‗feeling for someone‘ (implying a clear motivation to
reduce suffering in the latter but perhaps not in the former) could prove ultimately at least
somewhat specious in the real social world, promoting potentially artificial distinctions that
don‘t truly reflect ‗natural kinds‘. In this chapter, we will therefore argue for the still
unproven but commonsense view that resonance with affective suffering – feeling sadness in
reaction to witnessing someone else‘s sadness or pain at someone else‘s pain – likely does not
happen when there is a true lack of concern for suffering on the part of another party, but
surely there may be a wide variation of shared affect/resonance among concerned (motivated)
observers of painful affects, a variation that may offer some support for Singer‘s position.
This question of a relative conjoining vs. a relative disjunction between affective resonance
vs. motivation to reduce suffering remains both a central definitional and mechanistic
question for future empathy investigation and research.
In previous reviews (Watt, 2005, 2007), the first author argued against such a highly
nuanced semantic distinction between sympathy and empathy and for an acceptance of
conventional social/operational use of these three terms (‗compassion,‘ ‗sympathy‘ and
‗empathy‘) as being roughly synonyms. It surely would make little sense at all to the vast
majority of people if someone communicated that ―John is highly compassionate but
8 Douglas F. Watt and Jaak Panksepp

completely lacks empathy,‖ or similarly ―that John has lots of empathy but no sympathy.‖
Such ultrafine semantic distinctions may promote conceptual confusion and may not, in the
end, prove clearly useful scientifically. More importantly, it may be troublesome for the field
at large to argue for such finely nuanced distinctions between empathy, sympathy and
compassion, when many textbook definitions and virtually all major dictionary references use
them as rough synonyms and often define them in terms of one another. All three terms
embed in their basic entomology a notion that the ‗observer suffers with another who is also
suffering‘. Indeed this shared entomology of ‗sym-pathy,‘ ‗em-pathy‘ and ‗com-passion‘
(‗suffering with‘) is perhaps the most telling argument against any truly meaningful
terminological separation. It also would be hard to envision any substantive empirical payoffs
for such ultra-nuanced notions that emphasize functional separations between empathy,
compassion and sympathy – with one notable exception discussed below in the sections on
contagion – that it indeed may make sense to talk about capacity for some form of affective
concern without much if any real contagion – but it is an open question as to whether this is
best described as „sympathy,‟ given again that this goes against decades of usage, and the
word‟s basic entomology. If distinctions need to be made, we may need more specialized
scientific terminologies that respect the profound hierarchical organization in brain functions
— e.g., primary (instinctual/affective), secondary (learned) and tertiary (cognitive) that
should soon be facilitating clearer discussions in emotion research (see Figures 1 and 2 and
Panksepp, 2011). In sum, these semantic controversies create endless opportunities for
ongoing debate and confusion. While we acknowledge that this issue is not settled, here we
will treat these three terms (empathy, sympathy and compassion) as roughly synonymous. In
our closing section of this chapter, and in our final chapter at the end of the volume, we offer
some suggestions for empirical probes that might clarify this controversy of a functional
separation vs. a functional conjoining of affective resonance and concern for suffering.

A Scheme for Mapping Hierarchical and Recursive Relationships between Emotional and
Cognitive Processes in the Mind/Brain

Figure 1. A summary of hierarchical bottom-up and top-down (circular) causation in neural networks, proposed to operate
in every primal emotional system of the brain. The schematic summarizes the hypothesis that in order for higher
MindBrain functions to mature and function, they must be integrated with antecedent ontogenetic and phylogenetic
BrainMind functions. Primary-process emotions are depicted as squares (red), secondary process learning as circles (green
enclosing Red Square), and tertiary processes, by rectangles (dark blue enclosing the two previous levels). The color-
coding aims to convey the manner in which nested hierarchies are integrating lower brain functions into higher brain
functions to eventually exert a top-down regulatory control. In applying this scheme to empathy phenomena, one might
suggest that simple contagion is the primary process, heavily modified by learning and social experience (secondary
process), while theory of mind, including affective theory of mind and basic emotion identification, are the tertiary
neurocognitive components that emerge later in optimal social development (adapted from Panksepp 2011). These
concepts were presaged in the work of John Hughlings Jackson.
 Empathy and the Prosocial Brain 9

COGNITIVE PROCESSES ↔ AFFECTIVE PROCESSES

Theory of Mind↔Perspective-Taking↔Emotion Identification↔Affective Theory of

Mind↔Affective Empathy↔Contagion↔Attachment

Figure 2. Graphical representation of a continuum of interactive cognitive and affective processes on

the emotion-cognition border, with more affective processes on the right and lower sides, and more
cognitive processes on the left side. Social functioning in the real world typically involves several or
even many of these processes virtually simultaneously as parallel processes.

In any case, the assumption of a basic dynamic relationship between affective resonance
and affective concern is deeply consistent with evidence that both attitudes of affective
concern and affective contagion – but not theory of mind – fail to develop in sociopathy
(Blair, 2005). Affective resonance with suffering (contagion) cannot be considered derivative
of a simple theory of mind, nor is it necessarily equivalent to or part of the accurate
perception of emotions in others, although clearly theory of mind, particularly affective
theory of mind, can be seen as an important cognitive concomitant to more affective forms of
empathy. In other words, although the issue of an overlap vs. a putative functional separation
of empathy from sympathy, compassion and caring concern remains unresolved (at least until
an emerging consensus or a new convention is officially consolidated that specifies how these
terms should be used), we believe that resonance/contagion/shared-emotions does not happen
in the real social world in the context of a genuine absence of concern for others or absence of
concern for their suffering. Put differently, we suggest that a genuine affective concern for
others – indexing a basic capacity for social bonds and for prosocial behavior within those
core attachments – may be fundamental to and foundational for whatever enables and
amplifies basic contagion mechanisms. However, this issue remains insufficiently studied
(and indeed, it may be hard to empirically resolve) and hence arguments cannot yet be based
on a clear and unambiguous weight of evidence.
In any case, we line up with Decety and Cowell (2014) who argue similarly, in
suggesting that, broadly defined, mature human empathy is a composite with three basic
‗facets‘: affective resonance, affective concern, and perspective taking. Our default
hypothesis – although again with a minimal evidence-base beyond anecdotal perspectives – is
that attachments open us up to contagion, amplifying its effects, and that this capacity for
sharing of affects is a basic „constitutional‟ feature of a prosocial brain. In other words, we
would simply suggest that the capacity for contagion is foundational for a prosocial brain.
Indeed, the animal data is beginning to suggest that contagion may provide one of the most
neglected critical foundations for a human pro-social brain. Contagion may be an essential but
perhaps not sufficient developmental component to create a highly social creature through a
long developmental social trajectory, perhaps in interaction with other prosocial emotional
systems (such as separation distress/PANIC, PLAY, and LUST – Panksepp, 1998), all of
which participate in and shape a life-span trajectory of social learning and potential social
competence. Since higher mental processes are hard to scientifically study in animals, as we
will see, recent empathy research in animals has taken to studying emotional contagion as its
core approach (Panksepp & Panksepp, 2013). Thus, we would argue that during development
such ‗lower-level‘ processes as contagion may be part of the critical scaffolding for the
development of higher order supportive and prosocial helping responses to suffering. In other
words, there may indeed be a developmental interaction and melding of these empathy-
10 Douglas F. Watt and Jaak Panksepp

related processes, and with important recursions between the more affective and more
cognitive components (as depicted in Figures 1 and 2).
All of these various processes on the emotion – cognition border relate to an affective
mind navigating the adaptive challenges of confronting and integrating the experience and
behavior of other affective minds while attempting to meet its own affective and homeostatic
needs. This suggests not any version of a functional bifurcation of cognition and affect but a
smooth and even seamless functional integration of these domains (as seen in the Figure 1
graphic), in which affective neurochemistries and networks presumably control and motivate
learning, while ultimately cognitions become critical resources to enhance a developing
organism‘s ability to meet affective needs, survive, and eventually reproduce and take care of
its offspring – the core mechanism of selection. Exactly how affective and cognitive
processes become so smoothly and seamlessly integrated in terms of the development of
distributed neural networks linking more ancient and more recently evolved neural systems
remains largely a mystery and a major scientific frontier. However, existing work (Liotti &
Panksepp, 2004; Northoff, et al., 2011) suggests that affective arousal programs recruit
cognitive resources that in turn, over time and with repeated practice become increasingly
honed ‗toolkits‘ for the satisfaction of what are still fundamentally affective goals. This cyclic
reciprocity of and recursion between affects and cognitions helps ensure the potential
enjoyment of multiple types of affective rewards emerging from the successful navigation of
complex and often challenging environmental and social landscape. One of the prototypic
adaptive challenges within such complex social landscapes is the maintenance and long-term
stability of reproduction-facilitating social bonds, with stable attachment strongly associated
with both better affective regulation and more empathic responding (Mikulincer and Shaver,
2005; Schore, 1994), although causal relationships between these three factors remain to be
more fully elucidated. From such perspectives, empathy appears critical and may predict
social success broadly defined. The vicissitudes of primary attachments in turn appear to have
a huge impact on overall quality of life as well as long-term physical and emotional health
(Seeman and Crimmins, 2001; Watt 2014). These deep interactions among the more ancient
affective and more recently emerging cognitive processes remain a great scientific frontier.
As the brain graphics below summarize, these core network processes need to be envisioned
on an interactive hierarchical continuum. Future neurodevelopmental research may allow us
to better appreciate how these cognitive and affective processes become so smoothly
integrated and reciprocally engaged in various real-world social challenges and situations.
In addition to the terminological confusion that may have fostered fragmentation of the
literature, how the affective and cognitive ‗currents‘ of empathy might be integrated in the
―here and now,‖ as well as well as from ontogenetic and phylogenetic perspectives, remains
an uncompleted critical task for empathy research. Understandably, many investigators
appear content to work within the confines of a particular methodology that may effectively
insulate them from some of these broader issues. Additionally, despite an explosion of
functional imaging studies in humans, and studies of emotional contagion in animal models
(see Panksepp & Panksepp, 2013 for more detailed review), the central question of how a
fundamental ‗affective resonance‘ is achieved within a complex neural system, either human
or other mammalian, has received almost no concerted empirical attention (see later section
on contagion). Functional brain imaging remains the primary neuroscientific modality for
investigating human empathy (as well as many aspects of related emotions), but it contains
many limitations, most especially its correlative nature, and, for fMRI, substantially more
 Empathy and the Prosocial Brain 11

than for PET, its insensitivity in detecting activity changes in more ancient brain regions rich
in affective and homeostatic networks. This insensitivity may be partly due to the fact that
neurons in subcortical brain systems typically fire more slowly than those in neocortical
regions and thus do not create a comparable signature of metabolic demand via measures of
blood flow changes. On the other hand, PET is more capable of clearly identifying affective
states (see Damasio et al., 2000) as opposed to the inextricable cognitive-affective admixtures
of fMRI imaging. PET can also monitor the release of key social chemistries such as opioids
(Zubietta, et al., 2003), which animal data that has long implicated endogenous opioids in
feelings and thereby social bonding (Panksepp, 1981, 1986), with attachment being a key
variable in how much individuals are likely to be motivated to actively help others.
In the emerging animal research, most work remains at largely behavioral and descriptive
levels, with few compelling neuroscience findings so far. Although animal research could
systematically evaluate the role of past social experiences in the emergence of empathic
responses (see chapter on Evolutionary Origins of Empathy), with this becoming an important
variable in the most compelling animal models of altruism/empathy (e.g., Sato, et al., 2015).
Thus, despite much attention to empathy, many basic questions remain to be explored, and
given the solely correlative nature of functional imaging, we still lack compelling neuro-
causal, developmental, and evolutionary perspectives. Thus, our summary here is constrained
by the absence of sufficient evidence on several key issues.
In sum, as Decety and Jackson (2004) emphasize, many if not most definitions of
empathy typically (but not invariably) involve three basic components: 1) ‗feeling what
someone is feeling‘ (affective resonance/contagion); 2) ‗knowing what someone is feeling‘;
3) ‗having some intent to mitigate their suffering‘. This simple definition links several
cognitive and affective components, including the important dimension of affective
concern/motivation to reduce suffering, and we accept this basic definition as a useful starting
point, while acknowledging the diversity of definitions and terminological controversies as
outlined in the previous section (and as discussed in detail in Cuff, et al., 2015). Although this
review will emphasize this more basic affective definition of empathy, this definition shares
an overlapping border with the cognitive processes of emotion identification, and with other
emergent higher cognitive processes involved in perspective taking, theory of mind, and
many aspects of social cognition. Such a more inclusive definition also underscores the
importance of a deepening understanding the emotion – cognition border, again as graphically
depicted in these two above figures (Figure 1 and 2).

ANIMAL MODELS EMPHASIZING SUBCORTICAL

NETWORKS IN MATERNAL CARE
When trying to understand processes happening within the staggering complexity of adult
human brains, there is heuristic value to developing animal models of target phenomena, and
testing those findings in the context of related processes in humans. Obviously, there are
many complex cognitive processes and behaviors for which this is not possible, such as the
primary use of language, religious experience, meditative states, just to name a few. However,
relatively simple animal paradigms with face validity provide initial templates for causal
study of empathic processes in humans. For instance: 1) The response of maternal nurturance
12 Douglas F. Watt and Jaak Panksepp

in mammalian and avian species to separation distress signals (and other kinds of distress
states) of their own and other‘s infants, deserves more attention; 2) The resonance of negative
emotional states such as fear when one animal is hurt in the presence of another. In the last
five years there has been a virtual explosion of such animal model results (see section on
animal work on contagion).

MAMMALIAN MATERNAL BEHAVIOR

AS A PRECURSOR FOR EMPATHY

A basic animal model for empathic responsiveness provided by maternal mammals leads
directly to several hypotheses:

 Based on the phenomenon of universal mammalian nurturance and maternal care,

most mammals presumably have some primitive empathic capacities.
 Empathy appears phylogenetically coincident with the social signaling functions of
emotion and formation of social bonds.
 Therefore, it seems reasonable to suspect that primitive empathic ability developed
concomitant with the evolution of social attachment mechanisms in the brain. Indeed,
during the course of mammalian brain evolution, maternal care and social bonding
appear to have emerged concurrently. Social bonding may be critically enhanced by
the ability to perceive, and relieve, the distress of a con-specific.
 The more complex phenomena of human empathy presumably reflect ―cognized
extensions‖ of such mammalian prototype processes, especially of nurturing behavior
towards young (Figure 4). This is most evident toward distressed young. Presumably,
such cognitive extensions of mammalian maternal nurturing behavior drive concern
for and motivation to relieve distress, increasing appreciation of the internal affective
spaces of others, and fertilize the development of a theory of mind and perspective
taking during human development.

Consistent with a fundamental division in basic emotion taxonomy between organism

self-defense (FEAR and RAGE) versus social connection (playfulness/PLAY, maternal
CARE, and PANIC/separation distress), the animal affective neuroscience research
summarized in Figures 3 and 4 suggests significant overlap of functional networks subserving
sexual arousal, separation distress/social bonding, and nurturance and maternal care (see
Panksepp, 1998 and Panksepp & Biven, 2012 for extended summaries – capitalization here
used as the convention for designating primary-process affective neural systems widely
distributed in subcortical brain regions). The animal data on maternal CARE and nurturance
suggests the working hypothesis that primitive empathic abilities may be organized around
basic systems subserving a complex of maternal-care and other attachment-related processes.
One fundamental hypothesis (advanced in Panksepp, 1998), is that attachment may reflect an
evolutionary ‗tweaking‘ of more primitive reptilian sexual choice mechanisms, suggested by
the large overlaps in functional networks outlined in the above graphics for sexuality and
maternal CARE, as depicted in Figures 3 and 4.
 Empathy and the Prosocial Brain 13

Figure 3. Lateral view of the rat brain summarizing two major areas contribute differential control over
male and female sexual behaviors. Males contain a larger POA (preoptic area), an area essential for
male sexual competence. The ventral medial hypothalamus (VMH) is clearly more influential in
female sexual response, but both these systems may operate by sensitizing various sensory input
channels that promote copulatory reflexes and sexual behaviors. The extent to which these circuits
control or influence more affective components of sexual behavior remains uncertain.

Figure 4. General overview of maternal behavior circuits in rodents. The central integrator is in the
dorsal preoptic area (POA) and the ventral bed nucleus of stria terminalis (VPN) which receives various
sensory cues for maternal behavior and distributes signals into widespread brain areas, including the
medial hypothalamus (MH), the ventral tegmental area (VTA), periaquaductal gray (PAG), the
habenula (HAV), and the septal area (S).
14 Douglas F. Watt and Jaak Panksepp

Figure 5. Legend: DMT = dorsomedial thalamus, PAG = periaquaductal gray, CB = cerebellum,

BN = bed nucleus of stria terminalis, dPOA = dorsal preoptic area of hypothalamus, VS = ventral
septum, AC = anterior cingulate, CC = corpus callosum, OB = olfactory bulb.

The distributed networks implicated in the animal work on nurturance and maternal
attachment center around preoptic areas of the hypothalamus, ventral portions of the bed
nucleus of stria terminalis, and ventral septum, with likely secondary but still important roles
played by other basal forebrain, diencephalic and midbrain systems such as habenula, and
other highly interconnected lower brain-stem areas. The preoptic and ventral bed nuclei with
connections to the mesencephalic Ventral Tegmental Area (VTA) and ventral Periaqueductal
Gray (PAG) appear to be the primary organizers of maternal CARE and LUST behaviors,
along with closely coordinated SEEKING urges. Large lesions to these primary regions truly
devastate the capacity of female mammals to care for their young (Numan & Insel, 2003).
This functional network may change and extend significantly in phylogenesis, with an
increasing involvement of paralimbic areas. Abundant evidence affirms that in primates and
hominids, the anterior cingulate cortex along with more limbic basal ganglia such as the
nucleus accumbens are increasingly critical for attachment, separation distress and maternal
behavior. All the various prototype emotional states all have basic architectures that funnel
down into different regions of periaquaductal gray (see Watt, 2000 for overview of PAG
connectivity/function). Devastation of the full PAG structure appears to collapse all the
prototype affective systems, including both those with more prosocial aims and those more
related to organism defense, and virtually all other forms of motivation, creating total
disability and akinetic mutism (see Watt and Pincus, 2004 for a more thorough discussion of
a closely studied human clinical case of an extensive PAG lesion, and for summary of animal
model work). Other relevant evidence from animal models include findings that mu opioid
receptor knock-out mice are deficient in attachment behaviors, with evidence that both
approach and orienting behavior towards mother and separation distress responses being
attenuated (Moles, Kieffer, & D‘Amato, 2004). This suggests that neuropeptides regulating
attachment and maternal care, particularly oxytocin (Uvnas-MÖberg, 1998; Carter, 1998) as
 Empathy and the Prosocial Brain 15

well as brain opioids and prolactin (Panksepp, 1998) have a broad relevance for regulating
empathic responsiveness, since they all robustly reduce separation distress (see more
extended treatment of this question in section on neuromodulatory issues and empathy).

THE SOCIAL-EMOTIONAL FOUNDATIONS OF EMPATHY –

PHYLOGENETIC PERSPECTIVES
Cross-species brain research can potentially clarify how empathic processes are linked to
specific brain processes. However, in animals that can‘t speak, we can only infer
psychological states by observing how animals behaviorally respond to artificial brain
arousals (as with direct brain stimulation) as rewarding and punishing states, as well as to
each other‘s psychological pains and pleasures. Obviously, a general principle is that the
primal social emotions – LUST, CARE, PANIC/GRIEF, and PLAY – promote more robust
social-emotional attunement than the negative defensive emotions of FEAR and RAGE.
Through maternal CARE behaviors, parents soothe distressed infants, and according to
present understanding social attachments arise through the concerted and complex
interactions and diverse co-ordinations of all of the above prosocial affective systems
(Panksepp, 1998; Panksepp & Biven, 2012). Those primal attunements and attachments may
lay the foundation for more complex forms of empathy. However, the fields of human
affective, cognitive and social neurosciences appear not quite ready to envision that cross-
species brain LUST and PLAY systems are primary sources of positive social resonances,
while negative primes such as FEAR and RAGE are emotions that do not figure heavily in the
‗empathic toolbox‘. On the other hand, of the various affective prototypes, separation distress
(PANIC) arousal may have a more fundamental phylogenetic relationship with empathy, as
infants obviously have separation calls, and mothers and sensitive others rapidly shift
attention toward distressed feeling states in offspring simply by hearing the cries of infants,
with this type of arousal in humans activating basal forebrain and subcortical limbic and
paralimbic networks more robustly in females than in males (Lorderbaum, 2004).
Lorberbaum‘s study indeed shows a high correspondence with basic animal model maternal
CARE networks, as depicted in Figure 4. Consistent with these notions, positive social
concerns are writ large in the expression of maternal CARE, and based on animal work, we
postulate that human empathic urges are intimately intertwined with the prosocial affective
dictates of PANIC/GRIEF, CARE and PLAY, as well as animals SEEKING solace and
comfort when in distress. Such intrinsic connections between more ancient affective systems
and empathy may ensure a fundamental kin-biased favoritism (Azevedo, et al., 2012;
D‘Amato, 1998), while also fertilizing the neural-affective ground from which complex
cognitive forms of empathy may later emerge (Gallese, 2003; Narvaez, et al., 2012).
In short, our understanding of empathy is strongly linked to our understanding of
affective consciousness (Panksepp, 2007), and the associated neural systems for prototype
emotion, particularly the prosocial affective prototypes (LUST, PLAY, PANIC/GRIEF and of
course maternal CARE, which may constitute a ‗proto-empathy‘ system (Panksepp, 1998). In
relationship to the maternal CARE System, Panksepp (1998) noted three major issues that
still, 17 years later, remain to be definitively answered, but where preliminary evidence favors
affirmation for each question:
16 Douglas F. Watt and Jaak Panksepp

1. Does the activation of distress circuits in young and relatively helpless animals evoke
resonant activity in the same circuits of nearby adults?
2. If such perceptually-induced affective resonance does exist, is the evoked activity
especially strong between more strongly bonded individuals?
3. Does such affective brain activity arouse and motivate caregiving in adults?

Emotional contagion probably goes back very far in animal brain evolution. Although
such fundamental processes of affective contagion often seem underappreciated in the
psychological sciences, brain damage studies of subcortical regions suggest they have a
foundational role in developmental bootstrapping of higher social brain functions – creating
fundamental mechanisms for primal affective minds to have an immediate sensitivity to what
is going on in other nearby affective minds, which could be highly adaptive (Seyfarth and
Cheney, 2013). Thus, a basic capacity for contagion may be a prerequisite for complex forms
of intersubjectivity, attachment, and social reciprocity and mutual dependency, although the
evidence base for such assertions needs to be fleshed out by more research. In its most basic
form, affective resonance (as a primal or ‗proto-empathy‘) may be a common property of
most if not all of the primary-process emotional systems. This may help insure perceptually-
induced resonance of affective states in nearby animals, as is needed in adaptive social group-
coordinated fearful flight behaviors (considered in more detail below). This resonance may
also underlie the evident intrinsic capacity of mothers to respond adaptively to the affective
shifts of their infants. For instance, separation-calls (PANIC network arousals) signal
psychological distress, which may have evolved from the brain‘s ancestral pain system (as
highlighted by shared chemistries, especially their shared opioid regulation, dampening
negative feelings while elevating positive ones (Eisenberger, 2012; Panksepp, 1981;
MacDonald & Jensen-Campbell, 2011). It would be of obvious survival advantage for
mothers‘ auditory networks to be hypersensitive to this type of distress, especially separation
distress vocalizations, of their infants (Swain, et al., 2007). Our working hypothesis is that
infant cries arouse the mother‘s own PANIC systems, allowing mothers intrinsic insight into
and motivation to relieve the plight of their offspring. Thereby mothers‘ PANICy feelings (as
a form of psychological pain) would resonate with their infant‘s distress, and the mutual
positive affects of maternal attention, would promote opioid and oxytocin mediated social
bonding (Nelson & Panksepp, 1998). Indeed, even relatively young human infants seem to
share this ability for basic contagion, and this has been noted that in many group-nurseries,
such that when one baby starts crying, others often rapidly join the ‗chorus‘ (Hoffman, 1975).
In this context, oxytocin-induced pro-social facilitation of behavioral synchronization
among nearby animals deserves increasing attention. The most obvious example is how
grazing animals exhibit flight in unison when threatened by predators, a phenomenon that is
not readily amenable to neuroscience research. However, examination of avian vasotocin
promotes essentially the same affective shifts in bird as its mammalian ortholog oxytocin, as
described by Panksepp (1992, 1998). Indeed, when newborn chicks (tested typically at 3-7
days of age) are given practically any dose above 0.1µg of oxytocin or vasotocin directly into
their brain‘s ventricular system, they exhibit dramatic reductions in isolation calls (Panksepp,
1998), as if being alone does not trouble them at all, along with dramatic elevations of three
visually evident simple behavior patterns—lateral head shaking, wing flapping and yawning,
when tested alone. To evaluate social ―infectiousness‖ in groups of 3-4 chicks, rates of two
distinct behaviors (yawning and lateral head shaking) exhibited no contagion effects within
 Empathy and the Prosocial Brain 17

the group while, in contrast, wing-flapping was dramatically elevated when birds were tested
in groups rather than alone (Panksepp, 1992). We suspect that may be happening because this
peptide increases social confidence (with diminished aggression perhaps also reflecting an
increased social confidence), an effect clearly evident in the intermale aggression of quail
(Riters & Panksepp, 1997). We believe that this kind of non-flight wing-flapping may
represent some kind of a social signal, perhaps reflecting heightened confidence and its social
display which may be an ‗infectious‘ state, spread through the same basic contagion process
as other better studied affective prototypes such as fear (Panksepp, 2009).
In sum, modern emotion neuroscience has provided essential tools to clarify how deeply
empathy is grounded in fundamental brain affective processes – especially the diverse
emotional networks that mediate our social nature and our essential social dependencies.
Perhaps the fundamental social emotions – CARE, PANIC/GRIEF, and PLAY – generate
more robust pro-social empathic resonances (thus helping to foster a basic emotional
attunement) than other prototype states aimed at organism defense, such as RAGE and FEAR,
affects that may not intrinsically promote what most investigators would regard as
fundamental pro-social empathic attunements. But as we explore in the next section, the
recent animal fear-research literature is rapidly becoming rich in envisioning how the primal
infectiousness of FEAR may be one of the most informative animal models for exploring
inter-animal affective ‗resonance.‘

PROTO-EMPATHY IN ANIMALS:
DATA ON FEAR CONTAGION
In neuroscience terms, the psychobiological foundations of human empathy may arise
from the perceptually-induced resonance of emotional states in nearby affective minds.
Affective ‗infectiousness‘, with a modest stretch of the imagination, can be envisioned as a
necessary phylogenetic forerunner to the pro-social empathic responses reviewed above. A
striking example may be the automatic capacity of mothers to experience certain affective
feelings of infants. For instance, PANIC networks of mammalian brains engender separation-
calls. This signaling of psychic-pain may reflect a sound-induced resonance between
emotional states in infants and in mothers (Panksepp, 1981, 1998; Eisenberger, 2012). In
other words, the auditory networks of mammalian and avian mothers may be attuned to the
arousal of the separation-calls of their infants emanating from their PANIC networks, and
thereby, the mother‘s affective feelings may resonate with the feelings of their babies.
However, no animal modeling has been done on this important social resonance systems so
far, while FEAR has proved by far the easiest primal emotion to study in terms of emotional
contagion. Our current review of that literature on fear contagion is informed by a recent
summary of this field by Panksepp & Panksepp (2012). (Additional review of animal models
of empathy can be found in the chapter on Evolutionary Origins of Empathy by Watanabe.)
Most studies have been largely restricted to experiments where one ―demonstrator‖
animal is induced into an emotional state with external stimulation (e.g., foot shock for
FEAR) while one monitors the FEAR-related behaviors in an ―observer‖ animals. Abundant
results have been accumulating that observer animals do resonate with the emotions of fearful
demonstrator animals that are getting foot-shock under a variety of conditions (Panksepp &
18 Douglas F. Watt and Jaak Panksepp

Lahvis, 2011). Most of this work proceeds at a behavioral level, understandably without much
discussion of the feelings of animals (Atsak, et al., 2011; Chen, et al., 2009; Kim, et al., 2010;
Jeon, et al., 2010). Of course, behavior-only studies we have no direct way to demonstrate
shifts in emotional feelings of the animals. That can only be inferred from the fact that deep
brain stimulations (DBS) of the relevant subcortical brain emotional systems are consistently
―rewarding‖ (for primal SEEKING, LUST, CARE and PLAY) or ―punishing‖ (for primal
RAGE, FEAR and PANIC), as summarized in Panksepp (1998). Although there may be a
confluence of behavioral, emotional contagion and related affective states, that remains to be
demonstrated. Hence here we must here remain at a strictly behavioral level of analysis, even
though affective constitutive issues of empathic states deserve future attention, perhaps most
effectively monitored through the analysis of emotional vocalizations, where the circuitry of
50 kHz social engagement calls has been validated by critical brain reward studies (Burgdorf,
et al., 2007), while 22 kHz complaints that prevail during threat and social defeat are obtained
from brain regions that have long been known to be aversive, such as the more dorsal areas of
PAG (Kroes, et al., 2008).
Both rats (Wöhr and Schwarting, 2008; Kim et al., 2010; Atsak et al., 2011) and mice
(Jeon et al., 2010) exhibit increased freezing behavior when distress is induced by painful foot
shock in a social partner, an effect that may be explained by emotional contagion within
nearby subcortical FEAR circuitries. The pain-related behaviors of mice appear to be
―infectious‖ since observer animals manifest pain induced distress states of social partners
(Langford et al., 2006). In rats, such state-matching is partly mediated by hearing the
negatively valenced 22-kHz ultrasonic vocalizations of other rats (Wöhr and Schwarting,
2008; Kim et al., 2010). In contrast mice are more sensitive to visual manifestations of social
distress (Langford et al., 2006; Guzmán et al., 2009; Jeon et al., 2010), while also being
responsive to vocal signals (Chen et al., 2009).
Past social interactions, which promote familiarity and perhaps even friendship (i.e.,
sustained social preferences between individuals), can also ‗prime‘ rodents for subsequent
empathic-type learning. In mice, social familiarity with non-fearful mice inhibits the learning
of conditioned fear as measured by freezing (Guzmán, et al., 2009). In contrast, earlier
experiences with fearful mice can amplify conditioned fear (Nowak, et al., 2013). Likewise,
past social experiences with fearful partners can enhance and retard (Bredy & Barad, 2009)
subsequent fear learning memories in rats and mice, respectively. Moreover, in rats,
concurrent testing with non-fearful (Kiyokawa, et al., 2009) or fearful (Kim, et al., 2010)
social partners decreases and increases fear learning, respectively. Thus, it is noteworthy that
such findings, suggestive of a basic ‗fear empathy‘, are also found with fear responsiveness
amplified by past exposure (familiarity) with a highly similar emotional experience (Atsak, et.
al., 2011, Kim et al., 2010) or even the familiarity of one‘s social partner to fearful past
experiences (Jeon, et al., 2010; Langford, et al., 2006). In sum, such work affirms that both
fearfulness and resistance to fear in rodents appears highly ‗transmissible‘/infectious, having
transitive (‗pass-through‘) effects on the fearfulness of companion conspecifics. This suggests
that affective regulation and affective ‗thresholds‘ are intimately influenced by the affective
state and affective regulation of conspecifics in our immediate environment. While such a
finding in humans would surely not surprise many psychotherapists, its emergence in rodents
underscores how ancient these critical processes supporting contagion/proto-empathy may be.
A variety of related rodent studies highlight also how subtle these effects can be, with
some preliminary understanding of the involved neural substrates. As more extensively
 Empathy and the Prosocial Brain 19

discussed in Panksepp & Panksepp (2012), during such task, brain regions that are known to
be part of the affective pain matrix in humans are also evident in rodents, including anterior
cingulate cortical as well as medial thalamic separation-distress PANIC (social separation-
distress) circuitry as well as lateral amygdala fear conditioning circuits (Jeon et al., 2010;
Knapska et al., 2006). Indeed, not only respond emotionally to the distress of their social
partners, they apparently actively alleviate this distress of others (e.g., Rice & Gainer, 1962).
In more recent studies, rats are willing to free other rats that are constrained in small holding
cages (Bartal, et al., 2012). However, as most experimental findings, there are multiple
interpretations that remain to be unambiguously distinguished. For instance, perhaps rats
―liberate‖ other rats constrained in tight spaces simply because they simply find freely
moving rats to be visually more ―interesting‖ than forcibly constrained animals. A most
recent study at this writing seems to get around such problems, as Sato and colleagues (2015)
found that rats would free a water-soaked cagemate from a restricted ―water area‖ into a safe
area. Critical analyzes indicated that the distress of the cagemate was essential for the rapid
door-opening behavior. Further, past experiences with soaking by helper rats promoted such
helping behaviors. Indeed, this helping behavior even predominated over concurrent food-
seeking behavior. Although such behaviors might suggest some kind of ideational processes
in rodent helping behavior beyond mere emotional contagion, many such experimental
findings may be explained by an animal‘s desire for simple social contact as opposed to
explicit helping-behavior (Silberberg, et al., 2014). Further experimental probing of these
questions in clever animal models should help tease apart these potentially competing
explanations.
Additional recent studies in rodents highlight that fearful experiences in demonstrator-
animals readily transfers to observer animals, making them more responsive to fearful
situations. In rats, such fearfulness can be ‗infectious‘ to other rats that have simply observed
‗demonstrators‘ that express conditioned fear reactions without actually seeing the
demonstrators exposed to painful foot shocks (see Panksepp & Panksepp, 2012). Moreover,
mice simply exposed to other rats in either contextual (Jeon, et al., 2010; Kavaliers, et al.
(2005) or cued (Chen, et al., 2009) fear-learning situations manifest increased primal FEAR
behavioral responses (e.g., freezing). Additional studies with mice (e.g., Jeon, et al., 2010),
have identified various affect-rich regions, including the lateral amygdala, medial thalamus,
and anterior cingulate cortical regions, as important brain regions for processing the
observation of fear in others. However, whether this affective contagion reflects more FEAR
or PANIC arousal remains unclear, as the lateral amygdala is more involved in FEAR
conditioning, while the medial thalamus is more involved in the PANIC response (separation
distress), at least in regional brain stimulation studies in species like guinea pigs with robust
separation distress vocalizations (Panksepp, et al., 1988). Furthermore, mice from an
especially gregarious strain (C57BL/6J) exhibited heart rate deceleration as they observed the
distress of others (Chen, et al., 2009) – a physiological response that characterizes empathic
concern in humans (Zahn-Waxler, et al., 1995). Furthermore, in rats, social interaction with
previously distressed cage-mates leads to amygdala arousal (as monitored with c-fos
activation), with maximal activations within the central amygdaloid nuclei of ‗observer‘ rats
(Knapska, et al., 2006), a brain region that is especially well established as a critical epicenter
of primal FEAR circuitry. Other recent work indicates that rats are not only especially
responsive to the distress of social partners but also, if given the chance, they will learn to
alleviate their companion‘s distress. For instance, rats observing physically constrained
20 Douglas F. Watt and Jaak Panksepp

partners emitting some distress calls learned to free them (Bartal, et al., 2011), replicating
observations from much earlier work (e.g., Rice & Gainer, 1962).
A key question is how secondary learning and memory processes might be involved in
these animal model findings, above and beyond contributions from primal affective
contagion. There is no reason to think that secondary processes (i.e., learning and memory)
add anything distinct affectively, except to help determine how empathic responses are
distributed in space and time, and towards whom (Solms & Panksepp, 2012; Panksepp &
Biven, 2012). In a sense, the secondary processes are completely unconscious, but regulate
temporo-spatial distributions of behavior and a more context-dependent activation, which is
adaptive. As we have seen, learning, especially social familiarity and experience with
emotion provoking situations substantially influences the intensity of empathic emotional
responses. Although learning surely moderates the intensity and distribution of emotional
feelings, it presumably does not substantively moderate the quality of the feelings, although
intensity could be easily affected. One major remaining question is what might the higher
cognitive (tertiary) mental processes contribute to empathic responses. In the previous section
we highlighted how animals that had experienced diverse fearful situations would exhibit
selective expressions of contagious emotions. But did they think about their decisions? And if
so, in what manner? The great dilemma of research on animals that do not speak is that these
tertiary processes can only be indexed by the complexity of behavioral choices (e.g. Steiner &
Redish, 2014; Rygula, et al., 2012), while primal affective feelings can be evaluated by
determining whether DBS induced emotional states are rewarding, punishing or neutral, with
the last outcome indicating that the states elicited presumably did not have significant
experiential ‗valence‘ and hence sufficient affect. In any event, we think that primary
contagion processes provide the solid evolutionary foundation for the emergence of higher
order forms of empathy.

WORK ON CONTAGION IN HUMANS –

REMAINING QUESTIONS ABOUT CONTAGION?
As a broad brushstroke, one might simply offer that all of the prototype emotions appear
to be ‗catchy‘ (infectious) as playful, smiling, and lustful, responses commonly facilitate and
activate the same states in others in close proximity, as of course do the prototype negative
emotions of fear and rage (Hatfield, et al., 1994). Unraveling emotional contagion would give
us critical insights into how different prototype emotional states generate affective resonances
in others, resonances that may be modulated in various ways by higher cognitive abilities, but
that may not depend on them. We sometimes don‘t even have to hear the specific joke a
nearby person might have heard to start laughing ourselves. Indeed, even the language of
―infectiousness‖ we commonly use speaks to the centrality of the phenomenon of affective
resonance, perhaps fundamentally organized in more ventral and subcortical regions of the
nervous system, where primary-process emotional networks are concentrated (Panksepp,
1982, 1998).
Both empirical investigations and theoretical overviews of contagion in humans (such as
Barsade, 2002) have highlighted such critical foundations for empathy. Sonnby-Borgstrom
(2002) compared facial mimicry reactions, as represented by EMG activity when subjects
 Empathy and the Prosocial Brain 21

were exposed to pictures of angry or happy faces, and the degree of correspondence between
facial EMG reactions and their own reported feelings. Subjects in the high-empathy group
were found to exhibit more mimicking behaviors, while low-empathy subjects showed
inverse zygomaticus muscle reactions such as ―smiling‖ when exposed to angry faces.
Arguing for a more primitive contagion component to evolved empathy, the author concluded
that differences between the groups in empathy appeared related to differences in automatic
somatic reactions to facial stimuli, rather than to differences in conscious interpretation of the
emotional situations. There is additional evidence that primitive contagion effects extend to
synchronicity of autonomic states between empathizing subject and distressed object
(Levenson, 1996), which may reflect potential ‗physiological substrates‘ for empathy. Play
and smiling responses critical for early attachment of infants and their mothers (Bowlby,
1977; Buck, 2011; Trevarthen & Aitken, 2001) also appear mutually inducted via contagion
mechanisms.
Interestingly, the human emotional contagion literature suggests two different
mechanisms: 1) a more subconscious, automatic, primitive emotional contagion (Hatfield,
Cacioppo, and Rapson, 1992) and 2) a more explicit cognitive process (see Gump & Kulik,
1997) that may reflect more a conscious ‗modeling‘ and imitation (the paradigm utilized in
Iacoboni et al., 2005 where neuroimaging of conscious imitation of affective facial
expressions was employed). Most work however suggests that contagion, especially in any
animal model, is typically defined in terms of its more automatic ‗primary processes‘ aspect.
This primitive contagion occurs through very fast processes based in automatic and
continuous nonverbal mimicry and feedback (Hatfield, Cacioppo, and Rapson, 1992; 1993;
1994), including automatic, nonconscious mimicry of the other‟s facial expressions
(Lundqvist and Dimberg, 1995; Dimberg, 1982), vocal tones (Hatfield et al., 1994) and even
body language (Chartrand & Bargh, 1999). These effects can be measured even for
subliminal facial presentations (Dimberg et al., 2000), and are typically transmodal (e.g,
vocal affects can modify facial affective expressions (Hietanen, Surakka, Linnankoski, 1998).
These presumably unconscious mimicry effects have been found even in infants as young as a
few days old (Field et al., 1982; Haviland & Lelwica, 1987).
The assumption that conscious ‗slow‘ imitation may be using the same neural pathways
as ‗fast‘ unconscious imitation is common in the empathy literature, (see method of Carr et
al., 2003), contributing perhaps to the earlier equation of mirror neurons as a putative network
foundational for empathy (Gallese, 2003). However, automatic and unconscious imitations
underling contagion work on much faster time scales (Hatfield, Cacioppo, & Rapson, 1992;
Dimberg et al., 2000) than the conscious imitation seen in mirror neuron studies. Indeed, there
may be widespread conflation of the mechanisms of contagion with notions of both mirroring
and ‗shared representations‘ (that similar actions/states across both self and other are mapped
to ‗pooled representations‘ – Jackson & Decety, 2004). However, contagion developmentally
precedes such ‗shared representations‘, which don‘t start appearing until at least 18-24
months (Hatfield, Cacioppo and Rapson, 1993). In any event, we would suggest an obvious
possibility that contagion mechanisms could form the poorly understood ‗developmental
ground‘ out of which later arriving and more cognitive ‗shared representations‘ or ‗mirroring‘
phenomena develop, but there is regrettably little relevant data on this. Additionally,
conscious action matching, while potentially similar to affective state matching, should not be
deemed synonymous, since distinctions between voluntary instrumental action, on the one
22 Douglas F. Watt and Jaak Panksepp

hand, and involuntary affective action, on the other hand, need to be respected even if there
are developmental continuities eventually linking the two older and newer forms of action.
Additionally, although not clarified yet in terms of neural substrates, contagion may
reflect induced changes in the activation of core structures for basic emotion. For example,
masked fearful and angry expressions increase, and happy expressions decrease, amygdala
activity (Morris et al., 1998; Whalen et al., 1998). Perhaps the balance between
primitive/automatic and more cognitively informed appraisal mechanisms for emotion
activation shifts significantly and progressively during development. For instance, Field et al.,
(1986) have suggested that early more automatic contagion is gradually inhibited during child
development, coincident with prefrontal system myelination, which may reflect maturational
development of affective modulation/inhibition (Hsee, Hatfield, & Chemtob, 1992). Despite
this, impressive capacities for emotional contagion appear to continue into adulthood, as seen
in laughter contagion (in many instances, we do not even need to hear the joke to begin
laughing when exposed to the laughter of others).
These reviews of both human and animal model work on contagion suggests several
remaining questions, and despite all this exploration from various experimental paradigms
and animal versus human subjects, empirical work has so far been modest, at least on the
neural substrates of contagion. We would frame the following major questions about
processes that appear essential to understanding prosocial brains:

1. Is contagion fundamentally amplified by positive emotional states within observers

and inhibited by negative affective states, particularly rage, toward specific social
―targets‖? In other words, does negative emotion towards another individual
fundamentally inhibit the positive sharing of affects? Imaging of neural activations of
empathic responses during simulated game situations, highlight that irritation and the
perception of unfairness strongly inhibits empathy networks (Singer et al., 2006). In
such situations, gender affects are strong, and men in particular are significantly
more predisposed towards ‗Schadenfreude‘ – gloating at the distress of others.
Another way of thinking about this is that positive regard for others may enable a
heightened capacity for, or vulnerability to, affective contagion effects, while
negative emotions may be inhibitory, but there may be partial exceptions to this with
respect to contagion effects of fear and rage. In other words, it would make adaptive
sense if contagion affords a ready mechanism that arrives relatively early during both
phylogenetic and ontogenetic development for sampling the affective states of others,
to have such a sampling process amplified or inhibited, depending on the adaptive
value of connecting versus disconnecting to others in the immediate social space.
Such hypotheses yield various testable predictions. Surprisingly, despite the now
enormous spread of empathy research, testing the simple prediction that a variety of
positive feelings towards a suffering other amplify contagion effects, while negative
feelings might constrict contagion has to our knowledge never been specifically
analyzed, although in Singer et al., (2006) there is evidence that irritation at unfair
play diminishes empathy. This basic prediction that empathy is amplified by positive
and inhibited by negative affects deserves a more extended experimental validation
or falsification.
2. How is contagion instantiated mechanistically, in terms of distributed neural
networks, neurochemical modulators, and critical brain regions? It seems fairly
 Empathy and the Prosocial Brain 23

obvious that it must reflect bridges between expressive/executive systems and

receptive/sensory systems, but its unambiguous presence and potency in various
animal models (Panksepp & Panksepp, 2012) suggests the possibility (as discussed in
Watt, 2007) that contagion reflects a basic receptive-processing capability embedded
deep in the core subcortical affect-executive systems as outlined in Panksepp (1998).
Although the more famous example of mirror neuron networks (Gallese, 2003)
underscores that neural reentry between executive and sensory systems is a potent
organizing principle at the level of the cortex, it seems reasonable to suppose that
such recursion between sensory and executive systems is also an organizing principle
at subcortical mesodiencephalic and brainstem levels as well. These questions have
been minimally probed, and merit more attention.

NEUROMODULATORY PERSPECTIVES ON EMPATHY

While it would be an untenable neo-phrenology to suggest that empathy is simply due to
any single neuromodulator or even a simple combination of neuromodulators, at the same
time, several key neuromodulators may have critical functional roles within the more ancient
subcortical and paralimbic neural networks implicated in various empathy-related processes,
particularly in relationship to pro-social behaviors in maternal nurturance, but also in
prosocial prototypes of play, and in separation distress (including central roles, as noted
previously, for opioids, oxytocin, prolactin, cannabinoids, and dopamine in these prototype
prosocial emotional systems). Additionally, there is empirical evidence suggesting that some
neuromodulators may enhance and others may possibly inhibit empathy, suggesting that
neuromodulatory perspectives, while requiring the above cautions, may still add significantly
to our understanding of empathic processes.
However, the neurochemistries of social bonding, including opioids (Panksepp, 1981,
1986) and oxytocin, both of which reduce separation PANIC robustly (reviewed in Panksepp,
1998 and Panksepp & Biven, 2012), may operate differentially on the overall empathic
process – opioids may diminish empathic responding by attenuating feelings of psychic pain,
especially the psychological pain engendered by separation distress, while pro-social
tendencies promoted by oxytocin, without evident analgesic effects, may more readily
promote active empathic responses. However, as there have been no direct empirical probes
on opioids and empathy in human subjects to our knowledge, it is entirely possible that
opioidergic effects might demonstrate a classic U-shaped curve: an inhibitory effect on
empathy might emerge at higher doses, while lower doses, which might enhance self-
confidence without generating euphoric complacency, might have more facilitatory effects on
empathy. Experimental approaches involving manipulation of opioidergic modulation in
various empathy paradigms however may be far less popular – and less doable – in the
current climate of increasing paranoia about opiate addiction, while research into
oxytocinergic manipulations may have far fewer obstacles. In any case, oxytocin appears to
more consistently promote the affective qualities of human parenting, which may arise from
feelings of ‗psychological strength‘ that is a hallmark of parenting competence and parent-
infant bonding (Feldman, 2012; Nelson & Panksepp, 1998). Oxytocin may not simply
enhance mutual trust but may improve discernment of social affect (Domes et al., 2007),
24 Douglas F. Watt and Jaak Panksepp

thereby potentially further supporting a primary role of polymorphisms in oxytocin receptors

that impact empathic capacities (Rodriguez et al., 2009). From psychotherapeutic
perspectives, it is noteworthy that intranasal oxytocin seems to facilitate the efficacy of
psychoanalytic interventions in the treatment of postpartum depression (Clarici et al., 2015).
The affective tendencies of fathers and mothers observing their infants may tend to be
more synchronized because their plasma oxytocin and vasopressin levels are more
synchronized, which may support heightened parental social attunements (Atzil, et al., 2012;
Feldman, 2012). Additionally, fathers given intranasal oxytocin exhibited increased social
gaze and reciprocity, along with elevated playfulness, accompanied by increased circulating
oxytocin levels in their babies (Weisman, et al., 2012). Oxytocin administration to infant rats
also elevates their attractiveness (as measured by approach tendencies) to maternal cues
(Nelson & Panksepp, 1996). Indeed, oxytocin acting to facilitate social coordination among
nearby animals is an intriguing possibility. For instance, as noted earlier, intraventricular
infusions of oxytocin as well as vasotocin to newborn chicks, tested individually, robustly and
consistently elevates three simple behaviors – head shaking, wing flapping, and yawning
(Panksepp, 1992). To see if these behaviors are socially ―infectious‖ animals were tested in
social groups, and, indeed, oxytocin promoted wing-flapping in the presence of social
companions, but levels of head-shaking and yawning were not promoted. It is hard to
interpret these effects without understanding the functional meaning of synchronous wing-
flapping – perhaps it is the only one of the three observed behavioral measures that reflected
elevated social confidence and/or sensitivity, but that remains to be more fully clarified.
Some of the above finding may also be related to the effects sex hormones, which is
especially important, since testosterone modulates vasopressin in a facilitatory fashion, while
estrogen promotes oxytocin influences in the brain. In general, evidence suggests that
testosterone is an ‗anti-empathy‘ molecule, potentially through its strong functional impact on
various subcortical aggression networks. In contrast, estrogen can diminish aggression while
increasing nurturance. Thus, it is no surprise, that investigators have found testosterone to
diminish empathy, while increasing dominance strivings (Mascaro, et al., 2013), while
oxytocin does the reverse (Brown, et al., 2013), suggesting a plausible conclusion that
dominance may reflect a fundamental ‗opponent process‘ to empathy (see closing section).

FUNCTIONAL HUMAN BRAIN IMAGING STUDIES OF EMPATHY

AND RELATED PROCESSES

From an initial modest dozen or so functional imaging studies of empathy and related
processes available at the turn of the 21st century and up until roughly 2003, the current
literature offers literally hundreds of such studies using various and in some cases disparate
empathy paradigms, resulting in great difficulty in comparing and clarifying results and
conclusions. Given space considerations, we will provide only basic overviews of this still
expanding literature. This work suggests that there are some basic networks heavily involved
in affective empathy, or closely related cognitive processes. For example, in classic studies
evaluating empathic responses to the pain of others, anterior cingulate and insular activation
is consistently observed (see Lamm, Decety and Singer, 2010 for excellent summary
overview and meta-analysis). Following their comprehensive meta-analysis, these
 Empathy and the Prosocial Brain 25

investigators conclude that bilateral anterior insula activation along with anterior medial
cingulate and parts of posterior cingulate cortices constitute „a core network for pain
empathy,‟ a neural network pattern that ―holds true across studies performed in different
countries, by different investigators on different MRI scanners, and using different types of
paradigms‖ (p. 2500). The authors also argue that the considerable overlap between this
network and the pain matrix network broadly supports theoretical notions emphasizing
‗shared neural representations‘ supporting our ability for intersubjectivity and for
understanding others. Lastly, the authors argue that this core empathy network can be
recruited by two different pathways, one underlying the understanding of actions and the
other the understanding of mental states. Which pathway will be predominantly recruited to
elicit empathy depends on the type of information available for the elicitation of empathy
(concrete vs. abstract), and how ‗social‘ the situation is in which the subjects are placed
(Lamm, et al, 2010).
Another recent meta-analysis (Fan et al., 2010) demonstrated a highly overlapping
distributed network involving dorsal anterior cingulate, dorsal mid-cingulate, supplementary
motor area and bilateral anterior insula as being consistently activated by various types of
empathy probes. The authors also distinguished various distributed brain networks and
regions more involved in affective and cognitive forms of empathy: cognitive forms of
empathy (typically recruiting left orbital frontal, left anterior mid-cingulate cortex and left
dorsomedial thalamus) while more affective empathy probes typically implicated right dorsal
anterior cingulate, right anterior insula, right dorsomedial thalamus and midbrain regions. In
addition, the left anterior insula was typically recruited in both cognitive and affective forms
of empathy. Collectively these meta-analytic studies suggest a central role for classic
paralimbic cortices, especially both anterior cingulate and insular regions, along with
associated thalamic and midbrain structures in the more affective forms of empathy. There
was also evidence to suggest that right hemisphere regions may be more critical for affective
forms of empathy, which is consistent with abundant data that the right hemisphere is
generally more attuned to affective issues, while the left hemisphere is more cognitively
oriented.

HUMAN DEVELOPMENTAL INVESTIGATIONS OF EMPATHY

AND ITS PRECURSORS AND ANTAGONISTS

An interesting question might be how early do empathy precursors in the form of

contagion or other relevant processes appear in development and how are they modulated and
by what factors? Many studies demonstrate that infants are capable of basic contagion
responses from a very early age, perhaps as young as two months (Field et al., 1982). By one
year, infants demonstrate robust capacities for contagion, coupled to the emergence of proto-
helping behaviors, even though at that age they are easily flooded by contagion effects, in a
fashion that can be disabling in terms of disrupting their efforts at helping a distressed other.
In several studies, Hamlin and colleagues (2013) explored social cognition in preverbal
infants, and mapped critical processes that appear to function as foundational to an inhibitory
‗gating‘ or down-regulation of empathy. For example, Hamlin et al. 2013 found a
developmental trend in which nine-month and 14 month infants were progressively
26 Douglas F. Watt and Jaak Panksepp

predisposed towards harsher treatment for dissimilar others, while being favorably disposed
towards others like themselves (with similarity and dissimilarity defined in terms of simple
food preferences). The authors conclude that ―identification of common and contrasting
personal attributes influences social attitudes and judgments in powerful ways, even very
early in life,‖ suggesting that the identification of similarity may be a potent modulating
variable on empathic responses. Similarly, Mahajan and Wynn (2012) also found that
preverbal infants were inclined to treat similar others more favorably, while being
predisposed to treat others seen as unlike themselves more harshly. This may reflect early
neurodevelopmental foundations for later arriving concepts of ‗Us versus Them‘, and
foundational for creating basic in-group vs. out-group distinctions, which have long been
thought to be critical for empathy modulation, especially as demonstrated in the work of
Singer et al., (2006). Although these investigators do not consider themselves to be primary
empathy researchers per se, we believe that this work underscores potent negative modulators
of empathy, and complements other work demonstrating modulation of empathy by the in
group/outgroup boundary (as summarized in Bernhardt and Singer, 2012).
These findings across several investigations suggest basic predispositions towards a more
empathic stance towards ‗like others‘, and a less empathic stance towards ‗dissimilar others‘.
Such predispositions may operate in the developing brain to improve cohesion between ‗like
others‘ (potentially amplifying affective and behavioral cohesion between members of a
group self-defined as sharing broad similarities), perhaps at the cost of a significantly harsher
in-group vs out-group boundary. This suggests an selection for processes that may amplify
group cohesion, but at the cost of inhibiting prosocial attitudes towards members of an out-
group characterized as ‗dissimilar others.‘ These investigations by Mahajan and Wynn (2012)
and Hamlin et al. (2013) point to poorly understood genetic predispositions operating early in
neurodevelopment that may positively promote or funnel empathy more powerfully towards
those whom we see as ‗like us,‘ while attenuating empathic responses significantly in
relationship to those who are seen as ‗unlike us‘. How much of the darker chapters of human
history to say nothing of our chronic struggle with prejudice in various forms might be at
least partially illuminated in this simple yet provocative set of findings from developmental
psychology research?

SUMMARY OVERVIEW –
SIX MAJOR VARIABLES MODULATING EMPATHY?
This review focused primarily on affective empathy, modeled as a ‗gated‘ (heavily
modulated) emotional resonance of internal distress between nearby organisms, conjoined
with an intrinsic motivation alleviate the distress of another. Although motivation to relieve
distress and mitigate suffering of others has sometimes been viewed as an ‗add-on‘ process
(and has been variably termed ‗affective or empathic concern‘ or ‗sympathy‘ or ‗compassion‘
and not as intrinsic or essential to affective empathy in some definitions of empathy (but see
Decety and Cowell, 2014 who argue for a viewpoint similar to ours), we have found no
compelling empirical evidence supporting such a functional segregation. Although not yet
fully clarified empirically, observational and anecdotal data, including research on
psychopathy (Blair, 2013), suggests that genuine motivation to relieve distress on the one
hand (sometimes termed ‗affective/empathic concern‘-- (see Decety and Svetlova, 2011) and
contagion susceptibility on the other hand, are mostly a ‗package deal‘ and not typically
 Empathy and the Prosocial Brain 27

functionally separated. At least the preliminary evidence suggests that both „states‟ as well as
„traits‟ in which affective concern for the other is profoundly inhibited such as sociopathy
typically predicts a corresponding and proportional inhibition of contagion effects from the
other‟s affect. We would propose this as a reasonable default proposition, still perhaps largely
untested, but with substantial face validity, where both validation and falsification could be
achieved in any number of empirical probes looking at the relationship between contagion
and prosocial concern. Degree of attachment to and familiarity with a suffering other, which
may strongly amplify concern for their well-being, may also amplify basic contagion effects
correspondingly and proportionally, including amplifying empathy for pain (as already
demonstrated in Langford et al., 2006). This means that contagion induction of the other‘s
suffering, and a conjoined motivation to relieve such suffering can undergo an enormous
range of ‗amplification values‘ dependent on variables modulating empathy activations, as
outlined below in relationship to several primary variables.
Without motivation to mitigate suffering, we argue that one cannot properly talk about a
full ‗affective empathy‘, although we concede that the ‗weight-of-evidence‘ for this position
(that contagion and concern for suffering are for the most part tightly functionally conjoined)
remains anecdotal, and many terminological/definitional issues still befuddle research on
empathy and other higher-order affective topics (again see Cuff, et al., 2015 for extended
treatment). We also advocate a view of affective empathy as modulated by many affective
variables. Both our current and previous emphases (Watt 2007) on ‗gating‘ or modulating
variables ramping empathic activations up or down, and earlier automaticity views (as seen in
Preston and DeWaal‘s (2002) extensive BBS review with commentaries) may both point to
fundamental features characterizing all affective activations: namely, on the one hand, they
appear to be relatively involuntary and thus seem „automatic,‟ and, on the other hand, they
are modulated by interactions between all the internal and environmental variables that
impact activation of positive versus negative affective states. In other words, as empathy is
fundamentally allied with positive affects towards others, it is fundamentally inhibited by
strong negative affects towards another. This is consistent with a basic competition between
negative and positive affect, and the manner in which positive affects generally allow and
facilitate other positives, while negative affects do the reverse and generally facilitate other
negative affects (although there are also some more modest inhibitory and competitive
interactions between different types of negative and different types of positive emotions – see
Panksepp 1998). These basic considerations would argue that negative affects towards a
suffering party are a potent inhibitor of empathy. In this review we emphasize the importance
of understanding the modulating of empathy in part because we believe that it underscores its
more ancient affective foundations, even if one must concede that any full ‗cognized‘ human
empathy is a complex multilevel phenomenon massively bridging the cognition-emotion
border. We would argue that in general the modulation of empathy while not totally
neglected, has been under-emphasized, both in terms of empirical work and in terms of
theoretical formulations.
Several of these six major modulating variables impacting empathy have still been
minimally researched, as discussed in Watt (2007): 1) complex polygenic genotypic aspects
(for which we have almost no established science excepting perhaps negative endowment in
relationship to a putative ‗sociopathy gene‘ (Feresin, 2009)); 2) phenotypic aspects
(emerging from early attachment history and other critical forms of social learning, and from
more versus less empathic parenting and peer group socialization), with both of these
28 Douglas F. Watt and Jaak Panksepp

genotypic and environmental factors determining an emerging baseline empathy capacity that
becomes a behavioral-affective phenotype. In other words, the early social environment must
interact with still minimally mapped spectrum of genotypes to create a broad spectrum of
basic empathic capacities that become relatively stable personality traits. A large scientific
frontier here is mapping the various genotypes (presumably associated with polymorphisms)
that might enhance versus blunt empathic capacity in social development, a basic genotyping
of empathy about which we currently know almost nothing. From this emerging empathy
baseline capacity (the emerging phenotypic personality trait indexing an enduring baseline of
empathic abilities or dysfunction), there appear to be several potent contextual variables
which either promote or blunt empathic activations in a situation-dependent manner: 3) state-
dependent influences (emerging from the current affective state of the empathizer); and 4)
the perceived qualities of the suffering party, including perceived social attractiveness
(particularly ‗cuteness‘ and social or biological vulnerability, both of which amplify
empathy), consistent with its strong intrinsic tie to maternal CARE (Panksepp, 1998); 5)
social familiarity, particularly any strong social bonding between empathizer and subject,
and; 6) basic in-group/out-group characteristics – as a highly salient form of familiarity. In
relationship to this last variable, preliminary evidence from the work of Wynn, Hamlin and
colleagues suggests that a potent selection effect operated in the direction of promoting
ingroup social cohesion at the cost of a harsher ingroup/outgroup boundary (consistent with
development research in which similarity and dissimilarity become empathy modulating
variables). This preliminary model, emphasizing a set of six variables, suggests that surely
the ‗activation space‘ of empathy is complex, and yet at the same time, not so complex as to
escape several basic predictions that this model might readily generate. Several of these
variables impacting empathy activations, particularly the role played by the perceived
qualities of the suffering party (‗cuteness‘ and vulnerability) have been minimally probed. An
obvious prediction – still untested – is that small vulnerable infants, with round faces and big
eyes will elicit vastly more empathy than will powerful alpha males, independent of species
(in other words this modulatory variable will predict higher versus lower empathic activity in
witnesses of both suffering humans as well as suffering animals). Another implication of this
multivariate-multiaxial model is that negative and positive regulators could be summed and
graded to create better real world predictions of the expected degree of empathic activation, in
contrast with any single or ‗primary factor‘ modeling. As but a simple example, the model
predicts that more empathic genotypes prone to high contagion, with good parenting and
social learning, dealing with highly vulnerable young children, to whom they are attached but
not currently irritated or otherwise experiencing negative emotion towards the suffering party
would have the strongest empathic activations in relationship to witnessing suffering.
Additionally, any comprehensive model aiming for any degree of predictive efficacy in the
real world would need to integrate that females, on average, are more empathic than males.
We believe that such a multiaxial and multivariate model is far more likely to yield better
predictions that more closely conform to real-world social observations than models
emphasizing one or even two or three variables.
Regarding the last variable in the model, the ingroup/outgroup modulation of empathy
appears to have special relevance to current historical-cultural concerns with prejudice,
racism, and terrorism (see the last chapter in this volume for a more extended treatment and
discussion). This ingroup/outgroup variable in empathy activation may have emerged from a
selection bias for processes that would amplify small-group cohesion and a mutuality of in-
 Empathy and the Prosocial Brain 29

group cooperation in hunter-gatherer groups (Tomasello et al., 2012). Although the evidence
base remains modest and there has been minimal exploration of how group boundary and
similiarity vs. dissimilarity mechanistically impacts empathy activations, we might suggest a
tentative hypothesis that evolution selected for the promotion of more cohesive small groups
at the cost of a potentially more „brutal‟ ingroup – outgroup boundary. Thereby, a down-
regulating of empathic responsiveness towards members of other groups, while potentially
up-regulating it in relationship to one‘s own group, as well as with other individuals with
whom one shares a sense of similarity, remains an important and perhaps underappreciated
factor in empathy. Recent important developmental psychology research amplifies our age-
old appreciation that humans are a ‗tribal‘ species in a fundamental manner, and with the
building blocks for pro-tribal identifications (a strong preference for ‗similar‘ others and a
relative antipathy for ‗dissimilar‘ others) emerging early, in prelinguistic development, and
visible even in infancy (Mahajan and Wynn 2012; Hamlin et al. 2013).
Such a biasing of the ingroup/outgroup boundary (Stürmer et al., 2006; Bernhard and
Singer, 2012), may help to partially explain our warlike and highly sectarian history as a
species. Other ‗opponent processes‘ to empathy may include basic dominance seeking
(paradigmatically energized by testosterone), along with virtually any other form of strong
negative affect or negative judgment about the other party. Anger and rage at another appears
to temporarily virtually terminate affective empathy, leaving (at most) only theory of mind
and cognitive understanding as remaining perspectives for angry individuals facing the
potential suffering of another – although again this has been only modestly probed. In their
harshest and conjoined forms however, these various ‗anti-empathy‘ or ‗opponent‘ processes
can lead to a virtually complete dehumanization of a hated and feared outgroup. Such
processes may potentiate not just regional wars between nation states and other cultural and
ethnic groups, but also underpin genocide and terrorism, as empathy must be completely
extinguished as a prerequisite for large scale violence to take place. The perennial seductions
of protean forms of dehumanizing ideology may thus be another fruitful and relatively
neglected research frontier to appreciate the ‗down-regulation‘ of empathy, particularly
within highly stressed cultural groups, operating powerfully at the ingroup/outgroup border,
and often fomented by charismatic leaders with sociopathic features seeking to consolidate
power by ramping up fear and hatred of an outgroup. Individual psychopathology and
developmental attachment trauma (which can clearly down regulate empathy and may even
powerfully derail development of basic empathy) may amplify vulnerability to these larger
social forces. While Hitler and Nazism remain perhaps the most powerful and prototype
paradigms for these complex ‗anti-empathy‘ social processes, they were unique only in the
scale of their atrocity, not in a basic and shared psychology/psychodynamics (Longerich,
2003). While these questions have been given new urgency in the context of recent
international conflicts and a growing focus on fundamentalist ideologies and their role in
terrorism, our entire recorded history has been filled with too many sad examples of our
recurrent vulnerability to seduction by these potent empathy ‗terminators‘. These
considerations suggest an underappreciated and powerful relevance of empathy research, in
illuminating these patterns within human history and in understanding recurrent forms of
human conflict. Such perspectives may offer at least some restraint against the old siren songs
of many cultural, national and religious groups rallying their members towards yet another
instantiation of violent sectarianism. In other words, modern empathy research underlines our
30 Douglas F. Watt and Jaak Panksepp

deep vulnerability to seduction by such calls and sheds new light on our ancient human
tribalisms.
Aside from these more contemporary socio-political and cultural implications of empathy
research, progress towards a deepening integration of human and animal models, and the
parallel integration of cognitive and affective processes remains our most challenging
scientific frontier in empathy research. Contagion is beginning to be better mapped at the
behavioral level in animals, but has so far only received modest neuroscientific attention in
terms of unraveling its neural substrates. The relative neglect of this topic may point to poorly
understood receptive processing capabilities, of the subcortical affective/instinctual brain, as
intuited by McDougall more than 100 years ago. Emotional contagion may be an ancient and
developmentally primitive emotion-induction mechanism, especially in young mammals and
humans, that cognitive development modifies. Over ontogenetic and phylogenetic time,
contagion may be largely but not totally supplanted by increasingly complex forms of highly
cognitive appraisal, but contagion may remain a underappreciated building block for the
construction of prosocial brains. Contagion may developmentally energize an emerging
theory of mind, emotion identification, and declarative knowledge about basic emotions, all
in the context of ongoing social attachments to somehow create complex cognized human
empathy. Thus, while theory of mind/perspective taking, shared affects, supportive behaviors,
and relief of suffering can conjoin in a parallel process, we have to strongly suspect that the
capacity for shared affect is likely foundational, and required for building what emerges as a
complex affective/cognitive composite.
Functional imaging work in empathy demonstrates consistent participation by a network
of anterior/executive and more posterior sensory cortices in classic paralimbic areas of
cingulate and insula (Lamm, Decety and Singer, 2010), consistent with models positing
adaptive functional linkages between sensory and executive brain areas in empathy. This
basic finding, now widely replicated, is also consistent with how these paralimbic regions
form a large neural bridge linking the ancient subcortical affective and homeostatic executive
brain with the newer arriving cortico-cognitive brain, along both executive and sensory axes.
In summary, we might offer the encouraging conclusion that despite the complexity of
the phenomena, the continuing confusion re: definitions and terminology, and the sometime
disparate voices in a sprawling and formidable literature that a basic scientific consensus
about empathy is slowly emerging. Empathy is a complex developmental achievement
involving both affective and cognitive components, melting relatively ancient with more
recent arriving functions of the human mind/brain, and one critical to the long-term stability
of social bonds, to the mitigation of suffering, and for other prosocial capacities and functions
of our brains and minds. Empathy research thus seems primed and well situated to continue
its growth and maturation, as a rich and deep territory for ongoing psychological and
neuroscientific investigation.

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In: Psychology and Neurobiology of Empathy ISBN: 978-1-63484-446-8
Editors: Douglas F. Watt and Jaak Panksepp © 2016 Nova Science Publishers, Inc.

Chapter 2

EVOLUTIONARY ORIGINS OF EMPATHY

Shigeru Watanabe
Division of Cognitive and Behavioral Research
Research Centre for Human Cognition, Keio University
Minato-ku, Tokyo, Japan

ABSTRACT
Empathy is an intrinsic emotional response to the emotional expression of others.
Darwin believed that infrahuman animals have a sense of empathy and wrote, ―Many
animals certainly sympathize with each other‘s distress or danger.‖ Empathy for positive
emotions occurs when the positive fortune of others generates similar positive emotions
in the observer, and empathy for negative emotions occurs when observing the distress of
others activates similar distress in the observer. These emotional responses are considered
to be potentially adaptive for the observer, because the good fortune of others may signal
positive fortune for the observer while the misfortune of others may signal danger for the
observer. Empathy for positive emotion results in social facilitation and empathy for
negative emotion can result in rescue or helping behavior that potentially serves to
alleviate both the observer‘s and the subject‘s distress. In both forms of empathy,
emotions are generally state-matched between the demonstrator and the observer.
‗Reversed empathy,‘ or envy, occurs when distress results from observing the fortune of
others. This emotional response may be a contributing basis for the sense of fairness.
Schadenfreude occurs when pleasure is derived from the misfortune of others. Reversed
empathy and Schadenfreude are forms of non-state-matched empathy, and were
previously thought to be unique to humans. However, recent animal experiments have
suggested that non-human animals also exhibit non-state-matched empathy, pointing to
an earlier evolutionary origin of these phenomena. In this chapter, experimental evidence
for the four types of empathy in animals is presented, and the evolutionary origin and
biological function of empathy is discussed.


E-mail: swat@flet.keio.ac.jp. Tel: +81-3-5443-3896.
38 Shigeru Watanabe

INTRODUCTION
Empathy has been a topic in philosophy (e.g., Woodruff, 1989; Nussbaum, 2001), social
science (e.g., Ellis, 1993; Calloway-Thomas, 2010), and developmental psychology (e.g.,
Eisenberg, 1989) for some time, but has only recently become an intensely studied topic in
neuroscience and comparative cognition (Preston and de Waal, 2002a; de Waal, 2006;
Panksepp and Lahvis, 2011). Empathy is based on an intrinsic relationship between the
emotional states of an observer and those of a demonstrator, and involves not merely
understanding the emotional states of others, but also matching one‘s own emotional state
with that of others (see extended discussion in first chapter of this volume about definitional
and terminological controversies around empathy concepts). Hence, empathy bridges self-
recognition and social cognition (Kuczaj et al., 2001). Human empathy is surely complex, but
it is not human unique emotion. It should have evolutionary origin. Charles Darwin observed
sympathy in animals as a response to the distress or danger of others and, in 1872, wrote,
―Many animals certainly sympathize with each other‘s distress or danger‖ (Darwin, 1872).
This chapter examines the evidence base for various forms of empathy in animals, and
discusses the evolutionary origin and biological function of empathy.

1. CLASSIFICATION OF EMPATHY
Empathy has been variably defined as simple shared emotion (Mehrabian and Epstein,
1972), a cognitive ability dependent on perspective taking (Hogan, 1969), reflecting both
shared emotion and perspective taking (Barrett-Lennard, 1962), the decoding of the emotional
state of others (Omdahl, 1995), the inference to understand personal experiences of another
person (Danziger et al., 2006), with perhaps these abilities reflecting ‗communicative genes‘
(Buck and Ginsburg, 1997). (For further review of these definitional controversies, see
chapter 1 of this volume and Cuff et al., 2015). Some researchers have classified empathy
along a simple-to-complex continuum: Decety and Jackson (2004) differentiated simple
emotional contagion from more complex empathy, and Preston and de Waal (2002b)
proposed a hierarchical classification of 1) emotional contagion (the emotional state of the
observer directly results from perceiving the emotional state of the demonstrator), 2) empathy
(the emotional state of the observer results from perception of the situation or predicament of
the demonstrator), 3) cognitive empathy (a shared emotional state that is arrived at through
cognitive means) and 4) sympathy (a state in which the observer feels sorry for the
demonstrator as a result of perceiving the distress of the demonstrator). Although empathy
has been described as emotional, cognitive, or motor (Blair, 2005), with motor empathy in
Blair‘s description being roughly synonymous with concepts of contagion, the original
German term is ―Einfuehlung‖ (translated from German to English by Titchener, 1909),
which refers to feeling or emotion rather than cognition; therefore, in this chapter, empathy is
defined as the emotional response evoked by the expression of emotion of others. In a narrow
sense, empathy traditionally refers to the emotional response of an observer to the expression
of distress of a demonstrator, but clearly observers can also feel pleasure when observing
happiness of demonstrator. Thus the induced emotions can be classed as positive or negative.
A negative emotional response to the distress of a demonstrator is perhaps the most basic
 Evolutionary Origins of Empathy 39

empathic response. In contrast, empathy for positive emotion is a positive emotional response
to the happiness or other positive emotion of a demonstrator. In both empathy for negative
and for positive emotions, the emotion of the observer matches that of demonstrator;
therefore, in this sense, empathy is typically state-matched. However, in a different vein,
empathy concepts have been extended to emotional responses that are not same as that of the
demonstrator (‗non-state-matched‘) (Figure 1).
Some researchers have excluded such non-state-matched emotions from the definition of
empathy and, in doing so, exclude all occasions in which the emotion of the observer does not
match that of the demonstrator (e.g., de Vignemont and Singer, 2006), but we can find
support for empathy concepts in which the emotion of observers is not matched with that of
the demonstrator.

Figure 1. Classification of empathy. See text for explanation.

‗Reversed empathy‘ occurs when the pleasure of the demonstrator induces an aversive
emotional experience in the observer. This can occur in competitive situations; for example,
when foraging for limited food, observation of the demonstrator eating food may index
potential starvation or at least malnourishment of the observer and thus induce an aversive
emotional experience. However, ‗reversed empathy‘ can also occur in non-competitive
situations. Envy and jealousy are examples of such reversed empathy. ‗Reversed empathy‘ in
a non-competitive situation is considered a non-adaptive emotional response, because it has
no obvious direct benefits for the observer. Another example of ‗non-state-matched empathy‘
is pleasure derived from the misfortune of the demonstrator. This can be considered adaptive
in a competitive situation, but can also occur in non-competitive situations, and is termed
‗Schadenfreude.‘ Subsequent sections of this chapter present empirical results in relationship
to each of these types of empathy in animals and discuss the evolutionary benefit that may
have been conferred by each type of empathy.

2. EMPATHY FOR NEGATIVE MOTION

Empathy for negative emotions is perhaps the most basic form of empathy. The distress
of others may indicate danger to the observer; thus, sensitivity to other‘s distress has a clear
40 Shigeru Watanabe

survival value. In this section, empathy for negative emotion in animals is described, followed
by a discussion of how empathy for negative emotion may have conferred an evolutionary
advantage.

2.1. Aversive Properties of the Distress of Others

Many studies have demonstrated that the expression of distress of conspecifics has clear
aversive properties. Monkeys exhibited behavioral signs of fear when watching other
monkeys in fear, even when they could not see the fear stimulus (Mineka and Cook, 1993).
Empathy for negative emotion has not only been observed in primates (O‘Connell, 1995), but
also in elephants (Bates et al., 2008), pigs (Reimert et al., 2013), and rodents (Panksepp and
Lahvis, 2011). For example, Kiyokawa et al. (2006) reported that rats placed in a box in
which they had previously seen their cage mates receiving an electric shock showed more
freezing, rearing, and sniffing than control rats.
Distress of a conspecific can cause physiological responses. In pigs, the distress call of a
conspecific caused a heart-rate response that differed from that observed in response to
artificial sound (Düpjan et al., 2011) and, in mice, exposure to a conspecific receiving tone-
shock conditioning also caused a change in heart rate (Chen et al., 2007). In deer mice,
exposure to a conspecific being attacked by biting flies caused an increase in corticosterone
levels (Kavaliers et al., 2003).
Behavioral suppression by pain response of others is another manifestation of empathy
for negative emotion that has been observed in animals. Church (1959) trained rats to perform
a lever-press task to receive a food reward. When rats witnessed cage mates receiving an
electric shock in a chamber next to the operant chamber, the rate of lever pressing was
suppressed (Church, 1959). Similarly, pigeons that were trained to perform a key-pecking
task showed suppression of the operant behavior during observation of the pain response of a
bird in the adjacent chamber (Watanabe and Ono, 1986). Evidence of empathy for negative
emotion in animals has also been obtained from preference experiments. Mice preferred odors
from a non-stressed conspecific to those from a stressed conspecific (Carr et al., 1980), and
rats avoided pressing a lever associated with playback of conspecific vocalization induced by
electric shock (Otsuka et al., 2009). In contrast to these kinds of results on the other hand, rats
pressed a lever to turn off white noise more often than they pressed a lever to turn off
conspecific vocalizations induced by pain (Lavery and Foley, 1963). However, the relative
volume of the noise and the affective vocalization may have confounded this particular result,
as loud noise can also have aversive impact.
Overall, these data suggest that distress of a conspecific is itself innately aversive.
However, there is evidence that animals can also easily adapt to this aversive property. Rats
(Church, 1959) and pigeons (Watanabe and Ono, 1986) recovered the operant behavior after
repetitive exposure to the pain responses of conspecifics, suggesting that there is rapid
adaptation/habituation, resulting perhaps in significant inhibition of empathy for negative
emotion in animals. If the distress of conspecifics functions as an alarm signal, the alarm
function may be suppressed by habituation after repeated exposures not followed by real
danger.
Empathy for negative emotion is an innate response capacity, but it can also be acquired
and enhanced. One process by which empathy for negative emotion can be acquired is
 Evolutionary Origins of Empathy 41

classical conditioning, in which the distress of the demonstrator is the conditioned stimulus
and an aversive experience, such as electric shock, is the unconditioned stimulus. After such
conditioning, rats (Church, 1959) and pigeons (Watanabe and Ono, 1986) exhibited
conditioned empathy for negative emotion. This is a special case of a conditioned emotional
response or conditioned suppression in operant conditioning. Another process by which
empathy for negative emotion can be acquired is through the sharing of common aversive
experience. Rats (Church, 1959) and pigeons (Watanabe and Ono, 1986) showed enhanced
and prolonged suppression of operant behavior if they had experienced similar electric shocks
to those received by the demonstrator. These observations suggest that a shared experience
base is an important factor in empathy for negative emotion. These results could index a kind
of cross-modal transfer between visual observation of the pain response of others and the
somatosensory memory of experiencing pain. Atsak et al., (2010) confirmed such a role of
prior experience in empathy for negative emotion of rats, and human brain imaging studies
also support this hypothesis. Singer at al. (2004) reported that the anterior cingulate cortex
and anterior insula were activated by participants‘ own pain and when participants observed
the pain response of others. Preis and Kroener-Herwig (2012) also hypothesized that prior
experience positively amplifies empathy. Empathy for negative emotions would be expected
to elicit dysphoria and anxiety, and consistent with this, injection of diazepam, an anti-anxiety
drug, reduced the behaviorally inhibiting effect of conspecific pain response on operant
responding in pigeons (Inagawa and Watanabe, 1991).
If the distress of the observer and the observed distress of the demonstrator have a similar
effect, the effects may synergize. Langford et al., (2006) reported that a pain response induced
by injection of formalin into the hind leg of mice was enhanced when a cage mate was also
injected with formalin. The relative magnitude of the induced pain apparently influences the
empathy for negative emotions. When the observer was injected with a low dose of formalin
(1%) and the cage mate was injected with a high dose of formalin (5%), the pain response of
the observer increased, and when observer was injected with a high dose of formalin and the
cage mate was injected with low dose, the pain response of the observer decreased (Langford
et al., 2006). Thus, lessened pain response of a conspecific serves to reduce the observer‘s
pain response while the greater pain response of a conspecific serves to increase the
observer‘s pain response.

2.2. Social Learning

The distress of others can signal danger; therefore, empathy for negative emotions can
enable observers to learn what is dangerous through enhancing social learning. Deer mice
learned of the danger posed by a micro-predator, the biting fly, through observation of
conspecifics attacked by the fly; after the observation, the observer displayed enhanced self-
burying avoidance responses when exposed to the fly (Kavaliers et al., 2003). This social
learning was influenced by kinship, familiarity, and the dominant/subordinate relation
between the observer and demonstrator (Kavaliers et al., 2003). Bruchery et al., (2010)
demonstrated that rats learned aversive stimulus properties through observing the fear
response of a conspecific, and Kim et al., (2010) reported social transmission of an aversive
stimulus property via an ultrasonic distress call in rats. Jeon et al., (2010) reported that
observer mice expressed freezing behavior when they were adjacent to a fearful demonstrator
42 Shigeru Watanabe

mouse that was receiving repeated shocks, and when the observer mouse was placed back
into the specific context where the demonstrator had experienced the shock, it again
expressed freezing behavior. In addition, a reduction of fear after the observation of fearless
conspecifics has been reported in mice (Guzman et al., 2009).
Many species of birds learn their predators through social or observational learning.
Some species exhibit a ‗mobbing‘ response to possible predators. When ―student‖ European
blackbirds were exposed to a neutral object and ―teacher‖ birds were exposed to a stuffed
owl, the teacher birds exhibited a mobbing response to the owl. The student birds were not
able to see the stuffed owl or the teacher birds, but they were able to hear the sound of the
teacher birds mobbing, and they learned to exhibit a mobbing response to the object (Curio et
al., 1978). Similarly, monkeys acquired fear of snakes after watching other monkeys‘ fear of
snakes (Cook and Mineka, 1989), and offspring of crows that had been captured and released
produced an alarm call when exposed to humans wearing the same mask as worn by the
captor (Cornell et al., 2011), with this result potentially indexing epigenetic transmission.
Taste aversion, when observers learn dangerous foods by observing illness of others, may
be another example of social transmission of danger avoidance. Social transmission of taste
aversion has been observed in red-winged blackbirds (Mason and Reidinger, 1982), but
although Levin et al., (1980) reported socially-mediated taste aversion in rats, this has not
been supported by other studies (Galef et al., 1983; 1990; Grover et al., 1988). Most rodents
are neo-phobic, therefore the default value of many if not all novel foods is generally at least
mildly aversive. As such, although information regarding ―safe‖ food may have some value,
information regarding ―dangerous‖ food does not give new information, and this may explain
the lack of socially-mediated taste aversion in rodents.

2.3. Rescue Behavior

The aversive property of the demonstrator‘s distress presumably has a large role in rescue
or helping behavior. If the distress of a conspecific is an aversive stimulus, termination of the
distress means that the observer will escape from the aversive stimulus. One of the earliest
reports of rescue behavior is from Mirsky et al., (1958), who observed that rhesus monkeys
that had the experience of receiving an electric shock terminated shocks delivered to a
monkey in an adjacent chamber. Another well-known example of rescue behavior in primates
is offered by Wechkin et al., (1964), who observed that a monkey that was offered two
chains, one that provided food and another that provided both food and an electric shock to
another monkey in a connecting chamber, pulled the chain that did not deliver the electric
shock more often than the chain that delivered the electric shock. Rice and Gainer (1962)
reported a classic example of rescue behavior in rodents, whereby rats pressed a lever to
lower a conspecific that was hanging from a ceiling of the chamber more often than they
pressed a lever that lowered an inanimate object from the ceiling, suggesting that reduction of
conspecific distress is intrinsically positive. More recently, Ben-Ami Bartel et al., (2011)
placed a rat in an experimental arena with a cage mate that was trapped in a transparent tube,
and reported that the free rat learned to open the door of the tube to free the trapped cage
mate, but did not open the door of the tube if it was empty or contained an inanimate object.
The authors argued that these results demonstrate that the rats behaved pro-socially in
response to the distress of a conspecific.
 Evolutionary Origins of Empathy 43

Langford et al., (2010a) reported that mice placed in an alley that had a cage mate trapped
in a container at either end spent more time with a trapped cage mate in pain than a trapped
cage mate without pain. Similarly, mice stayed longer with a cage mate injected with formalin
into the hind leg than with a non-injected cage mate (Watanabe, 2012). It is possible that
observing the pain response of a conspecific induces curiosity in the observer, or that the
tendency to stay close to a suffering cage mate is a manifestation of pre-concern whereby
animals are attracted to the pain of another (de Waal, 2006). Alternatively, this behavior may
have an analgesic effect. Langford et al., (2010a) reported that a mouse in pain displayed less
pain behavior when accompanied by a cage mate, and the approach behavior may therefore
be a form of rescue behavior (pain presumably being reduced by social support and presence
of a conspecific). However, mice avoided a compartment of their cage that was associated
with a formalin-injected cage mate (Watanabe, 2012a), indicating that distress of a cage mate
may also have an aversive property, even though such distress induces approaching behavior
in conspecifics. Approaching a conspecific that is displaying pain or sickness may be
dangerous, due to the risk of infection. After mice had been primed with cadaverine (1,5-
diaminopentane), which smells of decomposed animal tissues, they avoided conspecifics that
were exhibiting sickness behaviors (Renault et al., 2008). Thus, rescue behavior towards
conspecifics exhibiting sickness behavior is not a universal phenomenon or at least can be
inhibited by stimuli that also activate disgust or that suggest immunological challenge. This
conflict is discussed further in Section 5.

2.4. The Biological Basis of Universal Morality

Empathy for negative emotions is widely observed in humans. Hauser (2006) proposed
the concept of universal morality of Homo sapiens, based on the idea that most humans
display a basic capacity for ethical behavior. According to Hauser, humans have ‗universal
morals‘ analogous to ‗universal grammar.‘ Because distress of others intrinsically activates
distress in the observer, escape and avoidance of distress for others can provide motivation
for the rescue behavior seen in empathy for negative emotions. Facilitation of empathy for
negative emotions by common experience also supports the idea. A possible biological origin
for human morality may therefore be avoidance of one‘s own distress generated via empathy
for other‘s negative emotions and suffering.

3. EMPATHY FOR POSITIVE EMOTION

Empathy for positive emotion is an emotional response in which observers feel pleasure
when observing the happiness of demonstrators. Adam Smith (1759) pointed out that seeing
happiness of others caused pleasure, even though the observer derived nothing from it except
for the pleasure of seeing it. This phenomenon is challenging to confirm in non-human
animals, but can be inferred from descriptions of social reinforcement, social facilitation,
social learning, and helping behavior. Additionally, the contagiousness of play responses
(Panksepp, 1998) may index a kind of empathy for positive emotion.
44 Shigeru Watanabe

3.1. Social Reinforcement

Social stimuli such as conspecific have reinforcing property. Using a social choice
paradigm in which two stimulus mice were placed in Plexiglas cylinders, Brodkin et al.,
(2004) demonstrated that female C57/Bl mice exhibited approach behavior to a conspecific,
suggesting an affectively positive quality of the conspecific, whereas female Balb/c mice
exhibited avoidance behavior suggesting negative affective activations emerging from contact
with the conspecific. Social preferences (positive reinforcing property) in rodents are also
influenced by developmental stage (Panksepp and Lahvis, 2007), environmental context
(Pearson et al., 2010), housing (Douglas et al., 2004), and social status (Van Loo et al., 2001).
Mice learned to press a lever to receive a visual display of a conspecific (Antonitis and Baron,
1964), and juvenile rats showed a preference for playing with cage mates in a T-maze
(Humphreys and Einon, 1981). These results support the reinforcing property of the social
stimuli (social reinforcement).
Conditioned place preference (CPP) is a common paradigm by which to study the
reinforcing property of drugs. Animals are placed in a test box that consists of two or three
compartments, each of which has unique environmental cues, such as the color of walls, floor
texture, etc. The amount of time spent in or near each compartment (staying time) is
measured (pre-conditioning baseline). The animals are then injected with a drug and restricted
to one chamber. The following day, they are injected with a vehicle and restricted in a
different chamber. This treatment (conditioning) is repeated several times before staying time
at each compartment is measured once again. If the drug has positive affective properties, the
animal will stay longer in the compartment associated with the drug injection after
conditioning than they did before conditioning. Calcagnetti and Schechter (1992) employed
this procedure to examine affective reward properties of rough-and-tumble play in rats. The
rats demonstrated conditioned place preference (CPP) in which playing was associated with a
particular chamber of the cage. Also using CPP procedure Fichett et al., (2006) showed home
cage odors caused CPP in subordinate mice. These CPP experiments demonstrated the
positive affective properties of social stimuli, particularly play, and suggest the possibility of
empathy for positive emotion, but do not provide clear evidence that the demonstrator and
observer shared the same emotional experience.

3.2. Social Facilitation

Social facilitation is enhancement of behavior by doing the same behavior together,

presumably driven by basic social rewards, although mechanisms may be multivariate. There
have been many studies about the social facilitation of feeding behavior, whereby observation
of demonstrators eating food induces eating behavior in the observers. However, such
facilitation may increase competition for food when resources are limited or may cause anti-
predatory behavior due to delusion effects of group feeding. Other possible examples of
social facilitation are found in pharmacological experiments, where there are many cases of
social facilitation of drug effects. For example, people tend to drink more when they are with
other drinkers and often start smoking if they have friends that smoke (Glynn, 1989), and it is
well known that social factors can play a strong role in the initiation and maintenance of drug
abuse. Experiments on social factors in reinforcing property of drugs give, however,
 Evolutionary Origins of Empathy 45

somewhat confusing results. For example, Bardo et al., (2001) reported that rats reared
together with social partners consumed less amphetamine than rats reared in social isolation
(suggesting that isolated rats were potentially needing to treat a dysphoric state), and Schenk
et al., (1986) reported that social isolation reduced amphetamine-induced CPP in rats. Social
reinforcement and drug reinforcement are often additive. Thiel et al., (2009) reported that
neither low-dose nicotine nor social partnering resulted in any CPP when given alone, but that
simultaneous delivery of nicotine and social rewards elicited a CPP in adolescent rats.
Similarly, although a low dose of cocaine and social pairing failed to produce a CPP when
examined alone, the combination of the social reward and the drug did produce a CPP (Thiel
et al., 2008). These results indicate that the positive reinforcing properties of drugs are
influenced by social cues and presumably amplified by social rewards.
In addition to the presence of a cage mate, the pharmacological status of the cage mate is
also important in the social modification of pharmacological effects of drugs. For example,
adolescent rats consumed more ethanol following interactions with a social partner that had
been injected with ethanol than following interactions with a social partner that had been
injected with water (Hunt et al., 2001; Maldonado et al., 2008). However, Gauvin et al.,
(1994) reported that the presence of a cage mate reduced conditioned aversion to alcohol in
rats, regardless of whether the cage mate had consumed alcohol, indicating that although
conditioned alcohol aversion was sensitive to social interactions, normal and intoxicated
mates elicited similar effects. To clarify whether the common experience with a drug
influences the reinforcing properties of that drug, the reinforcing properties of
methamphetamine were examined in a social context using a CPP paradigm in mice
(Watanabe, 2011a). The paired and control-paired groups both received CPP training with a
cage mate. In the paired group, both mice were injected with methamphetamine, or both were
injected with saline. The control-paired group received CPP training with their cage mate but
treatment was reversed. When one mouse was injected with methamphetamine and the other
was injected with saline. There was facilitation of CPP in mice that were conditioned together
with similarly treated cage mates but not in mice that were conditioned together with
differentially treated cage mates. These results indicate that social facilitation does not simply
represent the summation of drug rewards and social rewards but rather that a common
neuromodulatory/neurodynamic substrate is crucial for social enhancement of the positive
reinforcing properties of methamphetamine.
Morphine is another drug that has a powerful impact on various affective systems, and
amplifies play and potently suppresses separation distress (see Panksepp, 1998 for detailed
exposition). It affects the social behavior of juvenile rodents, suppressing or facilitating social
behavior depending on the context and dosage (Panksepp et al., 1985; Vanderschuren et al.,
1995; Kennedy et al., 2012).
In addition, dominant rats showed CPP with morphine, but their submissive partners did
not (Coventry et al., 1997). If a dominant rat was defeated, CPP was absent from the formerly
dominant rat. These findings suggest that morphine-induced CPP may be sensitive to the
social status of the subjects. However, in contrast to the social facilitation observed for the
positive reinforcing properties of methamphetamine (Watanabe, 2011a), the reinforcing
properties of morphine were suppressed by the presence of a morphine-injected cage mate
(Watanabe, 2012b).
46 Shigeru Watanabe

Figure 2. Design to examine social facilitation of reinforcing property of methamphetamine. Mice

received CPP training alone in Single CPP group, mice received the CPP training together with
similarly treated cage mates in Paired CPP group, and mice received CPP training together with
differentially treated cage mates, where one mouse was injected with saline when the other was injected
with methamphetamine in Control-paired group (Watanabe, 2011a).

Social facilitation functions to strengthen the bonding within a group and can thereby
elicit positive emotion. Although the emotional state of the demonstrator and observer are the
same in social facilitation, empathy for positive emotions is defined as the pleasure elicited
from seeing happy demonstrators, regardless of the state of the observer (Adam Smith, 1790).
In this sense, the phenomenon of social facilitation is not strictly equal to that of empathy for
positive emotion. However, social facilitation can give us some indication of a empathy for
positive emotion-like phenomenon in animals.

3.3. Social Learning

As the empathy for negative emotions has a role in social learning of possible dangerous
stimulus, the empathy for positive emotions may have a role in social learning. There have
been reports of social transmission of food preference in rats (Galef, 1996; Terkel, 1996),
monkeys (Fragaszy and Visalberchi, 1996), rabbits (Bilkó et al., 1994), dogs (Lupfer-Johnson
et al., 2007), and hamsters (Lufper et al., 2003), but it is not clear if social transmission of
food preference is mediated by empathy for positive emotions. Observers detected the
 Evolutionary Origins of Empathy 47

combination of novel food smells and carbon sulfides in saliva (Galef et al., 1988) and
olfactory receptors for carbon disulfides were involved in the transmission of food
preferences (Munger et al., 2010). In rodents, social transmission of food preference was
strongly dependent on facial interactions with live demonstrators (Galef et al., 1985), but in
an asocial strain of mice, olfactory cues were sufficient to cause transmission of food
preference (Ryan et al., 2008; Zaccaria and McCasland, 2010). The social transmission of
food preferences was disturbed by injection of scopolamine (an inhibitor of cholinergic
transmission) (Carballo-Márquez et al., 2009) and naltrexone (an opioid antagonist) (Mole et
al., 1999), but facilitated by injection of benzodiazepine (potentiating of GABAergic
transmission) (Choleris et al., 1998). Although these observations suggest that social
emotions are important in the social transmission of food preference, it is unclear whether the
transmission is mediated by empathy for positive emotions.

3.4. Helper and Rescue Behavior

There are many examples of helping behavior in animals. The classic idea of the
helper/helping behavior is based on kin selection, whereby helpers engage in taking care of
infants to increase inclusive fitness. However, there have also been reports of non-kin helpers.
Non-kin helper behavior may occur because experiences of helping with parental care result
in good breeders (Komdeur, 1996) and efficient foraging (Heinsohn, 1991), or because they
enable helpers to display their breeding ability to potential mates (Sherley, 1990). However, it
is not clear if empathy for positive emotions is involved in this behavior, and it is hard to find
evidence for a positive state in the helper temporally close to the helping behavior.
Miller et al., (1966) trained monkeys to deliver food to other monkeys, but the results
were not clear enough to draw conclusions regarding helping behavior. In contrast, a similar
experiment using termination of electric shock to a monkey in an adjacent chamber clearly
demonstrated helping behavior (Mirsky et al., 1958). In experimental settings, chimpanzees
and tamarins do not consistently take advantage of opportunities to deliver food rewards to
others, but capuchins and marmosets did (Silk and Hause, 2011). In a natural setting, Silk et
al., (2005) reported helping behavior between unrelated chimps, and Vogel and Fuentes-
Jime‘nez (2006) reported that, during an inter-social group encounter, the victim of a mother–
infant pair of white-faced capuchin monkeys was rescued from potential injury or death by
the intervention of an adult male from their social group. Theoretically, reciprocal empathy
for positive emotions may provide an explanatory basis for these instances of helping
behavior, and the reports of helping behavior in animals may thus be indicative of empathy
for positive emotions. However, to determine that helping behavior is maintained by a
positive affective state in the helper, it must be demonstrated that the helped conspecific
generates a positive affect for the helping animal or that animals look for the opportunity to
rescue others. At present, there is no clear evidence that such a positive state is involved in
helping behavior in animals. Alternatively, helping behavior may be simply motivated by
positive effects of reducing conspecific distress.
48 Shigeru Watanabe

4. REVERSED EMPATHY
‗Reversed empathy‘ is non-state-matched empathy, in which distress results from
observing the fortune of others. It is generally considered to be non-adaptive or less adaptive
because it does not offer an obvious benefit for the observer. Reversed empathy has been
studied in animals using the memory-enhancing effects of stress (Watanabe, 2011b). Stress
has an interesting effect on memory, particularly on memory of an aversive experience
(Miracle et al., 2006; Roozendaal et al., 2009). Rats that experienced restraint stress showed
stronger retention or natural recovery of fear conditioning in a test performed 2 days after
extinction of conditioned fear, and were more resistant to extinction of conditioned fear than
rats that did not experience stress (Miracle et al., 2006). Chronic food deprivation stress also
caused enhanced retention of passive avoidance learning in C57 mice (Hashimoto and
Watanabe, 2005). Cabib et al., (1996) reported that the memory-enhancing effects of stress
were modulated by corticosterone, a stress hormone, in a dose-dependent manner. These
experiments showed stress experience enhanced aversive memory and I employed this
phenomenon to examine reversed empathy (Watanabe, 2011b).
Reversed empathy has been studied in mice using restraint stress delivered to solitary
mice, mice that were restrained with a restrained cage mate, and mice that were restrained
while cage mates were free (Figure 3; Watanabe, 2011b).

Figure 3. Design to examine reversed empathy of restraint stress in mice. Control group that received
no stress, Single stress group that received stress alone, Empathy group that received stress in group
with cage mates, and Reversed empathy group that received stress with no-stress cage mates.

All animals received an electric shock from the floor when they stepped down onto the
floor of the experimental chamber, and were then placed on the floor without electric shock
 Evolutionary Origins of Empathy 49

(‗extinction trial‘). If the animal learns that the floor is no longer dangerous, they should
quickly step down on the floor in the test after the extinction trial. Mice were tested at several
time points after the extinction trial. Mice that experienced restraint stress took longer to step
down onto the floor than mice that had not experienced stress, indicating that restraint stress
enhanced the aversive effects associated with shock stress – which is hardly surprising.
However, the enhancement of aversive effects was less in mice that were restrained with cage
mates than in mice who were restrained alone, indicating that a socially equal condition
reduced stress-induced effects or at least moderated them. On the other hand, the
enhancement of aversive memory was greater in mice that were restrained while cage mates
were free than in mice who were restrained alone, suggesting that although the stress-induced
effects were reduced by empathy, they were increased by ‗reversed empathy‘ or envy. The
level of corticosterone after the restraint was highest in mice that experienced restraint with
free-moving cage mates and lowest in mice that experienced restraint with restrained cage
mates (Watanabe, 2011b), indicating that the degree of stress differed according to the social
situation, even though the restraint time was the same. These results suggest that ‗reversed
empathy‘ or something one could term a capacity for basic envy is present in animals –
presumably emerging from the ability to compare their own and another‘s predicament.

Figure 4. Stress-induced hyperthermia (SIH). Equality condition (restraint stress with also restrained
cage mates) reduced SIH but inequality condition (restraint stress with free moving cage mates)
enhanced SIH. Vertical bars indicate SE. *P < 0.10, **P < 0.05,**P < 0.005. (From Watanabe, 2015).

Stress raises body temperature (Bouwknecht et al., 2007 for review). A variety of
stressors have been reported to induce hyperthermia, including a novel cage (Houtepen et al.,
2011), social threat (Pardon et al, 2004), social defeat (Keeney, et al., 2001), and restraint
50 Shigeru Watanabe

(Thornhill et al., 1979). This author measured stress-induced hyperthermia (SIH) three
different social conditions in mice by thermographic measurement of the body surface
temperature (Watanabe, 2015). Placing animals in cylindrical holders induced restraint stress.
This author also examined the effect of the social factors in SIH using the thermograph (body
surface temperature). Mice restrained in the holders alone showed SIH. Mice restrained in the
holders at the same time as other similarly restrained cage mates (social equality condition or
empathy) showed less hyperthermia. Interestingly, restrained mice with free moving cage
mates (social inequality condition or reversed empathy) showed the highest hyperthermia.
These results are consistent with a previous experiment measuring the memory-enhancing
effects of stress and the stress-induced elevation of corticosterone, and suggest that ‗social
inequality‘ enhances stress, and offering further evidence that animals can and do compare
their situations and predicaments to that of conspecifics.

4.1. Sense of Fairness

Several studies have suggested that human social intelligence involves a strong sense of
fairness, and that humans want to punish the unfair behavior of others, even if they have to
pay for the punishment (Fehr and Gachter, 2002), suggesting that fairness has high reward
value. Brain imaging studies in humans have shown activation of the brain area that is
involved in the sensation of pain when observing the pain response of others, but this
empathetic response did not appear when observing the pain response of individuals who had
played unfairly in a game before the scanning (Singer et al., 2006). Furthermore, male
participants showed activation of the nucleus accumbens, which is usually activated by
pleasure, when they saw pain response of the unfair player (Singer et al., 2006), suggesting
that witnessing ‗just desserts‘ for an offending player is clearly rewarding. Non-human
animal studies indicate that a similar sense of fairness also exists in primates. For example,
capuchin monkeys refused cucumbers when others obtained presumably tastier grapes instead
of less tasty cucumbers (Brosnan and de Waal, 2003). This behavior appears non-adaptive,
because receiving some food is better than receiving no food, yet the aversive property of
inequitable outcomes has been demonstrated in several non-human primates (Yamamoto and
Takimoto, 2012), again suggesting that affective concepts encoding a basic sense of fairness
and equity do not exist only in humans. Put differently, these results suggest that a sense of
fairness has deep evolutionary roots, substantially predating the appearance of hominids and
Homo sapiens.
There is a relative shortage of unequivocal evidence of a sense of fairness in non-primate
animals, but owners of dogs believe that their dogs experience jealousy (Morris et al., 2008)
and some sense of fairness (Salovey and Rodin, 1989). Range et al., (2008; 2012) trained
dogs to ―give the paw‖ and then extinguished this behavior. Dogs displayed extinction of this
behavior more quickly when trained with another dog who was rewarded than when alone
with the experimenter (Range et al., 2008; 2012). However, dogs preferred a trainer that over-
rewarded to other dogs for sitting on command to a trainer that provided fair rewards
(Horowits, 2012) suggesting no preference for the fair trainer. The dogs had no preference
between an under-rewarding trainer and a fair trainer suggesting again no preference for the
fair trainers. Therefore, although dogs exhibited ‗reversed empathy‘ as rapid extinction with
others receiving reward, they did not have a preference for fairness.
 Evolutionary Origins of Empathy 51

It is likely that an aversion toward inequality and a sense of fairness has helped to sustain
human society and helped to form basic foundations for principles of social exchange,
reciprocity, and law. Both the happiness of an individual in the presence of unhappy
individuals, and the unhappiness of an individual in the presence of happy individuals are
unequal, but humans feel a much stronger sense of unfairness in the latter case than in the
former case. Although universal happiness is perhaps ideal, our biased sensitivity for
unfairness means that humans prefer everybody being unhappy to a mixture of happy and
unhappy people, as this appears unfair to most of us.

5. SCHADENFREUDE
Schadenfreude, the mirror image of reversed empathy or envy, occurs when the failure or
misfortune of demonstrators induces pleasure in the observer. This term is derived from
―Schade,‖ which means sorry, and ―Freude,‖ which means pleasure. Mice spent more time
with cage mates that had received a pain-inducing formalin injection in their hind leg than
with cage mates that had not received an injection (Watanabe, 2012a). If the staying time is
taken very concretely to indicate the reinforcing more rewarding effects of the cage mate, this
approach behavior could suggests a Schadenfreude-like phenomenon – but the motivational
basis for such an interpretation would of course be completely mysterious, given that
Schadenfreude is associated with a desire to punish rule violators. Instead, and more
probably, this behavior may also be considered to represent a kind of predisposition to basic
empathy or rescue behavior or pre-concern as part of an empathy continuum (see Section
2.3). The results of a CPP experiment in which one compartment was associated with the
presence of a cage mate with pain suggested that the property of the formalin-injected cage
mate was negative (aversive) rather than positive (preferred) (Watanabe, 2012a). However,
examination of individual data revealed that some mice showed conditioned aversion whereas
others showed conditioned preference, indicating that the distress of a cage mate induced
either empathy for negative or positive emotion, depending on some kind of individual
variation. This inter-individual variability may be heavily influenced by the degree of prior
social relationship between the observer and the demonstrator.

5.1. Social Status

Virtually all human and non-human animal societies have stratified social classes, or
dominance hierarchies that are fundamental emergent properties of social groups (Ellis,
1993), and where the adaptive basis of stratification is the intrinsic competition for limited
resources such as food, water, territory, and reproductive opportunities. In human studies,
passive observers experienced Schadenfreude when observing failure by a higher-status
achiever (Feather and Nairn, 2005; Feather, 2008). Social status, or the dominant/subordinate
relation, plays a crucial role in social preference in mice (Van Loo et al., 2001; Fichett et al.,
2006). Subordinate mice spent more time with a dominant cage mate that had received a pain-
inducing formalin injection than with a mid-rank cage mate that had not received a formalin
injection but this preference was not evident when the dominant cage mate had not received a
52 Shigeru Watanabe

formalin injection (Watanabe, 2014). Time spent at the formalin-injected dominant mate was
negatively correlated with ‗dominancy distance‘ between the two mice. Dominant mice did
not display any preference for subordinate mates, regardless of drug treatment (Watanabe,
2014). The pain response of a slightly more dominant mate may imply that there is a higher
probability of overturning the relative hierarchical positions than the pain response of a cage
mate of a much higher dominance rank. There were no explicit attacks by the subordinate
mice on the suffering demonstrators, but it is plausible to assume that low-ranking animals
may try to attack high-ranking animals in pain, because the pain response of high-ranking
animals may index a relative weakness, by virtue of their predicament. These results suggest
that the pain response of a dominant mate has a rewarding property for a subordinate, in other
words, that a Schadenfreude-like phenomenon occurs in mice in these conditions.
Introduction of an unfamiliar male reduced the pain response of male mice, indicating an
analgesic effect (Langford et al., 2010b), which is perhaps designed to conceal the appearance
of weakness. In hamsters, the presence of a dominant mate reduced the pleasure induced by
intracranial self-stimulation of electrical current delivered to the brain, but the presence of a
subordinate mate had no effect (Kureta and Watanabe, 1996). This may represent another
example of the modification of positive reinforcement by the dominant/subordinate relation.
Human observers may also feel more Schadenfreude when the demonstrator is of a
slightly higher social position. Human Schadenfreude has one particular feature, whereby its
expression might be more hidden at least in some cases. In many casual settings, it is socially
acceptable to explicitly enjoy the minor misfortune of close friends but it is impossible to
enjoy the misfortune of persons of higher position explicitly, even if pleasure is felt during the
apology. In other words, if Schadenfreude is a socially prohibited pleasure (or at least its open
expression is inhibited by social display rules), and public display of Schadenfreude therefore
may be considered impolite, and in some contexts, even punished. This is not the case for
animals. Hiding the experience of Schadenfreude is likely unique to humans, and hidden
Schadenfreude can be considered a social skill that has been developed to avoid conflict
among humans.

6. Range of Empathy

There is strain-to-strain variability in the empathy exhibited by mice (Chen et al., 2007).
Thus, it seems reasonable to infer that some species experience more empathy than others.
For example, social species may show more empathy than solitary species. Humans strongly
empathize with distressed family members or friends, but less strongly empathize with
distressed strangers, and even less strongly with members of identified out-groups and
individuals seen as different from one‘s in group (see more detailed discussion of this in first
and last chapters in this volume). However, humans can also feel empathy toward some non-
human animals (Bradshaw and Paul, 2010). Harrison and Hall (2010) reported relations
between perceived empathic and communicative variables, and a strong relationship between
these variables and phylogenetic relatedness to humans. Experimentally, the pain response of
pet dogs produced an emotional response in humans (Daly and Morton, 2006). These results
suggest that the empathy for negative emotions of humans is inter-species, and this wide
range of human empathy for negative emotions may be the basis for the moral tendency for
animal welfare.
 Evolutionary Origins of Empathy 53

There may also be examples of inter-species empathy in non-human animals. Distress of

one species may have informative value to other species because of common danger such as a
predator. Kuczaj et al., (2001) cited examples of cross-species rescue behavior, including a
hippopotamus rescuing an impala from a crocodile, and De Waal (2006) described a female
bonobo picking up an injured bird and releasing it from the top of a tree, a seal rescuing an
old dog in a river, and a gorilla picking up a child who dropped in an enclosure and carrying
him to a door. However, although monkeys pressed a bar to terminate electric shocks
delivered to another monkey, they did not exhibit the same behavior to an albino rat,
suggesting potential limits on cross-species empathy, particularly between predator and prey
species where cross species empathy would be highly maladaptive (Mirsky et al., 1958) – to
say nothing of deeply counterintuitive.
It is also true that some animals do not always express empathy for conspecifics. In mice,
although the pain response of a known cage mate evoked empathy, that of an unfamiliar
mouse did not (Langford et al., 2006), and although hens showed clear behavioral and
physiological responses to the mild distress of mother/offspring chicks (Edigar et al., 2011),
they did not exhibit an empathetic response to mild distress of unrelated but familiar adult
conspecifics (Edigar et al., 2012). Pet dogs displayed empathy for positive emotions toward
their owners, and the empathy for positive emotions in animals may depend on the degree of
bonding that has occurred between the demonstrator and the observer (see first chapter in this
volume by Watt and Panksepp and also Watt, 2007 for detailed treatment). There is no
information about range of reversed empathy and Schadenfreude in animals, but the
demonstrator–observer relationship must be crucial to evoke such empathy.

CONCLUSION
The empathetic response of humans to the emotional display of others has an
evolutionary origin and is clearly biologically protective and adaptive, even though some
forms of this emotional response may appear superficially or initially maladaptive. Empathy
may be part and parcel of a more prosocial brain, and essential to the promotion of social
bonds and the stability of those bonds as well as the repair of ruptures between socially
bonded individuals (see Watt, 2007 and first chapter of this volume for extended treatment).
While it seems unnecessary to feel negative emotions in response to the negative emotions of
others, the negative emotions of others may signal our own danger or aversive experience,
and more critically, may signal threat and stress to individuals to whom we are socially
bonded, and on whose welfare we depend. We do not have to feel pleasure for the pleasure of
others, but feeling pleasure together may improve the social bonding of the group or dyad.
Contagion mechanisms and the sharing of affective states may thus promote group cohesion
and thus extended fitness, survival and reproductive opportunities within the social group, the
central mechanism of selection. We do not have to feel negative emotions in response to the
happiness of others, but this may underlie a sense of fairness that has a key role in society, the
creation of social reciprocities and social exchange, principles eventually codified into social
laws, and forming critical components of societal structures and all advanced cultures. We do
not have to feel pleasure in response to the misfortune of others, but this may be a signal to
change social ranking. More experimental and comparative studies are needed to trace the
54 Shigeru Watanabe

evolutionary history of human empathy, but this review has summarized recent work on some
of the precursors of human empathy in animal models, suggesting that a fundamental or basic
proto-empathy is widely distributed within the mammalian kingdom.

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Reviewed by Professor Toru Shimizu in University of South Florida.

In: Psychology and Neurobiology of Empathy ISBN: 978-1-63484-446-8
Editors: Douglas F. Watt and Jaak Panksepp © 2016 Nova Science Publishers, Inc.

Chapter 3

THE POSITIVE (AND NEGATIVE)

PSYCHOLOGY OF EMPATHY

Sara Konrath1,2,3 and Delphine Grynberg4

1
Indiana University, Lilly Family School of Philanthropy, Indianapolis, Indiana, US
2
University of Michigan, Ann Arbor, Michigan, US
3
University of Rochester Medical Center, Rochester, New York, US
4
Charles de Gaulle University – Lille III, Villeneuve-d‘Ascq, France

ABSTRACT
The current chapter summarizes research on empathy in terms of its benefits and
costs. The majority of research on empathy finds desirable correlates. For example, high
empathy is associated with more prosocial behaviors and stronger relationships with
others. Yet, excessive empathy can also be problematic in a variety of ways. Taken
together, the positives and negatives of empathy can best be understood within an
evolutionary framework in which empathy evolved to address issues of survival and
reproduction. Empathy seems to facilitate caregiving behavior to close others, at the
expense of outgroups and society at larger, and sometimes (but not always), at the
expense of the self.

INTRODUCTION
In this chapter we review research on empathy in terms of its benefits and costs. Scholars
have a difficult time agreeing on a definition of empathy. Some think of empathy as emerging
from more cognitive mechanisms (emphasizing perspective taking and related theory of
mind) which involves imagining another‘s point of view or internal experience (Borke, 1971;
Deutsch & Madle, 2009), while other scholars think of it as a more affective process (Batson,
1990; Bryant, 1982; Panksepp, 1998; Watt, 2007) with relatively ancient roots in the
mammalian kingdom. This affective process includes emotion-matching with others, which is
typically described as ‗emotional contagion‘ or affective resonance (Feshbach & Roe, 1968;
64 Sara Konrath and Delphine Grynberg

Watt, 2007). It also includes concern for others‘ suffering and a desire to reduce suffering that
does not necessarily involve isomorphism with the other‘s feelings, which is often called
‗empathic concern‘ (Batson, Ahmad, & Stocks, 2004; Davis, 1983). Some have posited that
affective resonance naturally implies empathic concern, which is an important point to
address in future research (Watt, 2007). Still other theorists see the emotional and cognitive
aspects of empathy as more overlapping than separate (Hoffman, 1984). Finally, another
relevant distinction is between ‗dispositional‘ or ‗trait‘ empathy (Bryant, 1982; Davis, 1983)
versus ‗situational‘ or induced empathy (Batson, 1990). People scoring high in dispositional
empathy see themselves as having chronic tendencies to respond empathically, yet nearly
everyone can have their empathy engaged under the right circumstances, or conversely,
disengaged under opposed circumstances, suggesting that empathy is a heavily ‗gated‘ or
modulated process (Watt, 2007). Dispositional empathy measures are typically used in
correlational studies, limiting the causal inferences that can be made from them, whereas
situational empathy is induced by randomly assigning participants to imagine the world from
needy targets‘ perspectives versus remaining objective when exposed to needy targets (see the
work of Daniel Batson and colleagues for more details).
Despite all of these distinctions, it is still possible to come up with a general definition
that encompasses both cognitive elements and emotional ones, and can also be applied to trait
and situational empathy. Thus, we would define empathy in line with prior theorists as feeling
care and concern for others and imagining their perspectives (Batson, 2011; Davis, 1983).

PART 1: THE POSITIVE PSYCHOLOGY OF EMPATHY

Empathy has a good reputation, and as we will review, there are good reasons for this.
The majority of research on empathy finds desirable correlates (for dispositional empathy)
and outcomes (for situational empathy), whether for empathic individuals themselves, or their
social interaction partners. It is difficult to find studies that point out potential problems with
empathy, but even roses have thorns, and empathy comes with a few potential thorns despite
its mostly prosocial, attractive, and adaptive qualities. These will be discussed in Part 2 of this
chapter.

Is Empathy Good for Others?

Empathy for strangers. The most obvious and widely studied benefit of high empathy is
its association with more prosocial behaviors directed toward strangers. In a meta-analysis
examining the relationship between different kinds of empathy and prosocial behaviors such
as helping, sharing, and giving to others, researchers found significant positive relationships
between the two, regardless of how empathy was measured (i.e., self-reported traits, observer-
reported traits, self-reported empathic emotions, or situational inductions to empathize versus
remain objective; Eisenberg & Miller, 1987).
Moreover, the work of Daniel Batson and his colleagues has tested the limits of such
empathy-based prosocial responding (for a detailed overview, see Batson, 2011). Using
experimental studies, they have found that when participants are asked to imagine the feelings
 The Positive (and Negative) Psychology of Empathy 65

and perspectives of others they are more likely to demonstrate prosocial behaviors and
attitudes even when:

i) escaping from the situation is easy (Appendix B in Batson, 2011),

ii) helping is anonymous and participants cannot receive credit for helping
(Appendix C),
iii) there are good reasons to avoid helping; doing so is easily justified (Appendix
D),
iv) participants are not given feedback about the effectiveness of their help, thus
they are not motivated by feelings of gratification or self-efficacy (Appendix F),
and
v) when not helping leads to a similar mood boost as helping would (Appendix G).

Moreover, increased situational empathy also makes the helping more sensitive and
attuned to the recipient‘s needs. After empathy is induced, participants seem to genuinely care
about whether their help actually addresses the other‘s need, and report feeling bad if their
efforts were not helpful, even if it was through no fault of their own (Batson et al., 1988;
Batson & Weeks, 1996). This suggests some kind of direct linkage between affective
resonance/contagion mechanisms and an intrinsic motivation to reduce suffering (as
hypothesized in Watt, 2007). More evidence of their increased sensitivity comes from
research finding that empathy-induced participants are only more likely to help if it is good
for the recipient in the long-term. If there is a short-term benefit of helping the recipient, but
at the cost of a long-term harm to this recipient, people induced to be in more empathic states
are actually less likely to help (Sibicky, Schroeder, & Dovidio, 1995).
Situational empathy also increases people‘s cooperativeness in prisoner‟s dilemma games
( Batson & Ahmad, 2001; Batson & Moran, 1999; Cohen & Insko, 2008; Rumble, Van
Lange, & Parks, 2010), which are games in which participants choose to cooperate or defect
with partners and receive payoffs based on their decisions. If both participants cooperate, the
payoffs are highest, however, individual participants can receive a high payoff if they defect
but their partner cooperates, which increases the incentive to defect. If both participants
defect though, payoffs are low for both. Remarkably, empathy increases cooperation rates in
prisoner‘s dilemma games even when participants are aware that their partner has already
defected (Batson & Ahmad, 2001). For example, in this extreme situation, cooperation rates
increased from 5% in the control condition (―remain objective‖) to 45% in the empathizing
condition on a one-shot (single-interaction) prisoner‘s dilemma game (Batson & Ahmad,
2001). Related to this, empathizing has been shown to be helpful in negotiation settings as
well, leading to greater gains for both parties relative to not empathizing (Galinsky, Maddux,
Gilin, & White, 2008).
Empathy in close relationships. Considering that empathizing makes people kinder and
more cooperative, it is not surprising to find that empathy may have positive implications
within close relationships. For example, empathy in parents seems to have a noticeable
positive effect on their children (Feshbach, 1990; Moses, 2012; Rosenstein, 1995). One
example of this is a study of pediatric cancer patients in which the researchers found that
more empathic parental responses to their children‘s pain during a medical procedure was
associated with the subjective experience of less pain in the children (Penner et al., 2008).
66 Sara Konrath and Delphine Grynberg

Within romantic relationships, some research has found that people scoring high in
perspective taking (cognitive empathy) report being more satisfied with their relationships
(Franzoi, Davis, & Young, 1985). Of course, this could mean that more relationship
satisfaction leads to higher perspective taking, but this explanation is less likely because
relationship satisfaction is more likely to fluctuate than a personality trait (as a classic
example of state versus trait). Another interesting study found that married people with higher
dispositional empathy are less likely to ruminate over perceived transgressions, and more
likely to forgive their partners for these transgressions, with downstream consequences on
higher marital quality (Fincham, Paleari, & Regalia, 2002; Paleari, Regalia, & Fincham,
2005). Again, the correlational nature of the research makes interpretations difficult, but the
same reasoning as above applies: perceptions of marital quality are also more likely to
fluctuate than personality traits.
Longitudinal studies confirm that the direction of causality is likely to go from empathic
traits towards better relationships. For example, one recent study found that higher
compassionate goals at one time point were associated with increased closeness, trust, and
support in relationships at a later time point (Crocker & Canevello, 2008). Another study
found that people with higher dispositional empathy (measured at baseline) gave more
emotional and instrumental support when their relationship partner was put in a stressful
situation during a later laboratory session (Feeney & Collins, 2001).
Yet here is where things may get more complicated. Most of us enjoy having (and being)
empathic partners, but there are certain circumstances where this may not be as desirable. For
example, when there is uncertainty or threat in the relationship, being able to accurately read
your partner‘s mind might give you a window into his or her doubts, interest in others, or
desire to end the relationship. There are a number of studies that confirm such a possibility,
by using a performance-based measure of perspective taking. This involves having Partner A
report on what he or she was thinking and feeling during a videotaped segment (e.g., while
discussing a relationship problem together), and then having Partner B guess what Partner A
was thinking and feeling. The more similar Partner B‘s guesses are to Partner A‘s responses,
the higher his or her empathic accuracy (Ickes, 1997).
In long-term dating relationships, which are seen as relatively more secure by virtue of
their endurance, higher empathic accuracy is correlated with more relationship satisfaction
(Thomas & Fletcher, 2003). In other words, more satisfied longer-term couples can more
accurately read each others‘ thoughts and feelings while discussing relationship problems,
perhaps because they are experienced in doing so. Yet the opposite pattern is found for short-
term dating relationships, where higher empathic accuracy is correlated with less relationship
satisfaction (Thomas & Fletcher, 2003). In other words, less satisfied shorter-term couples are
quite good at reading each others‘ internal states when discussing relationship problems. This
may be because many relationships dissolve within the first few months, and less satisfied
new couples may be especially vigilant to potential signs of threat. Other research directly
manipulates levels of threat, finding that when couples are discussing problems that are very
threatening to their relationship, the more empathically accurate that perceivers are about
their partner‘s thoughts and feelings, the more their feelings of closeness decline from the
beginning to the end of the study (Ickes, Oriña, & Simpson, 2003). However, if they are
discussing less threatening topics, greater empathic accuracy is associated with increased
feelings of closeness with their partner (Ickes, et al., 2003). Indeed, some partners may
strategically become ―mind-blind‖ (lose their theory of mind so to speak) as a relationship-
 The Positive (and Negative) Psychology of Empathy 67

enhancing strategy. People who feel insecure about the stability of their relationship are very
poor at accurately reading their partner‘s feelings and thoughts in high-threat situations (e.g.,
when their partners are asked to rate the attractiveness levels of attractive members of the
opposite sex; Simpson, Ickes, & Blackstone, 1995). It is probably wise to have poor empathic
accuracy skills when such skills would reveal their partner‘s interest in attractive others. Yet,
some people cannot seem to inhibit their empathic accuracy in the face of such threats: those
with chronic anxious-ambivalent attachment styles (Simpson, Ickes, & Grich, 1999).
Ultimately this is upsetting both to them (more contagion-based distress) and their
relationships (less close, more likely to end; Simpson, et al., 1999).
Why have we included these complex results in the section on the ―positive‖ psychology
of empathy? This is because it is unclear whether they are truly negative. Being aware that
your partner has been experiencing doubts or may be attracted to someone else could
facilitate a conversation about it, which could ultimately strengthen the relationship. Or, it
might selectively facilitate relationship dissolution in relationships that are unhealthy or
otherwise problematic. The long-term implications of empathic accuracy are unclear, even if
in certain contexts less (empathic accuracy) is more (for relationships). In any case, there is
currently very little experimental research in the domain of empathy and close relationships
(Batson, 2011). Given these mixed results, examining the effect of randomly assigned
empathy interventions (versus control interventions) on relationship outcomes is needed.
Such interventions should also consider the moderating role of threat, since some
relationships may be destabilized by increased empathy.
Empathy in professional settings. There is a robust literature on the role of empathy in
professional settings, and especially within caring-related professions such as teaching,
medicine, and clinical psychology. Teachers, doctors, and therapists with high empathy may
positively influence their students‘ educational outcomes, and patients‘ physical health and
mental health. For example, studies find associations between empathy in instructors and
higher student motivation and effort, using both correlational and longitudinal designs
(Coffman, 1981; Waxman, 1983). Empathy in instructors is also positively correlated with
actual achievement outcomes (Aspy & Roebuck, 1972; Chang, Berger, & Chang, 1981), a
result that is consistent regardless of the type of outcome (i.e., objective outcomes such as
multiple choice questions, versus more subjective outcomes such as essays). Results are also
similar for objective (e.g., based on observer or student report) versus more subjective (e.g.,
based on self report) measures of empathy. However, there is a need for research that
experimentally links enhanced teacher empathy with student outcomes. Interestingly, college
students‘ perceptions of the professor‘s concern and consideration (i.e., empathy) is the single
largest predictor of overall teacher evaluations (Keaveny & McGann, 1978). Perceived
teacher empathy explains 54.1% of the variance, while perceived teacher competence
explains only 6.9% of the variance. Perhaps that fact alone would be enough to convince
educators to participate in empathy training sessions. Such results may also suggest that
students actually need more empathy – and feel more insecurities – than teachers and
professors typically anticipate.
Empathy in physicians (as rated by self-report or by observers) is related to a number of
patient outcomes including higher patient satisfaction, better recall of medical information,
improved adherence to physician-recommended protocols (e.g., medication), and more
positive health outcomes such as fewer symptoms and improved quality of life (Beck,
Daughtridge, & Sloane, 2002; Derksen, Bensing, & Lagro-Janssen, 2013). There are similar
68 Sara Konrath and Delphine Grynberg

associations between empathy in psychologists and therapists and patient mental health
outcomes (Kurtz & Grummon, 1972; Truax et al., 1966). It is notable that empathic doctors
also report making fewer medical errors, although this may be explained by a self-report bias
(West et al., 2006).
Empathy, aggression, and prejudice. High empathy also seems to have an inhibiting
effect on antisocial behaviors such as aggression, bullying, and various types of criminal
behavior (Batson, et al., 2004; Jolliffe & Farrington, 2004; Miller & Eisenberg, 1988).
However, the effect sizes found in meta-analyses are relatively small overall and depend on a
number of factors such as the type of measurement of empathy and antisocial behavior
(Jolliffe & Farrington, 2004; Miller & Eisenberg, 1988). For example, the effects are
strongest in self-reported measures of trait empathy, which may reflect self-perceptions of
empathy rather than truly altruistic motivations (Batson, Bolen, Cross, & Neuringer-Benefiel,
1986). It is possible that the desire ―to look like a nice person‖ can make people self-report
that they are both nice and also low in aggressiveness (Batson, et al., 2004) – a selective
reporting bias rather than a true association.
In studies where empathy is manipulated, the results are inconsistent. For example, one
study found that perspective-taking instructions had no effect on aggressive behavior, but this
was possibly because participants received negative feedback from the target of aggression
before the empathy manipulation (Eliasz, 1980). Another study found that perspective-taking
instructions did cause a decrease of aggressive behavior, but only under conditions of low
threat. After a provocation, participants who received the empathy manipulation responded
with similar levels of aggression as those in the control group (Richardson, Hammock, Smith,
Gardner, & Signo, 1994). Yet another study has found that perspective-taking instructions led
to decreases in aggression-related brain activity after an insult. These decreases corresponded
with decreases in self-reported hostility (Harmon-Jones, Vaughn-Scott, Mohr, Sigelman, &
Harmon-Jones, 2004). Other related research has found that people scoring high in narcissism
(a trait characterized by low empathy) are susceptible to increased aggression after they are
threatened by insults or rejection (Bushman & Baumeister, 1998; Konrath, Bushman, &
Campbell, 2006; Twenge & Campbell, 2003). Inducing a sense of similarity between
themselves and the ego-threatener attenuates this effect (Konrath et al, 2006).
Taken together, there is some experimental evidence that empathy may inhibit
aggression, but this literature needs further work and development. Yet, when moving beyond
general assessments of aggression, there is consistent evidence that empathy interventions do
seem to reduce certain specific kinds of aggression in which empathy is directly implicated
(e.g., abuse, sexual harassment, and victim blaming; Aderman, Brehm, & Katz, 1974;
Schewe, 2007; Schewe & O‘Donohue, 1993). Moreover, there is some evidence that empathy
can reduce prejudice against stigmatized people or members of out-groups. Participants who
are induced to feel empathy for people from different ethnic backgrounds, disabled people,
the elderly, AIDS patients, homeless people, drug dealers, and even murderers report more
positive feelings for them (Batson, Chang, Orr, & Rowland, 2002; Batson, Polycarpou, et al.,
1997; Clore & Jeffery, 1972; Dovidio et al., 2004; Finlay & Stephan, 2000; Galinsky &
Moskowitz, 2000; Vescio, Sechrist, & Paolucci, 2003). Reductions in prejudice after such
empathy inductions:

i) exist regardless of whether or not targets are stereotypical group members

(Vescio, et al., 2003),
 The Positive (and Negative) Psychology of Empathy 69

ii) increase the likelihood that participants will actually help a member of the
stigmatized group (Batson, et al., 2002), and
iii) can persist for weeks and months (Batson, Polycarpou, et al., 1997; Clore &
Jeffery, 1972).

Inducing empathy for stigmatized groups can be a useful prejudice reduction tool because
it is easy and inexpensive to administer. However, to date the majority of studies on this topic
have examined the role of empathy in changing attitudes or feelings toward these groups. The
effect of empathy on prejudice is more complicated when considering how empathy affects
actual intergroup social interactions – as we will see in Part 2 (See chapter by Watt and
Panksepp in this volume for further discussion of in-group/out-group effects on empathy).

Is Empathy Good for the Self?

Excessively low empathy is a clear mental health risk factor, albeit with relatively broad
implications. For example, one of the diagnostic criteria for Narcissistic Personality Disorder
is a lack of empathy (APA, 2000). Similarly, although low empathy is not a directly stated
diagnostic criterion for Antisocial Personality Disorder (APD), those with APD show a ―lack
of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or
stolen from another‖ (APA, 2000). This clearly implies low empathy among this population
without perhaps making it more explicit. However, the Psychopathy Check List (Hare, 1999),
which is the most commonly used measure of psychopathy, includes an item related to low
empathy. In addition, studies find that among individuals with an antisocial personality, the
cognitive factor of empathy is preserved while the affective component is impaired.
Individuals with antisocial personality have similar performance on Theory of Mind tasks
compared to healthy individuals (e.g., Richell et al., 2003), but show weaker emotional
responses when confronted with someone in distress (Blair, 1999; House & Milligan, 1976).
People with autism spectrum disorders (ASD) are also thought to have lower empathy
relative to normal controls. These populations indeed report low compassion in general and
lower abilities in identifying the mental states of others (Bons et al., 2013; Frith, 2001;
Mathersul, McDonald, & Rushby, 2013). ASD involves impairments in social functioning, in
communication, and is associated with restricted repetitive and stereotyped patterns of
behaviors, interests and activities. Individuals with ASD report lower levels of affective and
cognitive empathy (e.g., Berthoz, et al., 2008; Frith, 1989) and have lower performance on
Theory of Mind tasks (Hill & Frith, 2003). Several studies have found that individuals with
ASD have difficulties in understanding others‘ intentions depicted in vignettes, in correctly
identifying the mental states expressed by eye gazes, and in understanding false belief
scenarios (Brent, Rios, Happe, & Charman, 2004; Hamilton, 2009; Mitchell, Robinson,
Isaacs, & Nye, 1996). Moreover, neuroimaging studies have found anomalies in brain regions
that are involved in Theory of Mind (Frith, 2001). For instance, when healthy participants and
participants with ASD had to attribute mental states to visual animated triangles acting like
humans (e.g., chasing), individuals with ASD showed less activation than healthy participants
in the three brain regions involved in Theory of Mind (medial prefrontal cortex, temporal
parietal junction, and the temporal poles; Castelli, Frith, Happé, & Frith, 2002). However,
given that many measures of empathy rely on verbal skills, it is unclear to what extent this is
70 Sara Konrath and Delphine Grynberg

one potential explanation for the relatively lower performance of individuals with ASD on
these assessments.
Within non-clinical populations, there are many studies demonstrating associations
between empathy-related traits and behaviors and good mental and physical health (for
reviews, see Batson, 2011; Konrath, 2013; Konrath & Brown, 2012; Post, 2007). These
studies cover traits such as empathy, compassion, altruism, narcissism (low empathy plus
inflated self-esteem), and generativity (concern for future generations), and behaviors such as
giving support to others, volunteering for non-profit organizations, and caring for animals.
The trait-based studies tend to be correlational or longitudinal, but across both methods there
are relatively consistent results. For example, highly empathic or compassionate people report
better mental health (e.g., lower stress, anxiety, hopelessness, and depression), participate in
fewer health risk behaviors (e.g., drinking or smoking), and have better physiological
indicators of stress regulation (e.g., vagal tone; Adams, 2010; Au, Wong, Lai, & Chan, 2011;
Diamond, Fagundes, & Butterworth, 2012; Ironson et al., 2002; Kalliopuska, 1992; Steffen &
Masters, 2005) even when controlling for potential confounds (e.g., coping, social support:
Au, et al., 2011), and even when considering a wide variety of populations (e.g., high school
students, college students, community samples, people with chronic illnesses). Longitudinal
studies confirm that having a more altruistic personality at one time point is associated with
better mental and physical health outcomes later on (Dillon & Wink, 2007; Ironson, 2007;
Konrath & Fuhrel-Forbis, 2011; Wink & Dillon, 2002). However, the role of covariates needs
further clarification, with some studies suggesting that social class differences may be
important (Dillon & Wink, 2007; Stellar, Manzo, Kraus, & Keltner, 2012) and others finding
that the results are robust to a number of plausible confounds such as baseline health (Konrath
& Fuhrel-Forbis, 2011; Wink & Dillon, 2002).
Our research examines change in empathy and related traits over time by using the
method of cross-temporal meta-analysis, which is a meta-analysis that tracks trends in self-
reported traits over time. We have found that scores on the empathic concern and perspective
taking subscales of the Davis (1983) Interpersonal Reactivity Index have been declining over
the past 30 years in the United States (Konrath, O‘Brien, & Hsing, 2011). In addition, scores
on the Narcissistic Personality Inventory, which assesses high self-focus in combination with
low empathy, have been increasing across the same time period (Twenge, Konrath, Foster,
Campbell, & Bushman, 2008). Given these changes, the relationship between empathy and
health may become more important in the future if measures of empathy and related traits
continue to show parallel trends.
When reviewing the altruism-health literature it is important to consider the specific
definition of empathy that some scholars use, which may not represent true other-
orientedness. Personal distress is a more self-oriented reaction to others‘ suffering. It can be
assessed at the trait level, with sample items such as ―When I see someone who badly needs
help in an emergency, I go to pieces‖ (Davis, 1983), or as an immediate situational response
to others in distress, by asking participants the extent to which they feel emotions like
alarmed, distressed, disturbed, and upset, in response to others‘ distress (Batson, Fultz, &
Schoenrade, 1987). When assessed this way, personal distress and empathic concern are two
nearly orthogonal factors (Batson, et al., 1987; Davis, 1983). Although only calloused people
could observe extreme suffering without having any distress response, people with
unmitigated personal distress responses may be more motivated to help others in order to
relieve their own distress, rather than to relieve the other‘s distress ( Batson, et al., 1987;
 The Positive (and Negative) Psychology of Empathy 71

Davis, 1983). As such, they are likely to seek other opportunities to relieve their distress, such
as escaping the situation instead of helping, when possible ( Batson, 2011). Another way to
think of this is that empathic people may indeed suffer with those who are suffering (and thus
feel some distress on behalf of them), but we must also have ―intact affective regulation
abilities such that the suffering of the other party does not flood us, and we are thus able to
maintain our own affective equilibrium and largely positive state while we are motivated to
reduce the suffering of the other party‖ (p. 21; Watt, 2007). Personal distress often includes
unmitigated contagion with the suffering person, along with over-identification and poor
personal boundaries. Thus, it is not surprising that within the context of mental health,
personal distress is found to be associated with poor functioning (O‘Connor, Berry, Weiss, &
Gilbert, 2002).
To date, very few studies have examined how situational empathizing affects the
empathizers themselves. This is an important direction for future research because it can help
unravel issues of causality in this literature. In our lab we have been studying the direct
physiological consequences of empathizing for those who are asked to empathize versus
remain objective in response to others‘ suffering (Konrath et al., 2012). We elaborate on some
of these issues in Part 2.
There are actually similar results when examining how empathy-related behaviors are
associated with psychological and physical health. For example, it is difficult to randomly
assign people to regularly volunteer for non-profit organizations, although in recent years
some scholars have done just that (e.g., Experience Corps; Fried et al., 2004; Hong &
Morrow-Howell, 2010). Yet there is consistent evidence that people who regularly volunteer
for non-profit organizations have better psychological and physical health, even when
considering a variety of potential confounds (Konrath, 2013; Konrath & Brown, 2012).
Importantly, a recent study found that in order to receive a health benefit of volunteering,
people had to be motivated by care for others. Those who were motivated by potential ways
they could personally benefit from volunteering (e.g., learning something new; feeling good)
did not experience a later health benefit (Konrath, Fuhrel-Forbis, Lou, & Brown, 2012).
Although this study did not assess empathy directly, it does imply that empathically-
motivated giving is likely to be better for one‘s health than personally-motivated giving.
When it comes to the empathy-related behavior of giving social support to others (e.g.,
time, money, errands, emotional support), it is possible to randomly assign people to give
versus receive support, and thus causal inferences can be stronger within this part of the
literature. Yet the majority of studies still rely on correlational and longitudinal methods
(Konrath & Brown, 2012). Several correlational studies find that giving social support to
others is associated with better mental and physical health (Brown, Consedine, & Magai,
2005; De Jong Giefveld & Dykstra, 2008; Dunn, Aknin, & Norton, 2008; Ironson, et al.,
2002; N. Krause & Shaw, 2000; Schwartz, Keyl, Marcum, & Bode, 2009; Schwartz,
Meisenhelder, Ma, & Reed, 2003). These results are confirmed in longitudinal studies
(Brown, Brown, House, & Smith, 2008; S. Brown, Nesse, Vinokur, & Smith, 2003; Gleason,
Iida, Bolger, & Shrout, 2003; Ironson, 2007; McClellan, Stanwyck, & Anson, 1993; Piferi &
Lawler, 2006; Schwartz & Sendor, 1999; Vaananen, Buunk, Kivimaki, Pentti, & Vahtera,
2005). Experimental and quasi-experimental studies find that people who are randomly
assigned to such diverse behaviors as caring for animals or plants, giving money to others,
random acts of kindness, or giving massages to infants, all experience increased
psychological well-being and better physiological outcomes such as lower stress hormones
72 Sara Konrath and Delphine Grynberg

(Aknin et al., 2013; Brown, Konrath, Seng, & Smith, 2011; Field, Hernandez-Reif, Quintino,
Schanberg, & Kuhn, 1998; Langer & Rodin, 1976; Mugford & M‘Comisky, 1975; Smith,
Loving, Crockett, & Campbell, 2009; Tkach, 2005). However, inconsistent results have been
reported in the literature: sometimes benefits only apply to certain groups of people,
sometimes null relationships exist, and sometimes giving support can be associated with poor
mental and physical health, especially when giving too much support or receiving too little in
return (Buunk, Doosje, Jans, & Hopstaken, 1993; Fujiwara, 2009; Liang, Krause, & Bennett,
2001; Lu, 1997; Lu & Argyle, 1992; Schwartz, et al., 2009; C. Schwartz, et al., 2003;
Strazdins & Broom, 2007).
Taken together, we can tentatively conclude that at least in some circumstances
empathetic traits and behaviors are associated with good mental and physical health.
However, there are a number of remaining questions: How can these results be explained?
Why is empathy sometimes beneficial, yet other times costly for the self? Is there an optimal
level of empathy, and if so, can too much empathy be more costly than beneficial?

PART 2: THE NEGATIVE PSYCHOLOGY OF EMPATHY

These questions naturally bring us to the second part of this chapter, delving into a topic
that has received some attention in recent times (Batson, et al., 2004; Bloom, 2013; Oakley,
Knafo, & Madhavan, 2011; Prinz, 2011). Can empathy at times be harmful? We now review
research that suggests that empathy may have a ‗dark‘ or at least ‗costly‘ side and may be
maladaptive in some specific contexts.

Can Empathy Be Bad for the Self?

As reviewed in Part 1, low empathy is a feature of some psychological disorders.

However, some disorders may actually be associated with excessive empathy. One example is
the case of the Williams Syndrome, which is a genetic developmental disorder associated
with mental retardation and characterized by distinctive facial features (elfin). In terms of
interpersonal behaviors, Williams Syndrome individuals are described as hyper-sociable,
overly friendly, and affectionate (Jones et al., 2000). They also show unreserved approach
behaviors towards strangers compared to healthy individuals (Gosch & Pankau, 1994), and
greater evaluation of trustworthiness in faces (Bellugi, Lichtenberger, Mills, Galaburda, &
Korenberg, 1999). Paradoxically, preliminary findings suggest that despite their
hypersociability, these individuals are often socially-isolated and report having fewer friends
than individuals with mental retardation due to nonspecific causes (Dykens & Rosner, 1999).
Williams Syndrome individuals are also described as empathetic (Riby, Bruce, & Jawaid,
2012). However, evidence-based studies suggest that their empathic profile is complex. It has
been hypothesized that individuals with Williams Syndrome might show a dissociation
between cognitive and affective components. That is, their emotional responses to someone
else‘s feelings (such as affective resonance and concern for suffering) on the one hand and
their abilities to understand others‘ mental states on the other hand may not be well correlated
(Riby, et al., 2012).
 The Positive (and Negative) Psychology of Empathy 73

Several studies suggest that individuals with Williams Syndrome have greater emotional
responses to other people‘s negative feelings than individuals with other developmental
disorders. For example, children with Williams Syndrome show greater empathic concern for
an experimenter who pretended to hurt her knee compared to children with another
developmental disorder (Prader-Willi Syndrome; Tager-Flusberg & Sullivan, 2000).
Furthermore, Williams Syndrome children are more inclined to mimic facial expressions than
matched control children with other developmental disorders (Fidler, Hepburn, Most,
Philofsky, & Rogers, 2007), consistent with the distinction between contagion and theory of
mind. Parents also report that their Williams Syndrome children experience more empathic
emotional responses to others‘ distress compared to other children (Dykens & Rosner, 1999;
Klein-Tasman & Mervis, 2003). Yet when examining physiological indices of emotional
arousal, individuals with Williams Syndrome actually show lower skin conductance
amplitude in response to emotional faces compared to age-, IQ-, and language-matched
controls who present learning or intellectual disabilities (Plesa Skwerer et al., 2009).
However, the findings should be taken with caution as the authors calculated the
physiological responses without differentiating the emotional facial expressions that were
accurately versus inaccurately identified.
In terms of mentalizing or perspective taking (i.e., identifying others‘ mental states) the
data are not consistent (Kennedy & Adolphs, 2012). While some studies find that Williams
Syndrome children can recognize emotional facial expressions as well as mental-age matched
controls (Gagliardi et al., 2003; Porter, Coltheart, & Langdon, 2007), others have found
deficits in the ability to recognize facial and vocal emotional expressions compared to
matched controls, which might explain the previously noted lack of physiological arousal
(Lacroix, Guidetti, Roge, & Reilly, 2009; Plesa-Skwerer, Faja, Schofield, Verbalis, & Tager-
Flusberg, 2006; Porter, et al., 2007). Taken together, these studies suggest that it is not only
empathy deficits that signal clinical problems within individuals; excessive empathy
(specifically, emotional empathy) can also be indicative of certain psychological disorders. In
Williams Syndrome, the data support a dissociation between the affective and cognitive
components of empathy, such that Williams Syndrome is characterized by increased
emotional empathy, yet lower abilities to identify others‘ emotional expressions. This
suggests that Williams Syndrome is characterized by a cognitive empathy deficit and thus
more related to problems in theory of mind. If future studies support this dissociation between
the two components of empathy, this may shed light on why individuals with Williams
Syndrome are generally socially isolated. They might respond too much to others‘ feelings
relative to their ability to actually understand these feelings.
Moving beyond the clinical domain to general populations, an extreme level of empathy
may be dangerous if it motivates us to care for strangers – before establishing their safety or
trustworthiness – at a potentially keen risk to our own personal safety and survival. It is likely
that empathically-motivated and emotionally naïve ‗rescuing‘ has prematurely shortened
many lives in human history. And of course extending care to others leaves fewer resources
(time, money, energy) for the self. Most genetic selection theories assume that organisms
prioritize ―selfishness‖ in order to increase evolutionary fitness by surviving and reproducing
(Dawkins, 1976). However, this is a very utilitarian point of view that may not accurately
reflect the human experience of and motivation to care and empathize (Brown, Brown, &
Penner, 2011). It also clearly does not reflect the survival value provided by intimate, socially
bonded groups, and the fact that our preference for such groups appears to have been heavily
74 Sara Konrath and Delphine Grynberg

selected in hominid lines (Panksepp, 1998; Watt, 2007). Moreover, surviving just long
enough to reproduce would not necessarily increase evolutionary fitness – for maximal fitness
parents must effectively care for their children and grandchildren so that they in turn will
survive and reproduce (Hawkes, O‘Connell, Jones, Alvarez, & Charnov, 1998; Lahdenperä,
Lummaa, Helle, Tremblay, & Russell, 2004; Liu & Konrath, 2013).
Moving beyond extreme situations of empathy such as altruistic rescuing, it may still be
possible for normal levels of empathy to be problematic at times. Caring and giving can
sometimes be stressful, difficult, and draining, and concern for others can sometimes overtake
people‘s efforts at self-care, through caretaker fatigue and caretaker burden. Professionals
who work in human service occupations can suffer from mental and physical health problems
associated with the strain of giving as a full-time occupation (Figley, 1995). These problems
are common in medical professionals, psychologists, social workers, lawyers, and corrections
professionals, among others, in which regular exposure to highly stressful and traumatic
incidents – either directly or indirectly – is part of the job description. Consistent with these
notions, ―compassion fatigue‖ is defined as the experience of ―stress resulting from helping or
wanting to help a traumatized or suffering person‖ (Figley, 1995, p. 7). These feelings of
stress are normal and experienced by almost everyone within helping professions at some
point in their careers (Mathieu, 2007). Compassion fatigue refers to the immediate feelings of
stress that occur in such situations, however, these feelings can be chronically present among
helping professionals because of the nature of their jobs. Indeed, between 42-70% of social
workers experience ongoing high levels of personal and emotional distress as a result of their
work (Adams, Boscarino, & Figley, 2006; Bennett, Plint, & Clifford, 2005; Bride, 2007;
Pooler, 2008; Tehrani, 2010). “Vicarious trauma‖ occurs after repeated exposures to others‘
traumas, which causes a change in the helper‘s view of themselves and the world. It is ―a
transformation of the helper‘s inner experience, resulting from empathic engagement with
clients‘ trauma material‖ (Saakvitne & Pearlman, 1996, p. 40). As such, it affects many
different aspects of helpers – their emotions, their behaviors, their relationships, and their
professional accomplishments. The term ―burnout‖ is often used interchangeably with the
above two terms, but we understand it to reference a longer-term result of chronic experiences
of compassion fatigue that has shifted into vicarious traumatization. Often these experiences
occur in combination with heavy caseloads, overwork, and caregiver burden. The three
commonly used dimensions to define and describe burnout are feelings of exhaustion in
combination with a sense of cynicism and a feeling of ineffectiveness in one‘s work
(Maslach, Jackson, & Leiter, 1996).
There are many risk factors that predict increased compassion fatigue, vicarious trauma,
and burnout. For example, a number of individual differences seem to matter. People have a
higher risk of compassion fatigue (or a related outcome) if they tend to be very self-critical
(Osofsky, 2011), if they cannot emotionally distance when appropriate (Krause, 2009), and if
they have conflicting feelings about their job role (Holt & Blevins, 2011). Younger and less
experienced professionals (Baird & Jenkins, 2003; Hawkins, 2001), those without specialized
training in trauma exposure (Sprang, Clark, & Whitt-Woosley, 2007), and those who have
experienced prior abuse or trauma (Nelson-Gardell & Harris, 2003) are also more susceptible
to compassion fatigue. Good relationships with coworkers (Armstrong & Griffin, 2004; Choi,
2011; Fielding & Fielding, 1987) and high social support (Conrad & Kellar-Guenther, 2006;
B. Thomas, 2012) buffers the stresses of caring professions, as do flexible and supportive
institutional environments and policies (Brady & Growette-Bostaph, 2012; Brough & Frame,
 The Positive (and Negative) Psychology of Empathy 75

2004; Choi, 2011; Gershon, Barocas, Canton, Li, & Vlahov, 2009; Violanti & Aron, 1995)
and smaller caseloads (Noblet, Rodwell, & Allisey, 2009; Udipi, Veach, Kao, & LeRoy,
2008).
Yet ―compassion‖ fatigue may be a misnomer, since studies have found that higher
feelings of empathy and compassion actually buffer people in caring professions from such
negative psychological states (Burtson & Stichler, 2010; Dyrbye et al., 2010; Gleichgerrcht &
Decety, 2013; Shanafelt et al., 2005). Indeed, some scholars have suggested that the term
should be replaced by ―empathic distress fatigue,‖ since ―burnout in caregivers and empathic
[or personal] distress are characterized by the experience of negative emotions, which lead to
a self-oriented response with the desire to alleviate one‘s own distress and both have negative
effects on health‖ (Klimecki & Singer, 2011, p. 285). What is currently missing in this
literature is experimental studies that examine the effect of empathy training on the later well-
being and health of people in caring professions. With empathy training programs for people
in caring professions becoming more common in recent years (Barkai & Fine, 1983; Herbek
& Yammarino, 1990; Riess, Bailey, Dunn, & Phillips, 2012), this evidence is likely close at
hand.
Personal distress involves feelings of being worried, perturbed, or upset, for oneself,
while empathic concern involves feelings of compassion, tenderness, or warmth, combined
with distressed feelings for the suffering other ( Batson, Early, & Salvarani, 1997; Batson, et
al., 1987). These terms are regularly used in order to measure subjective reports of personal
distress and empathic concern in response to others‘ suffering. Based on the valence of these
terms and on evidence presented on compassion fatigue and burnout, one may hypothesize
that individuals who experience more personal distress (i.e., unrestrained contagion
mechanisms and poor boundaries), might also report greater physiological arousal and/or an
enhanced stress response compared to individuals who experience more empathic concern or
feelings of compassion.
Greater arousal or increased stress activates the central nervous system, measured by skin
conductance (Critchley, Elliott, Mathias, & Dolan, 2000; Lackner et al., 2010) and heart rate
and blood pressure (Lackner, et al., 2010). The stress hormone cortisol is also released during
acute stressful events, especially those that are uncontrollable and that lead to negative social
evaluation (Dickerson & Kemeny, 2004). Therefore, one may hypothesize that personal
distress feelings might be related to greater central nervous system activation and a greater
release of stress hormones compared to more modulated empathic concern reactions.
So far, few studies have examined this research question, but it has important applied
implications. One study found that when mothers observed their child performing a difficult
task, changes in the children‘s cortisol levels were associated with changes in their observing
mothers‘ cortisol levels (Sethre-Hofstad, Stansbury, & Rice, 2002). This was especially true
for more sensitive/attuned mothers. Another study found that when experimenters observed
participants giving a stressful speech (the classic Trier Social Stress Task), changes in their
cortisol levels were associated with changes in the participants‘ cortisol levels (Buchanan,
Bagley, Stansfield, & Preston, 2012). This was especially true for experimenters who scored
higher in dispositional empathy. Another study found that the more empathically accurate
perceivers were about targets‘ feelings of distress, the greater their CNS activation as indexed
by skin conductance and cardiovascular activity (Levenson & Ruef, 1992).
Taken together, these studies indicate that observing another person in distress may affect
one‘s own physiological reactivity, and especially in the presence of higher (dispositional or
76 Sara Konrath and Delphine Grynberg

situational) empathic concern. This would suggest higher capacities for, or alternatively lower
thresholds for, contagion type/affective resonance responses. These studies thus indicate that
empathic concern is associated with an emotional resonance with others‘ distress. Yet
resonance means that highly empathic people actually had lower stress responses if the
distressed other had low stress responses, and only had higher stress responses if the speech-
giver had high stress responses. This is different than saying that empathizing itself activates
a stress response. The design of these studies does not allow us to determine what would
happen in a more controlled setting, that is, if the target of distress remained constant.
However, another study that did just that found that empathic concern is correlated with
the release of cortisol when witnessing someone in distress (Barraza & Zak, 2009). This study
assessed the endocrine responses of participants before and after they watched an evocative
video depicting a father talking to his 2 year old child who had cancer. The researchers also
measured subjective reports of state empathic concern and personal distress in response to the
video. When controlling for feelings of personal distress, higher feelings of empathic concern
were associated with a rise in cortisol after viewing the video. Moreover, the opposite pattern
was found for personal distress: when controlling for empathic concern, higher feelings of
personal distress were related to a decline in cortisol after viewing the video. Yet this study is
still correlational, and the effects were not found at the raw correlational level – only after
controlling for either high personal distress or empathic concern feelings. Thus, it is difficult
to know how to interpret the results. An experimental research design can control for other
confounding factors that might be associated with natural variations in empathic feelings.
Ideally, participants would be randomly assigned to empathize versus remain objective in
response to observing a target in distress, and physiological assessments would be taken
before and after the observation.
In our lab, we are examining this very research question. The empathy protocol that we
use is taken from widely used and validated empathy inductions (Batson, 2011; Batson, et al.,
1988; Batson, Sager, et al., 1997). Participants in our studies are exposed to a distressed target
(e.g., a radio program about Katie Banks, who is supposedly another student who has recently
lost her parents in a car accident). Using standard instructions, participants are either asked to
―try to imagine how the person being interviewed feels about what has happened and how it
has affected his or her life, from his or her own perspective‖ or to ―try to remain objective
about the person being interviewed and try not to get caught up in any emotions.‖ We
hypothesize that empathizing (versus remaining ‗objective‘ and more detached) in response to
a distressed other may actually help to attenuate stress responses.
Some background research supports this hypothesis. One study found that participants
who were randomly assigned to give social support to a partner experiencing stress within a
laboratory paradigm experienced declines in cortisol levels during the experiment (Smith, et
al., 2009). Although ‗giving support‘ is not exactly the same as ‗empathizing,‘ this study does
suggest that focusing on others‘ needs may help to attenuate stress responses. Another recent
study examined the cortisol responses of participants who completed the standard Trier Social
Stress Task (job interview speech) compared to those who also gave a job interview speech,
but were asked to focus on how they could help others if they got the job (Mayer et al., 2011).
The researchers found that although participants in the compassionate condition reported
similar levels of subjective anxiety during the task, they showed attenuated cortisol responses
compared to those completing the standard task. Moreover, other studies have found
 The Positive (and Negative) Psychology of Empathy 77

moderate stress-buffering effects of compassionate traits or training programs (Cosley,

McCoy, Saslow, & Epel, 2010; Kok et al., 2013; Pace et al., 2009).
Clearly, more research is needed in this domain before we can determine the role of
empathy in causing better or worse psychological health, stress responses, and ultimately,
physical health outcomes. For now, we cautiously include this topic in Part 2 until more
conclusive research is available.

Can Empathy Be Bad for Others?

When held up to scrutiny, the evidence that empathy may be bad for the self looks weak.
But the ‗dark‘ side of empathy may lie in the interpersonal domain.
Empathizing with undesirable targets. Imagine that you are walking down the street and
you suddenly see a person being beaten up by another person. It is likely that if you feel
empathy for anyone, it will be for the person who was beaten up. Instinctively, it is easy to
believe that there are no situations that would make people empathize with aggressors or
understand their actions. Yet several studies suggest that some people are surprisingly willing
to empathize with certain undesirable targets (e.g., rapists, unfair or immoral people). For
instance, one paper found that males report higher empathy for rape perpetrators compared to
females (Smith & Frieze, 2003). In two studies, participants completed a questionnaire
assessing empathy for victims and perpetrators of rape. Results showed that men reported
lower empathy for victims, and higher empathy for perpetrators, compared to females.
However, because items were written to be gender neutral, authors could not evaluate if the
gender of the target might influence the level of participants‘ empathy. A recent study thus
went in more depth and examined the association between empathy, type of target (i.e., victim
versus perpetrator), participants‘ previous life experience (i.e., sexually perpetration or
victimization), and the gender of targets and participants (Osman, 2011). Participants
completed an adapted version of the questionnaire from Smith and Frieze (2003), which
assessed how much emotional empathy they might feel (emotional sharing with the victim)
for a female versus male victim of a female versus male rapist. They also reported how much
they took the perspective of the rapist (e.g., understanding of how powerful the rapist might
feel). Participants also reported whether they had been victims or perpetrators of sexual
aggression in the past.
Of interest to the current discussion is the degree of empathy that participants felt for
perpetrators specifically. When the victim was male, participants felt more empathy for
female rather than male perpetrators, but only among participants who had never perpetrated
sexual aggression. However, males with perpetration experience (sexual offenders)
experienced more empathy for male rapists compared to male non-offenders and female
offenders. This study thus suggests that it is possible, under some circumstances, to feel
empathy for undesirable targets. More specifically, this study showed that some factors either
related to the empathizer (e.g., sharing similarities with perpetrators because of prior similar
sexual offending experience), or the perpetrator (e.g., gender of perpetrator) might moderate
empathic responses for rapists.
Although examining a less serious behavior, a well-known study suggests that it is
possible to have empathy for people who are deliberately unfair (Singer et al., 2006). The
researchers examined empathy for a target‘s pain after the target had been fair versus unfair
78 Sara Konrath and Delphine Grynberg

on an economic game. In the Ultimatum Game (UG), participants have to accept or reject
monetary offers from other participants. One player, the proposer, offers a certain amount of
money to the responder who can either accept or reject the proposal. If the responder accepts,
the amount is divided according to the proposer‘s offer. If the responder rejects, both receive
nothing. Fair offers approach 50% of what the proposer is given. In this study, all participants
were responders, but the fairness of the offers by the proposers was varied by the researchers.
Some participants received fair offers from proposers and others received unfair offers.
Results indicated that there were gender differences in empathic responses to proposers
making unfair offers. Among males, there was lower activity in the brain areas associated
with empathic concern in response to unfair players‘ painful experiences, compared to fair
players, suggesting a clear attenuation of empathic response. There was even some activation
of reward areas in males‘ brains when viewing the pain of their unfair partners, suggesting
‗schadenfreude‘ (the sense that someone is getting their ‗just desserts‘ and does not deserve
empathy for a painful outcome). However, females showed similar empathic-related neural
activity in response to both fair and unfair players. This suggests that while males are
influenced by the fairness of their partners, and may be less likely to empathize with
undesirable (i.e., unfair) partners, females might be more likely than males to empathize with
unfair others who are in pain. In other words, females may be genuinely more forgiving of
unfair players while males take transgressions against principles of fairness more seriously.
Another study examined the effect of manipulating empathy levels on cooperation with
unfair others (Batson & Ahmad, 2001). Participants were randomly assigned to empathize
(versus remain objective) with a partner who they learned would not cooperate with them in a
prisoner‘s dilemma game (see previous description of the game). The results revealed that
participants who imagined their partner‘s feelings were more likely to cooperate with their
partner, even when they knew that their partner would not cooperate with them (i.e., would
defect). This study revealed that not only is it possible to empathize with undesirable others,
feeling empathy for them might lead to increased prosocial responses directed toward these
undesirable targets. Although prosocial behavior is typically seen as desirable (hence, this
study was discussed in Part 1), the desirability of prosocial behavior directed toward known
cheaters is more debatable.
Why does empathizing with unfair targets increase cooperation levels? There is some
evidence that it changes people‘s perception of the relative unfairness of offers, especially in
the presence of high serotonin levels (Crockett, Clark, Hauser, & Robbins, 2010). Serotonin
is a hormone that indirectly promotes prosocial behaviors and seems to inhibit aggressive
behaviors (Crockett, 2009; Krakowski, 2003). Serotonin is critically involved in affect
regulation (Selvaraj et al., 2012). People with better affect regulation (due to higher serotonin
levels) might be more prosocial while people with more impaired affect regulation might be
more likely to retaliate for unfair play. In their study, Crockett and colleagues (2010) used the
same game that was used by Singer et al., (2006): the Ultimatum Game. In high empathy
scorers only (based on a median split of trait empathy), the administration of a serotonin
reuptake inhibitor (relative to a placebo or norepinephrine reuptake inhibitor) caused
participants to judge more unfair offers as more acceptable, and thus, to be more likely to
accept them. Taken together, these studies suggest that empathy is not only associated with
adaptive behavior. Instead, they suggest that perhaps empathy should also be perceived as a
social risk factor: greater empathy for undesirable people might make empathic people see
unfair actions as more acceptable, which could make empathic people more vulnerable to
 The Positive (and Negative) Psychology of Empathy 79

exploitation and less able to set limits on unfair players or even antisocial individuals. This
may be one circumstance in which empathizing may be bad for the self.
Empathy (in terms of perspective taking) for undesirable persons might also have
negative consequences for the empathizer‘s own moral behaviors. Research has also
examined how taking the perspective of unethical or unfair partners in economics games
influences participants‘ judgment of their partners‘ unethical behaviors, and also how it
influences their own behaviors (Gino & Galinsky, 2012). Participants who imagined the
perspective of their unfair partners rated the behaviors as less immoral, shameful, and
embarrassing compared to control participants. Furthermore, they themselves were also more
likely to engage in unethical or unfair acts. These results may initially appear to contradict the
above studies, which found that empathy for unfair actors was associated with increased
prosocial behavior. However, in Gino & Galinsky‘s studies the object of participants‘
empathy and the recipient of the later unethical action were different people. Either way,
empathizing with undesirable targets is problematic (although it bears mentioning here that
empathizing in this context means perspective taking). On the one hand, it can make people
more likely to cooperate with untrustworthy others, and on the other hand, it can make people
internalize the undesirable behaviors of those untrustworthy others and recapitulate those
actions on some other unfortunate person. Overall, empathy – again defined here as
perspective taking in relationship to an antisocial player – might have negative consequences
at cognitive and behavioral levels when one empathizes with someone who is unethical or
immoral.
Other research supports the conclusion that empathy directed towards certain undesirable
targets can be morally problematic (Happ, Melzer, & Steffgen, 2011, 2013). In these studies,
researchers manipulate perspective taking levels, and then have participants play either a
good (e.g., Superman) or bad (e.g., Joker) character in a violent videogame. Participants who
are assigned to take the perspective of the ‗bad‘ character (e.g., by reading a fake Wikipedia
article that depicted Joker as having had a violent childhood and an aggressive father) exhibit
less prosocial behaviors (e.g., lower donations to a charity after the task), perceive neutral
facial expressions as more hostile, are more likely to endorse violent behaviors as justifiable,
and report more aggressive behavioral intentions (using scenarios) compared to participants
who are assigned to take the perspective of a ‗good‘ character (e.g., by reading a fake
Wikipedia article that described Superman as coming from a loving family). These results are
in line with the other results described above that contradict the assumption that being
empathic always increases altruistic behavior, and is always a preferred and positive response.
Rather, these two studies suggest that empathizing with (i.e., adopting the perspective of)
‗bad,‘ antisocial and aggressive characters can increase one‘s own aggressive and antisocial
tendencies.
In conclusion, research suggests that under specific circumstances, it is clearly possible to
take the perspective of or have empathy for unfair people or even sexual offenders and that
having empathy for these undesirable people might have negative consequences for the self
and others. However, it bears mentioning that the majority of this research operationally
defines empathy in the more cognitive way, as perspective taking, and as we noted earlier,
even people with antisocial personalities have intact cognitive aspects of empathy (i.e.,
Theory of Mind; Richell et al., 2003).
Empathy can be biased. Imagine that you are walking down the street and you suddenly
see someone being beaten up by someone else. Which victim would you be more likely to
80 Sara Konrath and Delphine Grynberg

feel empathy for – someone who was part of your own group or someone who clearly was
not? What if the victim was a woman rather than a man? An attractive woman rather than an
unattractive one? What about a child or infant compared to an adult? What about a puppy
rather than a person?
As reviewed in Part 1, empathy instructions or training can help to reduce prejudice
toward stigmatized others, yet, these instructions would not be needed if we already naturally
empathized toward these groups. Instead, people have a tendency to feel more empathy more
quickly for people who they see as similar to themselves (i.e., in-group members). For
example, one study asked participants to observe a target who was randomly assigned to
either have similar or different traits and values from the participant. The researchers then
measured participants‘ physiological reactivity while they observed their partner getting a
shock. Participants had higher reactivity for similar others (Krebs, 1975). Other experimental
research has found that participants report more empathic feelings and direct more helping
behaviors toward targets who are more similar to them (Batson, Turk, Shaw, & Klein, 1995).
This concurs with the meta-analytic finding that targets who are more similar to participants
receive more prosocial behavior, on average (z = .15; Eisenberg & Miller, 1987). Moreover,
several studies find that activity in empathy-related brain regions is attenuated for out-group
members experiencing pain, relative to in-group members (Mathur, Harada, Lipke, & Chiao,
2010; Xu, Zuo, Wang, & Han, 2009). Finally, emotionally close others also tend to receive
more empathy than more emotionally distant people (Beeney, Franklin Jr, Levy, & Adams Jr,
2011; Cialdini, Brown, Lewis, Luce, & Neuberg, 1997; Norscia & Palagi, 2011). In other
words, similarity, familiarity, and social attachment also modulate empathic feelings (Watt,
2007).
Other recipient characteristics also seem to influence the likelihood of receiving empathic
responses from others. Although similarity to self does seem to matter in terms of predicting
empathic responses, an even stronger influence is the extent to which targets are cute or baby-
like. One series of studies directly pitted similarity and ―nurturance‖ against each other in
terms of the likelihood of each evoking empathy (Batson, Lishner, Cook, & Sawyer, 2005).
Participants were introduced to Kayla, who had a broken leg that required surgery and
intensive rehabilitation. By random assignment, Kayla was either a 20 year old student
(similar to participants), a 3 year old child, a 5 year old dog, or a 4 month old puppy. The
results indicated that participants felt the least empathy for the most similar target (the
student) and the most empathy for the cutest/most vulnerable ones (i.e., the child and the
dogs). This suggests that some modulating variables for empathy inductions ‗trump‘ others,
and thus becomes further evidence that empathy is fundamentally tied to the mammalian
prototype of maternal nurturance and caretaking for relatively helpless infants, as suggested
originally in (Panksepp, 1998), and developed further in Watt (2005; 2007) and Preston
(2013).
This can also play out along gendered lines. For example, a meta-analysis found that
females (traditionally seen as the ―weaker‖ sex) are more likely than males to be recipients of
help (Eagly & Crowley, 1986), although it is unclear whether this is specifically driven by
increased empathy. In addition, the attractiveness of potential recipients seems to influence
whether they will receive empathy. People with higher trait empathy are more likely to
spontaneously and unconsciously mimic others‘ motor actions and facial expressions,
whereas lower empathy people tend to show spontaneous counter-empathic responses (e.g.,
smile in response to angry faces; Chartrand & Bargh, 1999; Sonnby-Borgström, Jönsson, &
 The Positive (and Negative) Psychology of Empathy 81

Svensson, 2003; Sonnby–Borgström, 2002). However, recent research has found that
empathic individuals are only more likely to mimic targets if they are attractive, but not if
they are unattractive (Müller, Leeuwen, Baaren, Bekkering, & Dijksterhuis, 2013). Taken
together, there is a tendency to empathize with weaker, more vulnerable, yet also more
attractive recipients. It is no wonder that the cultural archetype of the ―damsel in distress‖ is
so evocative.
Researchers have also found that participants who learn about single named individuals
experience more emotional arousal than after learning about unnamed individuals or groups
of people. This is called the ―identifiable victim effect‖ (Kogut & Ritov, 2005), and it
underscores the fact that empathy is in a real sense ‗personal‘ and enhanced by making
suffering parties appear to be real and identifiable people. However, it is unclear whether the
emotional arousal that is experienced is empathic concern (i.e., feelings of compassion,
tenderness, warmth, and feelings of distress for the victims) as one might assume. Research
finds that participants feel equal amounts of compassionate emotions for both types of
recipients. However, they experience increased feelings of personal distress (i.e., feelings of
being upset, worried, disturbed, and troubled) after learning about the plight of single named
individuals (Kogut & Ritov, 2005). However, researchers do not tend to distinguish between
feelings of distress for the self and feeling distress for the victims, the latter of which is
clearly empathic (Batson, Early, et al., 1997). Future studies could help to clarify the specific
role of empathic emotions in the identifiable victim effect.
Empathy and moral reasoning. The research reviewed above indicates that empathy can
at times be ‗biased‘ – favoring vulnerable, cute, attractive, similar, or close others, consistent
with the ‗gating‘ model of empathy proposed by Watt (2007). But can it negatively affect our
moral judgments in certain circumstances? In the past decades, there has been much scholarly
interest on the effect of emotions on moral judgments. For instance, researchers have found
that presenting disgusting smells or tastes results in hasher judgments of moral dilemmas
(Inbar, Pizarro, & Bloom, 2012), consistent with unpleasant sensory stimuli clearly biasing
affective activation in a negative direction. In addition, more feelings of anger can lead to
more utilitarian beliefs, for example, saying it is acceptable to kill one person to test a vaccine
in order to save millions of people (Choe & Min, 2011). These examples show that there are
obviously emotional components to moral decisions, particularly in relationship to moral
dilemmas.
Other research has suggested that empathy may also influence moral judgments. For
instance, psychopaths and people with antisocial personalities, who are characterized by
lower emotional responses (Pham, Philippot, & Rime, 2000) and lower levels of empathic
concern (Mullins-Nelson, Salekin, & Leistico, 2006), show less severe judgments of moral
transgressions such as taking money from a wallet found on the ground (Bartels & Pizarro,
2011; Blair, 1995). Thus, lower empathy clearly leads to less concern about harming others,
and thus to less severe judgments when harm actually occurs. Although it is true that other
emotional responses may also predict moral judgments (e.g., disapproval – Prinz, 2011),
empathy may still play an important role in moral decisions when there are direct victims of
transgressions. For instance, empathy is unlikely to predict moral judgments when there are
victimless moral transgressions or when there are no salient victims (Prinz, 2011). But feeling
empathic concern for victims of a transgression may help prevent harm to these people. For
example, one might readily consider it inappropriate to steal money from a found wallet
82 Sara Konrath and Delphine Grynberg

because one feels empathy for the owner of the wallet – even without actually meeting that
person.
However, research has revealed inconsistencies in the association between empathy and
moral judgments involving victims. Some studies have indeed shown correlations between
empathy and moral judgments that involved transgressions with victims (e.g., stealing;
Kalliopuska, 1983), while others have found no association (Lee & Prentice, 1988). These
inconsistencies might result from the fact that empathy may affect only certain moral
dilemmas. More specifically, empathy may play a particularly salient role in limiting
utilitarian moral reasoning, or choosing to harm one individual in order to save many
individuals (Greene, Nystrom, Engell, Darley, & Cohen, 2004). Imagine that a trolley
containing five people is heading for a broken track which will make it derail, killing all
individuals aboard. The only way to save these five people is to kill a stranger by pushing him
on the rails or by modifying the trajectory of the trolley so that it drives over a stranger lying
on the rails (adapted from Thomson, 1986). The decision is difficult because one must decide
whether to harm and kill one person in order to save five, either personally (i.e., by pushing
the stranger), or impersonally (i.e., by pulling a lever to redirect the trolley; Greene,
Sommerville, Nystrom, Darley, & Cohen, 2001; Thomson, 1986). Although it is unclear
whether responses to such hypothetical dilemmas correlate with real-world moral behaviors,
it is still important to understand factors that influence people‘s moral reasoning – since
milder and more realistic versions of ethical dilemmas are common.
Feeling empathy for the stranger who would be killed in order to save the others might
make people less likely to harm this person, which would thus prevent saving more people.
One study has examined how people who make utilitarian moral decisions are perceived by
others in terms of their empathy levels (Uhlmann, Zhu, & Tannenbaum, 2013). Targets who
choose to throw an injured man overboard in order to save a boat full of people from sinking
are viewed as less empathic by raters than those who decide to not throw the injured man
(thus causing the whole boat to sink, and all the people to die). Therefore, making ‗utilitarian‘
moral decisions is perceived as an intrinsically low empathy response.
In another study, researchers assessed the relationship between trait empathic concern
and responses to utilitarian moral dilemmas (Gleichgerrcht & Young, 2013). Importantly, the
authors distinguished between two kinds of dilemmas: more personal dilemmas (i.e., harming
someone directly, such as pushing a stranger onto the rails in the trolley scenario) versus more
impersonal dilemmas (i.e., harming someone in an indirect way, such as modifying the
trolley‘s trajectory so that it ran over a stranger lying on the rails). More empathic concern
was associated with less ‗utilitarian‘ moral decisions in personal dilemmas only. In other
words, high empathy people might not believe that one person should be sacrificed to
promote the general good. Thus, this is a case where high empathy may be good for specific
individuals at the expense of others. This inhibitory influence of empathy on personal
‗utilitarian‘ moral decisions was replicated in another study using a different measure of trait
empathy (Choe & Min, 2011). Yet another study that used virtual reality to increase the
dramatic realism of these scenarios found that participants who responded with more
autonomic arousal (perhaps an index of empathic arousal) were less likely to pull the switch
that would cause the single individual to die, and the others to be saved (Navarrete, 2012).
Taken together, higher empathic responses may result in less ‗utilitarian‘ moral judgments
(i.e., save as many people as possible), but especially when empathic people might be
personally involved in causing someone‘s death (i.e., directly harming or killing one person).
 The Positive (and Negative) Psychology of Empathy 83

The influence of empathic concern on moral decisions has also been supported among
clinical populations. For instance, patients who have frontotemporal dementia (FTD), which
is associated with deficits in empathic concern, are unable to rate the seriousness of moral
transgressions (Lough et al., 2006), consistent with evidence for orbital-frontal involvement
in FTD (Rosen et al., 2002). Furthermore, relative to patients with other dementing illnesses
(e.g., Alzheimer‘s disease) and to healthy controls, patients with a frontotemporal dementia
make more ‗utilitarian‘ decisions in personal moral dilemmas (Mendez & Shapira, 2009).
Other research finds that patients with lesions in the ventromedial prefrontal cortex, which is
also involved in empathic responses (Shamay-Tsoory, Tomer, Berger, & Aharon-Peretz,
2003), make more ‗utilitarian‘ moral decisions than neurologically normal subjects (Koenigs
et al., 2007; Moretto, Ladavas, Mattioli, & di Pellegrino, 2010).
Taken together, there is consistent evidence that inhibition of more ‗utilitarian‘ personal
moral decisions is at least in part driven by capacities for empathic concern. When one tends
to generally feel empathic concern for people who might undergo intense suffering, one
prefers not to personally cause the death of a single individual in order to save more people
from death. This thus suggests that being empathic might make it less likely that people will
serve the common interest by saving as many people as possible in these moral dilemma
scenarios. While this may appear maladaptive, it underscores that empathy is a proximal and
‗short-range‘ pro-social mechanism concerned with immediate suffering that is directly in
front of someone, as opposed to hypothetical suffering that might happen ‗down the road‘ in
the context of a particular contingency (see discussion of this in chapter by Watt and
Panksepp in this volume). Therefore, more empathic individuals might disagree with the
assumption that ―the ends justify the means.‖ They might also not believe that one person can
be or should be sacrificed in order to promote the general good. Future studies should
investigate whether responses to such dilemmas correspond with real-world prosocial
behavior.
Other studies also suggest that the mandates of empathy sometimes contravene what we
might conceptualize as ‗the common good.‘ There are many situations when one‘s empathy
for a loved one might potentially conflict with one‘s larger social responsibility. For example,
―a father may resist contributing to public TV, not to buy himself a new shirt, but because he
feels for his daughter, who wants new shoes‖ (Batson, et al., 2004, p 378). Or an aunt may be
empathetically motivated to preferentially hire her less qualified nephew over a more
qualified job candidate, and thus negatively impact her company‘s bottom line. In addition,
many occupations could be conceptualized as destructive to the environment or to notions of
larger social benefit, but the motives for keeping those jobs may be in part empathic (e.g., to
provide for one‘s family). Indeed, two papers find that when people are assigned to empathize
with specific targets, they preferentially allocate resources to this target at the expense of the
larger group (Batson et al., 1999; Batson et al., 1995). In this regard, empathy can be viewed
as potentially threatening to larger notions such as ‗the common good‘ as much as frank
egotism. And yet these studies also underscore the intrinsically short-range, proximal focus,
and social attachment basis of empathy – that we will readily sacrifice a larger and more
abstract social good in order to preserve our ‗home base.‘ Appreciation of such intrinsic
trade-offs may make the costs or downsides of empathy in these contexts appear less
obviously maladaptive. Indeed from the perspective of what has been selected evolutionarily
(see discussion of this in final section), preservation of the family, one‘s small group, and the
immediate social ‗home base‘ has been clearly prioritized.
84 Sara Konrath and Delphine Grynberg

Clearly, there are intrinsic trade-offs in terms of our potential personal allegiances versus
larger social needs, and yet empathy can also motivate a variety of larger pro-environmental
attitudes and behaviors with clear implications for the long-term common good (Allen &
Ferrand, 1999; Preylo & Arikawa, 2008; Sevillano, Aragonés, & Schultz, 2007; Shelton &
Rogers, 1981; Taylor & Signal, 2005; Walker, Chapman, & Bricker, 2003). Moreover, low
empathy traits such as narcissistic entitlement are associated with exploitative approaches to
natural resources (Campbell, Bonacci, Shelton, Exline, & Bushman, 2004). Given this, it is
possible that empathy may sometimes promote and other times oppose what one may
construe as ‗the common good,‘ depending upon the target of empathy and other social
contingencies. If individuals empathize with targets that represent the common good (e.g.,
animals, nature) then empathy might help to preserve it. But to the extent that they empathize
with other more intimate conspecifics, they may allocate their limited resources toward these
targets at the expense of the common good.
Research suggests that at times empathy can apparently contravene another basic moral
principle: concepts of fairness or justice. For example, studies have found that participants
who are induced to feel empathy for certain individuals (e.g., a terminally ill child) are more
likely to unfairly allocate resources to this individual (e.g., move her off a waiting list and
into immediate treatment, which means that others on the waiting list do not get the treatment
they need; Batson, Klein, Highberger, & Shaw, 1995). This occurs even though participants
readily admit that their actions are unfair. This demonstrates that at times, empathic feelings
can motivate unfair partiality, and thus at times lead to behaviors that might clearly violate
concepts of fairness and equal allocation of resources. This again underscores the proximal,
short range, and intimate/conspecific activation locus of empathy.
Aggression and prejudice. It is possible that empathy inhibits some types of aggression
(see Part 1), but may accentuate others. High empathy may mitigate aggression in response to
personal threats, but at the same time, it might accentuate aggression in response to threats to
loved ones. This is a topic that has received virtually no research attention. Yet recent work
on empathically motivated anger and punishment is an intriguing beginning (Haas, de Keijser,
& Bruinsma, 2012; Vitaglione & Barnett, 2003). Moreover, there is a strong theoretical
reason to predict that empathy might increase this type of protective aggression. Studies in
non-human mammals have found that oxytocin, a bonding hormone, causes an increase in
defensive maternal aggression (Campbell, 2008). One recent study found that breastfeeding
human mothers exhibited higher aggression after provocation compared to bottle-feeding
mothers and never-pregnant women (Hahn-Holbrook, Holt-Lunstad, Holbrook, Coyne, &
Lawson, 2011). The specific role of empathy is unknown in this study, but future research can
clarify whether people induced to feel empathy for others would act aggressively on their
behalf in order to protect them from threat. This set of findings again confirms and is
consistent with theoretical articulations of empathy as emerging from the mammalian
affective prototype of maternal care and nurturance (Panksepp, 1998; Preston, 2013), and also
consistent with empathy models coming from an affective neuroscience background (such as
Watt, 2005, 2007). These models predict that empathy drives intensely protective behavior in
relationship to relatively helpless infants and children, and that such protective behavior
would be powerfully selected. Indeed, any species where infants are both relatively helpless
and at the same time not powerful solicitors of protective responses from adult caretakers
would likely go extinct quickly.
 The Positive (and Negative) Psychology of Empathy 85

With respect to prejudice, when people are specifically instructed to empathize with out-
group members, attitudes toward out-group members become more positive (see Part 1), yet
empathy may not have a uniformly positive response on intergroup relations. Until recently,
research on this topic has examined the effect of empathy outside of the context of actual
intergroup social interactions. In contrast to abstract group rating tasks that do not involve
expectations of social contact, intergroup interactions can evoke salient evaluative concerns,
which are worries about how social interaction partners evaluate the self (Vorauer, Hunter,
Main, & Roy, 2000; Vorauer, Main, & O‘Connell, 1998). Of particular concern to many
Caucasian people is the concern that other-race social partners may see them as ‗racist‘
(Vorauer, et al., 2000; Vorauer, et al., 1998). Therefore, it is important to examine the role of
empathy in contexts where there is anticipated or actual social contact and the potential for
evaluation.
Research on this topic finds that efforts to empathize can have an ironic effect. When
Caucasians try to take the perspective of other-race interaction partners, what they ―see‖
through the other‘s eyes is not always positive. Indeed several studies have shown that efforts
to empathize (typically operationalized as perspective taking) may make Caucasians
preoccupied with how others evaluate them and their group members (Lau, Falk, & Konrath,
2013; Vorauer & Sasaki, 2009, 2012). This makes them less likely to self-disclose (Lau, et
al., 2013; Vorauer, Martens, & Sasaki, 2009), and even more so if they value being low in
prejudice. In other words, being low in prejudice makes participants ironically less socially
sensitive when they are asked to empathize with out-group targets, perhaps because their
relatively progressive attitudes make them feel more complacent during these interactions
(Vorauer, et al., 2009). Moreover, minority group social interaction partners report being less
satisfied with social interactions after their Caucasian interaction partners are asked to
empathize with them (Vorauer, et al., 2009). Taken together, it would be naïve to assume that
empathy is always an inhibitor of aggression or always beneficial for intergroup relations. A
deeper understanding of triggers of empathic aggression and problematic intergroup
interactions is needed for both theoretical and practical reasons, and recent research suggests
that harsh in-group out-group distinctions – potent variables in empathy induction and
empathy inhibition – were selected to promote group cohesion (see extended discussion of
this in chapter by Watt and Panksepp in this volume).

PART 3: RECONCILING THE POSITIVE AND NEGATIVE ASPECTS

OF EMPATHY– EVEN „GREAT THINGS‟ HAVE A COST?

From this review we can still conclude that the majority of research on empathy finds
desirable correlates and outcomes. However, any theory of the origins of empathy needs to
explain both the good and the bad (see Table 1 for a summary). We believe that the positives
and negatives of empathy can best be understood within an evolutionary framework in which
empathy evolved to enhance survival and reproduction – the central mechanism of all genetic
selection. Many scholars see empathy as specifically originating in the parent-infant dyad,
which then generalizes more broadly to other in-group members, then even broader still
(Batson, et al., 2005; De Waal, 2008; McDougall, 1908; Panksepp, 1998; Preston, 2013;
Sober & Wilson, 1998; Swain et al., 2012). ―If mammalian parents were not intensely
86 Sara Konrath and Delphine Grynberg

interested in the welfare of their young—so interested as to put up with endless hassles,
exhaustion, and even risks to their personal safety—these species would quickly die out‖
(Batson, et al., 2005, p. 20).
Although the ultimate foundation of empathy and altruism extended to strangers may be
parental caregiving, the proximal, or day-to-day mechanism is likely the enhancement of
social stability and the promotion of deep emotional bonds, which are typically stronger for
one‘s own offspring and kin, but can be evoked by nearly anyone under the right
circumstances. This is an old idea: ―Tender emotion and the protective impulse are, no doubt,
evoked more readily and intensely by one‘s own offspring but the distress of any child will
evoke this response to a very intense degree in those in whom the instinct is strong. In a
similar direct fashion the distress of any adult (towards whom we harbor no hostile sentiment)
evokes the emotion‖ (McDougall, 1908, p. 72–74). These feelings of connection motivate us
to suppress our own self-interest to promote the well-being of others, and are facilitated by a
number of neural and hormonal mechanisms that underlie both empathy and non-kin empathy
and prosocial behavior – called the ―caregiving system‖ (Brown, Brown, & Preston, 2012;
Preston, 2013), and also the system for maternal nurturance/care (Panksepp, 1998). For
example, there is evidence that certain brain areas (e.g., the anterior insula) and various
peptide hormones (e.g., oxytocin, opioids, and prolactin) are implicated in both parenting and
empathically-driven prosocial responses (Swain, et al., 2012; For a more detailed summary of
neurological perspectives on empathy, see chapter by Watt and Panksepp in this volume).

Explaining the Positives of Empathy

We reviewed evidence that empathy motivates more sensitive parenting, and also more
sensitive and effective caring within the helping professions. Beyond this, empathy increases
the likelihood that individuals will help those who are in need, and decreases the likelihood of
certain types of aggressive responses. It helps people to see others, including those who are
not part of their group, in a more positive light. Each of these findings could stem from the
‗parental instinct‘ and emotional systems originally selected for maternal care being
generalized to any needy or vulnerable target within reach, as argued by a number of theorists
(McDougall, 1908; Panksepp, 1998; Preston, 2013; Swain, et al., 2012). When specifically
considering the parental context, it is difficult to come up with any way in which increased
empathy might be harmful to one‘s own offspring, and easy to imagine how low empathy can
decrease the probability of the offspring‘s survival. If empathically driven aggression exists, it
likely emerges from the obvious need for parents to protect their offspring from predators and
would be highly selected. The more empathic these parents are, the more likely they should
be to defend their child. Similar reasoning could apply to most of the positives associated
with empathy.
What about the potential that empathy can help to promote optimal mental and physical
health outcomes? More experimental evidence is needed to verify the causal role of empathy
in creating such benefits, yet there are theoretical reasons to predict such outcomes in many
circumstances, based on the caregiving system model. Parental behavior involves both
approaching distressed offspring while simultaneously regulating one‘s own personal distress
responses (Swain, et al., 2012). Clearly the caretaker cannot be flooded and immobilized by
their own distress, but if a parent is not distressed by a significant injury to a child that would
 The Positive (and Negative) Psychology of Empathy 87

actually predict a relative absence of empathy, not its presence. Indeed intimately tied to
effective parenting responses are a cascade of neurophysiological signals that help dampen
stress responses (S. Brown, et al., 2012). For example, oxytocin is a hormone that is best
known for its role in reproductive behaviors. It is released during childbirth, breastfeeding,
sexual activity, and maternal caregiving behaviors (Carter, 1992, 1998). It has been shown to
simultaneously increase prosocial behaviors and inhibit stress responses such as
cardiovascular reactivity and cortisol surges (Bartz et al., 2010; Cardoso, Ellenbogen,
Orlando, Bacon, & Joober, 2012; Domes et al., 2007; Kosfeld, Heinrichs, Zak, Fischbacher,
& Fehr, 2005; Kubzansky, Mendes, Appleton, Block, & Adler, 2012; Uvnäs-Moberg, 1998;
Zak, Kurzban, & Matzner, 2004; Zak, Stanton, & Ahmadi, 2007). Oxytocin also promotes
positive physical health outcomes (e.g., inhibiting inflammation, while promoting wound
healing; Clodi et al., 2008; Gouin et al., 2010). Taken together, oxytocin is one potential
neurophysiological mechanism of empathic responses, and a potential contributor to how
empathy might have salubrious effects on general health, although this has been minimally
studied (Barraza et al., 2013).
Explaining the „negatives‟ of empathy. Perhaps one overall perspective on the apparent
negatives of empathy is simply that there is no ‗free lunch‘ so to speak, and that selection
effects upon behavioral mechanisms always reflect a prioritizing of certain needs over others
– a prioritizing that may be highly protective overall but may have downsides and adaptive
costs in some specific contexts. We reviewed evidence that empathy can negatively affect
relationship satisfaction in high threat contexts, can make people act in accordance with
undesirable targets of empathy, can be biased and suffer from partiality, can negatively affect
some types of moral reasoning, and may at times lead to compassion fatigue. In terms it being
associated with poorer relationship outcomes in higher-threat relationships, it might be a good
thing for empathy to function as a double-edged sword. Being able to accurately infer what
one‘s partner is thinking can serve to maintain relationships that are positive, and end
relationships that are more negative. This may facilitate caregiving behaviors from relatively
stable and happy caregivers, by encouraging the less stable and less happy among them to
find greener pastures.
How do we potentially reconcile findings around empathizing with ‗bad‘ targets
(antisocial actors)? People tend to naturally empathize with ‗moral‘ people. This is likely an
evolved mechanism designed to protect us from exploitation and to protect others from
copycat bad behaviors. But there are times that we may identify with ‗bad‘ antisocial parties –
and those times can be problematic, both in terms of making it more likely that we will
foolishly cooperate with untrustworthy or dangerous others, but also that we may become
more like them than we ultimately might want to. Our capacity to empathize does not seem to
have strict limits or absolute boundaries, which is desirable in terms of widening our circles
of compassion to include more and more people, but possibly problematic in terms of the
potential practical effects of empathizing with undesirable others. Imagine for a moment an
extreme case of a Jewish person empathizing with Hitler‘s sense of an aggrieved and
devalued Germany in the 1930s. This would be hazardous, to say the least, and might inhibit
a healthy sense of self protection and mistrust of Hitler‘s aims. This chapter cannot fully
resolve the tension between the two poles – that we are able to empathize freely with anyone,
but that it may not be advisable to do so in all circumstances – but it just points out that these
issues need to be addressed within evolutionary/biologically based models of empathy (see
chapter by Watt and Panksepp in this volume).
88 Sara Konrath and Delphine Grynberg

Evolutionary models of empathy do illuminate empathy‘s tendency to be biased, partial,

and morally problematic at times. Infants are needy, cute, and easily distressed: they are
masters at ‗pushing our empathy buttons.‘ But so can any needy person (and any
manipulative person who knows how to ‗push empathy buttons‘). And so can any cute,
infant-like person or animal. And by definition, members of our in-group are more similar to
ourselves than out-group members. But that does not mean that it is impossible to empathize
with less appealing others, or people on the other side of the world who might initially seem
so different from us. Empathy may have evolved because more attuned mothers had infants
who were more likely to survive and reproduce, but clearly its pro-survival comforts can
readily be applied to anyone. We also need to be more aware of the variables modulating
empathy if we want to know where barriers to empathy may lie.
Parental responses to infants are necessarily biased and partial. Most parents would never
sacrifice their own child to save five other people, as in the classic utilitarian moral dilemma.
And parents devote so much time and energy into their children that is clearly at the expense
of many other needy children. It is likely that if parents of a sick child were allowed to choose
whether their child should be pushed higher on a waiting list, they would not feel too
conflicted about the other children who would be pushed lower on the list as a result.
Successful parenting requires a level of dedication and commitment that has made some
theorists aptly compare healthy parental behaviors to obsessive-compulsive disorder
symptoms (Swain, Lorberbaum, Kose, & Strathearn, 2007). Committed parental care was
likely selected by a dangerous early evolutionary environment in which extremely sensitive
parents had offspring with greater odds of survival – and evidence suggests also that this
appeared well prior to the emergence of primate and our own hominid lines, clearly being a
shared feature of our mammalian heritage (Panksepp, 1998). So, if empathy indeed evolved
from parental caregiving behaviors, many of its negative attributes are perhaps less surprising.
The capacity for empathy also clearly contributes to the risk of compassion fatigue and
burnout. Evidence is still needed to better understand the specific and causal role of empathy,
but it is possible that in cases where parents give more than their resources allow, this could
be dangerous. If a parent has only one piece of bread to eat, many would instinctively give the
bigger half to his or her child. There is a reason why airlines have to remind us to ―put on
your own air mask first.‖ Within the evolutionary context, giving the child the larger portion
in a scarce environment is giving the child a chance to survive and then later reproduce, even
if one decreases one‘s own chance of survival, yet with young children or infants, the death of
a parent poses grave risks to the survival of any offspring. This suggests caution about
uncritically embracing notions of ‗selfish genes‘ (Dawkins, 1976), since powerful emotional
bonds to offspring may motivate us to sacrifice ourselves to attempt to preserve loved and
valued others. But as the air mask example suggests, it is possible for both parent and child to
die if parents ignore their own fundamental needs. Thus, ideally parenting optimizes the
resources between the parent and child, with a tendency to give a little more to the child if
resources are scarce. To the extent that compassion fatigue and burnout are intrinsic
vulnerabilities of empathy, the risk for this emerges in more extreme contexts, particularly
where empathic responses yield little improvement in suffering. More research is clearly
needed to understand the boundaries and limits of optimal empathy for one‘s own well-being
as well as empathy‘s costs.
 Table 1. Summary of the positive and negative correlates of empathy

Positive Negative
INTERPERSONAL
Prosocial behavior Evidence that empathy inductions increase altruistic Evidence that empathizing with undesirable targets
motivation to help strangers and cooperate, even under makes people act in accordance with them, which at
duress. times can reduce prosocial behavior.
Close relationships High empathy is associated with more sensitive parenting, In high-threat contexts, empathy is associated with
and more relationship satisfaction in romantic relationships. less relationship satisfaction. Experimental evidence
Experimental evidence needed.* needed.*
Professional contexts High teacher, doctor, and therapist empathy is associated Need more research on potential negative
with better outcomes for students and patients, respectively. consequences of teacher, doctor, and therapist
Experimental evidence needed.* empathy for student and patient outcomes.
Aggression Some evidence that empathy associated with less aggressive The possibility that empathy might be associated
traits and behaviors, such as aggression in response to with increases in other types of aggression, such as
personal threats or aggression directed toward vulnerable aggression in response to threats to loved ones, has
targets. not adequately been explored in the literature.
Prejudice Empathy inductions improve attitudes, feelings, and People are naturally more likely to empathize with
prosocial behaviors toward stigmatized groups. in-group members and close others. Empathy
inductions increase evaluative concerns during actual
intergroup social interactions, thereby reducing self-
disclosure and increasing the awkwardness of the
interactions.
Moral reasoning Weak or non-existent evidence that empathy can improve It is possible to empathize and identify with immoral
moral reasoning, although that depends upon the definition others, which may impact moral reasoning. High
of moral. For example is it moral to kill one person to save empathy people make less utilitarian moral
more people (i.e., to be utilitarian)? Also, prosocial behavior judgments (e.g., are more likely to save a single
is morally desirable. individual at the expense of a group of individuals).
Empathy inductions for intimates and other
conspecifics also lead to unfair preferential treatment
of specific individuals at the expense of others.
 Table 1. (Continued)

Positive Negative
INTRAPERSONAL
Psychological disorders Low empathy is a feature of some psychological disorders Excessive empathic concern and unregulated
(e.g., Narcissistic Personality Inventory, Antisocial emotional contagion is a feature of some
Personality Disorder, Autism Spectrum Disorders). This psychological disorders (e.g., Williams Syndrome).
indicates that high empathy may be protective from such
disorders.
Psychological Higher psychological well-being among people with higher Weak evidence that empathizing is associated with
well-being empathy and related traits and behaviors. Experimental poor psychological well-being. Experimental evidence
evidence needed.* needed.*
Physical health At times improved physiological and physical indicators of Empathic people experience physiological resonance
health for people with higher empathy and related traits and with others‘ experiences, which can be bad if exposed
behaviors. Experimental evidence needed.* to others‘ stresses. However, experimental research is
needed.*
*Indicates that experimental evidence is rare. Most studies are correlational so far.
 The Positive (and Negative) Psychology of Empathy 91

CONCLUSION
To our knowledge, this is one of the most comprehensive reviews to date on the potential
liabilities associated with empathy (and we also refer readers to the excellent reviews of
Batson, 2011; Batson, et al., 2004). Overall, we would situate this review within an
evolutionary/ biological framework that may help to reconcile some apparently contradictory
results. Empathy is nearly always a desirable attribute in relationships with our loved ones
and other social interaction partners, but it comes with a few ‗thorns‘ that need to be
reconciled with its otherwise highly adaptive nature. Roses have thorns because thorns were
protective and perpetuated their survival, and the adaptive costs and downsides of empathy
are likely explained in a similar way. An awareness of the limits of empathy can help us to
better regulate it and ourselves to mitigate its costs and enhance its benefits.

AUTHOR‟S NOTE
This work was supported by a grant from The Character Project (Psychology of
Character), from Wake Forest University, via the John Templeton Foundation, and from
direct grants from the John Templeton Foundation (#47993 and #57942). A version of this
paper was presented to the University of North Carolina, Chapel Hill, Department of
Psychology. We thank attendees for their valuable comments and insights. Address
correspondence to Sara Konrath, Indiana University, Lilly Family School of Philanthropy,
Indianapolis, IN, email: skonrath@iupui.edu.

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EMPATHY THROUGH THE LIFECYCLE
In: Psychology and Neurobiology of Empathy ISBN: 978-1-63484-446-8
Editors: Douglas F. Watt and Jaak Panksepp © 2016 Nova Science Publishers, Inc.

Chapter 4

THE DEVELOPMENT OF EMPATHY

IN EARLY CHILDHOOD

Maria Licata1,, Amanda Williams2 and Markus Paulus1

1
Ludwig Maximilian University, Munich, Germany
2
Dalhousie University, Halifax, Nova Scotia, Canada

ABSTRACT
Recent research employing a variety of different measures has shed new light on the
developmental origins of empathy. Beyond basic behavioral observations, current studies
also rely on neurophysiological and psychophysiological assessments to examine
empathic reactions and their correlates in young children. In this review, we first examine
classical models of empathy. We then present in greater detail recent findings on
empathic behavior in young children, focusing both on issues such as the neural basis of
early empathic behavior, the role of the parent-child relationship as well as cognitive and
social factors in children‘s empathy development. We conclude our review by reporting
training effects on empathy.

DEFINITION OF EMPATHY
Empathy constitutes a basic human ability and a core trait of human social behavior,
which is of great importance in daily social life, as it helps us harmoniously interact with
other people (Decety, 2012; Hoffman, 2000; Hutman & Dapretto, 2009; Moreno, Klute, &
Robinson, 2008; Smith, 2009). The term ‗empathy‘ is derived from the Greek work
empatheia (en: in; pathos: passion, feeling) and was translated into English from the German
word Einfühlung, which literally means ―feeling into‖ (Wispé, 1986). The term was first
introduced by Lipps (1903) in order to refer to a process through which a person empathizes
with another person, having observed his or her affective state. Since then, many theoretical
accounts and research have explored this topic.


Corresponding author: Maria.Licata@psy.lmu.de.
112 Maria Licata, Amanda Williams and Markus Paulus

Eisenberg and Fabes (1998, p. 702) define empathy as ―an affective response that stems
from the apprehension or comprehension of another‘s emotional state or condition, and which
is identical or very similar to what the other person is feeling or would be expected to feel.‖
For example, if a girl observes a sad boy, recognizes the boy‘s situation and consequently
feels sad herself, she is viewed as empathic. Thus, according to this definition, a central
component of empathy is that the emotional response is ‗isomorphic‘ with the other person‘s
emotional state (and what this might mean is not precisely clear, but it suggests that the
observer has to feel a quite similar state to the person observed). However, it has also been
claimed that another important aspect of empathy is that the observer has to be aware of the
victim‘s affective state not being quite the same as the observer‘s affective state (Bischof-
Köhler, 1989, 1994). Thus, according to this definition, empathy is not mere emotional
contagion without understanding the source of emotion, as the observer must realize that the
other person‘s emotion is not his or her own emotion (see also Eisenberg, Huerta, & Edwards,
2012). This suggests that definitions of empathy vary in terms of whether the emotional state
must be at least relatively and similar to the other person‘s feeling, and whether self-other-
distinction is a prerequisite of ―mature‖ empathy.
Moreover, many authors categorize empathy into two somewhat distinct or at least
potentially discriminable aspects, along the lines of a basic distinction between cognitive and
affective empathy. Affective empathy, which is also referred to as ―hot empathy,‖ involves an
emotional reaction to another person‘s feelings, and is based upon at least a partial sharing of
another person‘s emotional state. This affective activation and ‗sharing‘ of emotion may drive
motivation to relieve the other person‘s distress (Eisenberg & Fabes, 1990; Watt, 2007).
However, if the observer is too distressed by the victim‘s expression of negative emotions
(flooded in other words), this affective appraisal can also result in distress and high arousal,
which can inhibit prosocial behavior, as the observer must cope with regulating their own
emotions (conf. Eisenberg et al., 1996). Alternatively, the other type empathy, cognitive
empathy (―cold empathy‖ or cognitive empathy), involves perspective-taking skills and refers
to the ability to understand and predict the behavior of others by attributing to them mental
states, such as believing, guessing, pretending and knowing, which is also referred to as
Theory of Mind (Astington, 2003; Baron-Cohen, 2003; Shamay-Tsoory, Aharon-Peretz, &
Perry, 2009; Singer, 2006). However, Zahn-Waxler et al. (1992) refer to cognitive empathy
when talking about toddlers‘ ‗hypothesis testing,‘ which is operationalized by a child‘s
looking/checking behavior toward the victim (in this case the mother who pretended to have
hurt her finger), indicating that the child cognitively understands what has happened. This
cognitive aspect of empathy does not require a fully developed representational Theory of
Mind which children acquire only around their fourth birthday (Wellman, Cross, & Watson,
2001), but involves basic perspective taking skills and is operationalized by a child‘s
looking/checking behavior toward the victim, indicating that the child cognitively
understands what has happened. This process can, but does not necessarily have to result in
an affective reaction: Davis and Stone (2003) regard cognitive empathy as prerequisite of
affective empathy, arguing that one must be able to understand the other‘s mental state, in
order to be able to share his affective state and potentially react in a prosocial way. However,
other authors suppose that a Theory of Mind is not a prerequisite for empathy (e.g., Singer,
2006), a notion which is also supported by empirical findings showing that children show
empathic reactions before they acquire a representational Theory of Mind (conf. Wellman,
Cross, & Watson, 2001; Zahn-Waxler, Radke-Yarrow, Wagner, & Chapman, 1992). Besides
 The Development of Empathy in Early Childhood 113

cognitive and affective components of empathy, Blair (2005) adds another component,
namely motor empathy, which he refers to as an automatic and unconscious mirroring of
another person‘s facial expression (―facial mimicry‖) Decety and Morguchi (2007) argue that
motor, emotional, and cognitive empathy are independent from each other, as the observation
of an emotion activates neural circuits. However, this notion of ‗motor empathy‘
(prototypically, rapid and often unconscious mimicry of facial expression) likely just
repackages basic contagion (intrinsic to affective empathy) as a separate form of empathy, a
common terminological confusion according to Watt (2005; 2007). In any case, the cognitive
and affective processes outlined here are likely to be highly interdigitating, as attentional
mechanisms ensure parallel processing of emotional stimuli; the affective state of the other
resonates with the observer (emotional empathy), which, in turn, may facilitate emotion
recognition (cognitive empathy) and related theory of mind operations. This line of reasoning
is supported by empirical findings showing that the rapid and relatively automatic facial
mimicry of emotions (basic contagion) facilitates emotion recognition as well as social
interaction, thus potentially fostering both cognitive and affective forms of empathy (Stel &
Vonk, 2010). These findings have led to the notion that contagion (what Blair termed ‗motor
empathy‘) helps to activate the full envelope of emotional empathy, and this facilitates
cognitive empathy; all three may conjoin to create what we think of as the full range of
complex empathic behavior (conf. Stel & van Knippenberg, 2008; van Baaren, Decety,
Dijksterhuis, van der Leij, & van Leeuwen, 2009). In line with this perspective on empathy,
Decety and Moriguchi (2007) define empathy as the capacity to recognize, understand, and
share the emotional states of others. In another narrow, very detailed definition given by de
Vignemont and Singer (2006) empathy is suggested to require the following 4 preconditions:

(a) We have an affective state,

(b) which is isomorphic to another person‘s affective state
(c) which was elicited by observing or imagining another person‘s affective state, and
(d) when we know that the other person‘s affective state is the source of our own
affective state.

Notably, this definition does not consider certain closely related cognitive abilities as
prerequisites of empathy, such as understanding the origins of the affective state (which might
suggest again more ‗affective theory of mind‘). Moreover, if we accept such a narrow
definition, empathy must be distinguished from related constructs such as prosocial behavior,
simple personal distress at the witnessing of suffering (contagion-induced), and Theory of
Mind. The concept of Theory of Mind (ToM) is defined as the ability to infer and represent
other persons‘ mental states, such as intentions, beliefs, and desires (Premack & Woodruff,
1978). This definition shows that ToM does not include an affective reaction, but focuses on
the cognitive processes regarding other people‘s mental states (Singer, 2006). Some authors
furthermore distinguish sympathy from empathy, as sympathy does not imply that a person
has the same feeling as the other person – in other words that sympathy lacks affective
resonance/contagion. Instead, it is characterized by feelings of sorrow or concern for the
victim. Thus, sympathy can occur as a result of empathy, but can also result from cognitive
perspective taking (Eisenberg et al., 1994, 2006), although others (such as Watt, 2007) have
suggested that these definitions are at odds with common usage as well as dictionary
definitions, where sympathy, empathy and compassion are clearly used as rough synonyms
114 Maria Licata, Amanda Williams and Markus Paulus

and have suggested that such semantic hairsplitting does not really ‗cash out‘ empirically and
adds only to ongoing fundamental confusion about empathy. Moreover, simple distress
resulting from contagion mechanisms is different from empathy, as it is characterized by self-
focused, aversive feelings and reactions, such as anxiety, discomfort and tension (Kienbaum,
1993; Trommsdorff, 1995). If one has to deal with their own intensely negative emotions, and
one is relatively flooded by them, that person often times will not be able to focus on another
person‘s emotional state and act prosocially (Trommsdorff, 1995; Ulich & Volland, 1998).
Batson (1991) argues that distress potentially generated by contagion mechanisms leads to an
egoistic motivation of making oneself feel better, and not primarily being concerned with
another. Thus, according to the author, in order to react in an empathic, prosocial way, the
level of distress must not be too high. Thus, prosocial behavior is not a true synonym for
empathy, as empathy can, but does not always, lead to prosocial behavior. More importantly,
prosocial behavior is independent from an agent‘s underlying motive (Eisenberg & Mussen,
1989; Paulus & Moore, 2012). Thus, prosocial behavior is not synonymous with altruism, as
it can also stem from egoistic motivations, whereas altruistic behavior is primarily motivated
by a concern for the other (conf. Durkin, 1995; Grusec, Davidov, & Lundell, 2002). Finally,
assuming a narrow definition of empathy, simple emotional contagion can be distinguished
from empathy, as it does not require self-other-distinction: emotional contagion means that a
person feels exactly the same as the other person, without being able to clearly distinguish his
own feelings from the other person‘s feelings (Bischof-Köhler, 1989, 1994). However,
emotional contagion should also be regarded as necessary ‗component‘ of empathy, which is
melded with developmentally later arriving capacities, such as stable concern, Theory of
Mind, and a more mature emotion understanding to create ―mature‖ empathy (Watt, 2007). In
order to be able to react in an empathic way, one has to be aware that their own feeling is not
the same as the other person‘s feeling, as otherwise the observer is too distressed themselves
and instead of relieving the other person‘s distress, the observer has to cope with their own
emotion regulation (Eisenberg, 1986; Hoffman, 1982).
In sum, there are different definitions and models of empathy, some of them integrating
aspects like emotional contagion and prosocial behavior, and some of them strictly separating
related constructs from empathy. For the purpose of this chapter, we regard empathy as a
multidimensional construct which refers to an emotional response (with potentially but not
necessarily precedent cognitive perspective-taking processes) to another persons‘ affective
state, while being aware that the other person‘s feeling is not one‘s own feeling.

THEORIES OF EMPATHY DEVELOPMENT

Until the 1980s, psychoanalytic (Freud, 1940) and cognitive (Piaget, 1971) theories were
dominant, arguing that children under the age of four years were not able to experience and
show empathy primarily because it was assumed that at this age, they still lacked (social-)
cognitive skills necessary to experience empathy. For example, from a Piagetian (1971)
perspective empathy is only possible in the concrete operational phase, when children
overcame their egocentric way of thinking, which is prototypical for the pre-operational child.
However, all of these early models were highly theory-driven, and not based on careful
operational definitions and empirical hypothesis testing. From the 1980s onward, new
 The Development of Empathy in Early Childhood 115

theories developed assuming that children were able to feel empathy already as early as at
three years of age. These crucial theories of empathy development are presented in the
following chapter.

HOFFMAN‟S DEVELOPMENTAL THEORY OF EMPATHY

Hoffman‘s (1984, 1987, 2000) theory of empathy development in early childhood has
made a significant contribution to our understanding of moral and prosocial development. His
theory is at odds with classic social-cognitive (Piaget, 1971) and psychoanalytic (Freud,
1969) developmental theories, which mainly viewed young children as egocentric and
socially inept, both supposing that empathy did not emerge earlier than middle childhood.
Instead, Hoffman argued that children clearly show rudimentary empathic responses already
in their first year of life in terms of emotional contagion (e.g., crying when another infant
cries). Before their second year of life, children have more limited cognitive abilities, as they
lack self-other-differentiation and perspective-taking skills. As a result, they are not able to
distinguish another person‘s distress from their own feelings. Consequently, evidence
suggests that one-year-old infants experience primary contagion instead of more developed or
mature empathy, or help in an egocentric way. With improvements in cognitive, social and
affective regulatory abilities, children are increasingly able to experience sympathy and to
help in a non-egocentric way.
Based upon those considerations, Hoffman assumed five different levels of empathy
development, progressing in accordance to a developmental sequence and being closely
related to children‘s social-cognitive development. The first level named the newborn
reactive cry, which refers to primary emotional contagion, and which is experienced in the
first year of life and occurring when children attend to others‘ emotions. However, this does
not result in an other-centered empathic reaction yet (such as prosocial behavior), but in a
similar affective state, which is associated with personal distress and oftentimes with
emotional flooding. This is the case, as children in their first year of life are not able to
differentiate between self and other; thus, children react as if what happened to another
person happened to themselves (Vreeke & van der Mark, 2003). In the second level
(egocentric empathic distress), which is assumed to start at about one year of age, children
become increasingly aware of other people‘s feelings, and develop the ability to attend to
other people‘s emotions without getting overwhelmed themselves. As a result, children are
able to react with concern to the victim instead of feeling too distressed by the situation. At
the beginning of their second year of life, children become increasingly responsive to others‘
affective states and begin to react prosocially. This third level is called quasi-egocentric
empathy, and in this level children‘s prosocial acts are guided by their own assumptions about
what they would find consoling themselves. In the middle of their second year of life,
children are able show ―real‖ empathy. This fourth level is called veridical empathic distress.
Children at this stage are capable to understand that another person‘s feelings, wishes and
thoughts can differ from their own mental states. This process starts with children‘s emerging
perspective taking and early theory of mind abilities at this age. During late childhood,
children come to experience empathic distress beyond the situation. At this fifth stage of
empathy development, empathy is not restricted to one situation but is generalized on
116 Maria Licata, Amanda Williams and Markus Paulus

different situations of distress or deprivation (e.g., experience empathy for poor people in
general). Hoffman was the first who theoretically related empathy with children‘s cognitive
development, such as self-other-distinction. His theoretical assumptions generated an array of
empirical studies (e.g., Bischof-Köhler, 1989; 1994; Radke-Yarrow & Zahn-Waxler, 1984;
Zahn-Waxler, et al., 1990, 2001, which we will report later in this chapter).

PRESTON AND DE WAAL‟S PERCEPTION-ACTION MODEL

Preston and de Waal‘s (2002) perception-action model is a process model of empathy
which deals primarily with the actual genesis of empathy. It deals with the underlying
processes, particularly the putative cognitive mechanisms subserving empathy. Accordingly,
they define empathy as ―any process where the attended perception of the object‘s state
generates a state in the subject that is more applicable to the object‘s state or situation than to
the subject‘s own prior state or situation‖ (p. 4). It builds on a classical distinction of Mayr
(1961) according to which ultimate and proximate causes of a behavior can be differentiated.
Ultimate causes refer to evolutionary explanations, which explain the presence of particular
phenomena be referring to their evolutionary pay-off. Proximate causes, in contrast, focus on
(mostly mechanistic) explanations, which refer to the immediate causal chains that led to a
behavior. Mayr‘s distinction implies that the existence of proximate causes can be explained
be referring to ultimate causes. Thus, explanations by proximate and ultimate causes do not
need to be in conflict with each other. Preston and de Waal‘s (2002) model also relates to
previous work by McDougal (1929) and argues that empathy – while having important
evolutionary benefits such as the facilitation of group living or the mother-infant bond – is
proximately based on a common coding system. That is, while there are clear ultimate causes
of empathy, which may have favored the evolution of such a system, the concrete underlying
mechanisms can be explained by a common representational format. More concretely
speaking, the authors refer to recent perception-action accounts, which assume that perception
and action are closely linked to each other as they share common ‗representational codes‘
(e.g., Hommel, Müssler, Aschersleben, & Prinz, 2001; Paulus, 2012). The commonality of the
codes may be due to the acquisition of associations between actions and effects (e.g., Heyes,
2010), a process, which has been demonstrated in 1-year-old infants (e.g., Paulus, Hunnius,
van Elk, & Bekkering, 2012). Preston and de Waal‘s model can be seen as a special class of
these approaches in which emotions are conceived of in terms of reactions or actions. That is,
in the course of development the child relates an emotion to its specific behavioral correlates
(e.g., their own sad state with their crying behavior). When the child subsequently perceives
the crying of another person, the perceived crying is mapped onto the child‘s ‗representation‘
of crying (i.e., a shared or common ‗code‘ is activated), which in turn leads to an activation of
the associated emotion. This process happens automatically, unintentionally, and
unconsciously. Thus, the model gives a mechanistic account of how empathy might be
possible (although notions of ‗coding,‘ in terms of how the underlying neural processes might
work is still contentious).
It is important to note that, although the authors differentiate emotional contagion from
emotional empathy and sympathy, they argue that these phenomena cannot be totally
disentangled as the latter two involve and require emotional contagion to some extent.
 The Development of Empathy in Early Childhood 117

Depending on the further processing of the experience, this situation can lead to a variety of
prosocial responses to the other (e.g., consolation as an instrumental response to alleviate the
situation). Although this model does not primarily focus on ontogenesis, but rather the
mechanisms that bring about empathic responses in particular situations, its core ideas have
some developmental implications. First, given the automaticity of emotional contagion, more
cognized responses to the other party should occur later than immediate contagion. Second,
given that empathic reactions, in this model, depend on the activation of a common ‗code,‘
the model predicts that empathy should be greater as more is shared between the subject and
the other. This model is thus able to explain effects of familiarity and similarity on children‘s
empathy (see, for an overview, Preston & de Waal, 2002) by referring to one neurocognitive
mechanism. It thus may explain why we more readily emphasize with people who are more
like us as opposed to people very different from us. One further corollary of this view is that
although some effects might suggest considerations of reciprocity in children‘s empathy and
prosocial action (e.g., when children behave more prosocially towards friends than disliked
peers; e.g., Moore, 2009; Paulus & Moore, 2013), these effects could proximally be explained
by greater familiarity with the other and henceforth a richer representation of the other. (Note
that alternatives to this cognitive ‗representational‘ view of contagion - see chapter by Watt
and Panksepp in this volume - might emphasize simply that attachment to the conspecific
amplifies contagion as one of its primary ‗gating‘ or modulating influences, as do numerous
other social affective variables in relationship to the suffering party) Third, the model argues
that in the course of development – particularly with the development of the prefrontal cortex
– cognitive functions impact the experience and display of empathy. More specifically, it
suggests that increased imaginative and perspective-taking abilities allow individuals to evoke
empathy even in absence of a distressed other (e.g., when imagining how someone would feel
in a particular situation); and that increased inhibitory abilities allow the subject to modulate
contagion, which might help the subject to prevent becoming overly distressed. In sum, the
authors suggest that with increasing cognitive abilities, we see the onset of cognitive
empathy, which supplements and may amplify as well as inhibit the more automatic form of
direct empathic reactions.

DECETY AND JACKSON‟S MODEL OF EMPATHY

Decety and Jackson (2004; 2006) propose a multi-faceted model of empathy that
incorporates empirical findings from social psychological, developmental, and neuroscientific
research. This model is composed of three main components; affective sharing as the result of
perception and action coupling/contagion, which leads to shared representations;
differentiation between the self and other; and mental flexibility and regulatory processes.
While they note that no one component alone can independently account for empathic
responding, they argue that together these components produce an empathic response.
Decety and Jackson‘s first component, which is that affective sharing as the result of
perception and action coupling leads to shared representations, is largely based on the notion
of shared representations between self and other. Decety and Jackson discuss the importance
of shared emotion, and note the importance of being able to detect and understand the
emotions of others in developing and maintaining social relationships with others. They posit
118 Maria Licata, Amanda Williams and Markus Paulus

that the shared representation mechanism is related to emotion processing. Decety and
Jackson suppose that the unconscious automatic mimicry of a target (contagion in other
words) leads to an automatic response in the observer, which changes both physiological state
and facial expression in the observer. In other words, they posit that perceiving emotions
activates the same neural mechanisms that generate emotions (Panksepp, 1998; Adolphs,
2002; Decety & Jackson, 2004; Watt 2007) and offer the example that witnessing someone
smile may activate the same facial muscles associated with smiling, and this activation can
result in corresponding feelings of happiness. Depending on the emphases in one‘s definition
of empathy, i.e., whether empathy is regarded primarily as a primary affective capacity or as
more resting in cognitive ability or perhaps as an amalgam of these functions, the automatic
tendency to imitate other people‘s expressions versus the capacity to imagine one‘s self in the
situation and context of another person clearly differ, both in terms of their potential locations
within the neuroaxis, as well as their developmental timetables.
Decety and Jackson also highlight the significance of self-other awareness and the
creation of intact personal boundaries in empathic responding. While they discuss similarities
between self and other-regarding neural networks and responses, they emphasize differences
between first and third-person experiences of distress. Decety and Jackson also discuss the
importance of one‘s ability to clearly differentiate between their own and others affective
experiences, - which is also relevant to their third point – pertaining to mental flexibility and
self-agency/ emotional regulatory processes.
With regards to this final point, they posit that witnessing the emotional state of another
activates similar neural circuits as when one imagines, or adopts the psychological view of
the other - a view consistent with Goldman‘s (2006) simulation theory. Here, they empathize
the importance of self-other differentiation, hypothesizing that excessive contagion and/or
lack of boundary could result in over-arousal and severe emotional distress not conducive to
more mature empathy and that could in fact hinder one‘s ability to respond in an empathic
and prosocial manner. Thus, the importance of self-agency and emotion regulation are
important in this definition of empathy, as these abilities allow one to differentiate between
the feelings in themselves, and others, recognize to whom each belong, and also reflect on
one‘s own feelings, and emotions.
In conclusion, Decety and Jackson propose a model drawing from research across
multiple domains such as social psychology, developmental science, and neuropsychology.
Their model discusses the importance of the development of abilities that allow individuals to
share, and understand the experiences of others. Further, they emphasize the significance in
being able to differentiate between the experiences of self and others, and regulate and
monitor one‘s own cognitive and emotional processes.
Finally, they make clear the complexities of empathy, and stress that individual
components of their model to not adequately account for the experience of empathy
considered on their own. Only when considered together do these various interacting
cognitive and affective processes might begin to provide us with real insight into how
empathy develops, and is experienced.
 The Development of Empathy in Early Childhood 119

DEVELOPMENT OF EMPATHIC BEHAVIORS IN

EARLY CHILDHOOD - EMPIRICAL FINDINGS
In the following chapter, empirical findings about empathy, but also closely related
constructs such as sympathy and prosocial behavior are reported, as these various constructs
or not always strictly separated in empirical research. After giving a brief summary about the
developmental origins of empathy, we explain in detail various factors that have been shown
to effect empathic behavior, as well as aspects that, in turn, empathy is assumed to have an
effect on. We conclude the chapter by assessing evidence for whether empathy can be trained.

Developmental Origins of Empathy

Early forms or precursors of empathy are witnessed early in infancy, with even newborn
infants experiencing, and demonstrating personal distress in response to the cries of others
(Martin & Clark, 1987; Sagi & Hoffman, 1976; Simner, 1971). As mentioned previously,
Hoffman (1975) suggests that this phenomenon, which is often referred to as the basic
contagion of primary emotion, suggests a biological and ontogenetic preparedness for
empathic concern and responding. This response however, is involuntary, dysregulated, and
egocentric, whereas most concepts of empathy typically include an understanding of the
other‘s physical, psychological, or emotional state, in addition to experiencing the affective
state of the other (Zahn-Waxler & Radke-Yarrow, 1990). Therefore, although ‗precursors‘ to
empathy may be present within the first few weeks of life, ‗true‘ or more mature empathy, as
defined previously, does not emerge until later in development.
Evidence of both affective aspects of empathy (e.g., empathic concern which is
characterized by – expressing concern for the distressed individual through facial expression,
gestures, and vocalizations) and cognitive aspects of empathy (e.g., hypothesis testing
through inquiry behavior and attempts to understand the victim‘s state using vocalizations and
non-vocal explorations, such as touching the part of their own body that they witnessed
another hurt, or looking back and forth between the hurt body part and face of an injured
individual or other adult) have been observed in infants as young as 8 months of age. While
these early demonstrations of empathy were modest and present at relatively low levels at
eight months of age, empathy measured at 10, 12, 14, and 16 months of age showed gradual
increases over time with children showing quite strong levels of empathic concern and
responding by 16 months of age (Roth-Hanania, Davidov, & Zahn-Waxler, 2011). Prosocial
interventions, (e.g., comforting behaviors) also begin to emerge around this time - during the
second year of life. Though initial attempts at offering comfort typically occur in the form of
physical behaviors, such as hugging, interventions become both more frequent, and tailored to
the needs of the distressed individual with age (Radke-Yarrow & Zahn-Waxler, 1984; Zahn-
Waxler, et al., 1990).
In a longitudinal study exploring the development of empathy in a large sample of both
monozygotic (MZ) and dyzygotic (DZ) twins, empathic concern, hypothesis testing, and
associated prosocial behaviors were shown to increase with age (Zahn-Waxler et al., 2001).
Conversely, self-distress/simple contagion in response to another person in a distressing
situation was shown to decrease with age, and generally level off at around 24 months of age.
120 Maria Licata, Amanda Williams and Markus Paulus

These findings are consistent with Hoffman‘s theory (1984, 1987) as they show that with age
children move away from reacting to others in distress with a simple contagion response, and
towards more regulated, and other-oriented behaviors. Moreover, they also report consistent
relationships between MZ twins for both measures of prosocial behavior, as well as empathic
concern (at each time point), and hypothesis testing (at three out of four time points), while no
relationships between DZ twins were observed. These findings suggest that empathic concern
and responding are influenced by genetics, at least in the early years of life.
Between 20-24 months of age, more important developments that are believed to further
facilitate the development of empathic concern for others take place, as during this time,
changes in cognitive and linguistic abilities, self-regulation, self-awareness, and
understanding of standards and morality occur (Kagan & Lamb, 1987; Zahn-Waxler &
Radke-Yarrow, 1990). Though perspective taking abilities are not necessarily a prerequisite
to experiencing empathy, as children develop these skills, they become able to differentiate
between themselves and others, and recognize that they are separate entities, which allows
them to experience true empathetic concern for another observed to be in distress, as opposed
to simply experiencing personal distress (Zahn-Waxler & Radke-Yarrow, 1990).
In sum, it is generally believed that the capacity for proto-empathy (defined as a
fundamental capacity for affective resonance/contagion) is present from a very early age, and
evidence of early empathy forms has been observed in the first year of life. Empathy
continues to develop in the second year of life into ―real‖ empathy, and becomes increasingly
differentiated into more prosocial responses, as children continue to acquire novel skills and
develop cognitively.

Temperament

Children‘s temperament, which refers to ―constitutionally-based differences in reactivity

and self-regulation‖ (Rothbart & Derryberry, 1981, p. 37), has been frequently linked to
empathy. There are divergent findings regarding which features of temperament foster or
hinder empathic responses. Studies have linked empathy to different aspects of temperament,
such as behavioral inhibition and fearfulness (Rothbart, Ahadi, & Hershey, 1994; Young,
Fox, & Zahn-Waxler, 1999), sociability or positive engagement (Robinson et al., 1994; Zahn-
Waxler, Cole, Welsh, & Fox, 1995), and negative emotional reactivity (Eisenberg et al., 1996;
Robinson et al., 1994; Rothbart et al., 1994; Young et al., 1999).
Most commonly, an inhibited, anxious temperament has been negatively linked to
empathy (in other words predicting reduced empathy), in particular, to reduced comforting
behaviors. Studies found that temperamentally inhibited, anxious preschoolers showed less
empathic, sympathetic-prosocial behaviors, especially toward strangers in a laboratory setting
(Kienbaum, Volland, & Ulich, 2001; Miller & Jansen op de Haar, 1997; Rothbart et al., 1994;
van der Mark, van Ijzendoorn, & Bakermans-Kranenburg, 2002), but not toward their mother
(Young et al., 1999). Liew et al. (2011) showed that children‘s low fearfulness at 18 months
predicted comforting behavior at 30 months, even when controlling for comforting at 18
months. Those findings may indicate that inhibited/anxious children become overwhelmed
more easily by their own contagion responses, which interferes with empathic reactions or
could perhaps index other mechanisms besides this inhibiting or preventing prosocial
responses (Eisenberg et al., 1996). Thus, the capacity to regulate one‘s own negative
 The Development of Empathy in Early Childhood 121

emotions seems to play an important role in the development of empathy, and in particular
prosocial behavior (Decety & Svetlova, 2012; Eisenberg & Fabes, 1998). However, some
other studies found an inverse relationship between temperamental inhibition and empathy.
For example, Spinrad and Stifter (2006) demonstrated that a child‘s distress toward novel
objects, which is associated with anxious temperament, predicted more empathic concern
eight months later, suggesting that lower thresholds for affective activation may facilitate
empathy – consistent with basic contagion concepts. In line with these findings, Paulus et al.
(2013b) also found a positive longitudinal link between behavioral inhibition and self-
regulatory capacities in a gift delay task at 2.5 years and children‘s sharing behavior with
friends at 5 years. Thus, it is also possible that children who - due to their good self-
regulatory abilities - are more sensitive and attentive toward other persons‘ affective states in
general (and negative emotions in particular) identify with the victim more easily, and thus
show more empathic, and especially prosocial behaviors (Zahn-Waxler, Radke-Yarrow, &
King, 1979). In sum, the direction of the relation is not clear, however most of the findings
point to a negative relationship between an inhibited temperament and empathic, comforting
behaviors.
Another temperamental feature that has been related to empathic reactions is positive
affect. Whereas high negative emotionality has been linked to lower levels of sympathy
among preschoolers (Eisenberg et al., 1996), positive affect is related to higher empathic
reactions, especially prosocial behavior (Chapman, Zahn-Waxler, Cooperman & Iannotti,
1987; Robinson et al., 1994; Volbrecht, Lemery-Chalfant, Aksan, Zahn-Waxler, &
Goldsmith, 2007; Young et al., 1999). This relation could be attributed to higher social
competence in children high in positive emotionality, as studies have shown that more
sympathetic children are been rated as socially more competent when rated six years earlier
(e.g., Murphy, Shephard, Eisenberg, Fabes, & Guthrie, 1999). Thus, it is not clear whether the
positive or predictive relationship between empathy and positive affect is due to the overlap
of the latter with the construct of social competence, or whether it is really this temperament
feature that promotes empathy. However, it is predicted in models by Watt (2007) – see
further discussions in chapter by Watt and Panksepp in this volume.
In sum, studies suggest that certain temperamental features, especially inhibition and
positive emotionality, are respectively negatively and positively linked to empathic responses,
such as prosocial and comforting behavior. Most research indicates a negative link between
empathic behaviors and temperamental inhibition, and a positive link to positive affect;
however, the mechanisms underlying these relations are not quite clear yet.

Gender

Several studies have demonstrated that girls exhibit higher levels of empathy and
prosocial behavior than boys (Barnett, Howard, King, & Dino, 1980; Eisenberg et al., 1996;
Mills & Grusec, 1989; Zahn-Waxler, Robinson, & Emde, 1992), although the direction and
magnitude of these gender differences vary across studies (Eagly & Crowley, 1986;
Eisenberg & Fabes, 1998; Moreno et al., 2008). For example, Kienbaum et al. (2001)
identified gender differences in sympathetic-prosocial reactions and avoidance, with pre-
school aged girls showing stronger reactions than their male counterparts. Volbrecht et al.
(2007) also found a gender difference in favor of girls regarding empathic concern, whereas
122 Maria Licata, Amanda Williams and Markus Paulus

boys were found to engage in more hypothesis testing, which can be regarded as a cognitive
aspect of empathy. Thus, even though girls tend to show higher levels of affective empathy
and prosocial behavior, girls and boys seem not to differ in terms of their cognitive empathy.
Furthermore, Paulus et al. (2013b) found a gender difference in favor of boys in terms of
instrumental helping behavior in 18-month-old toddlers. This finding is in line with Kiang,
Moreno, and Robinson‘s (2004) assumption that boys tend to show more instrumental helping
(‗fixing problems‘), whereas girls express more empathic concern.
One can argue that a gender effect in empathic behaviors might largely be due to
socialization, as findings vary cross-culturally (Strauss, 2004). In Western cultures, girls are
socialized to show more empathic concern and prosocial behavior toward other people, and
antisocial behavior is considered less acceptable in girls (conf. Parke & Slaby, 1983).
Moreover, gender differences in empathy could also be attributed to girls having stronger
language skills (e.g., Keenan & Shaw, 2003; Moreno et al., 2008; Reznick, Corley, &
Robinson, 1997). Thus, it is possible that girls show higher levels of concern because their
advanced language skills might make the socialization of concern for other people easier
(conf. also Rhee et al., 2013), but mechanism cannot be attributed from these correlational
findings. Alternatively, females may be more prosocial intrinsically (Boehnke, Silbereisen,
Eisenberg, Reykowski, & Palmonari, 1989). To summarize, effect sizes of gender differences
regarding empathy are rather small (e.g., Moreno et al., 2008), and vary in terms of whether
affective or cognitive empathic features are assessed. Moreover, it is not clear whether those
differences can be attributed to gender per se or whether other factors, such as socialization
and language skills, account for gender differences regarding empathy.

Cognitive Factors

During the second year of life, considerable cognitive developmental changes takes place
which affect empathy development. Those skills include self-awareness and self-other
differentiation, and are believed to support the infant‘s ability to differentiate another person‘s
affective state from one‘s own. It has been argued that this basic ability to be aware of oneself
as independent from the others and thus to differentiate self from other is an important
prerequisite for showing real empathy and subsequent other-oriented behavior: The child
needs to be aware that the source of his negative feelings is the other, and not the self (Decety
& Meyer, 2008). Without such a differentiation, the child cannot attribute the negative
feelings to the other, is more inclined to become distressed and seek support himself instead
of alleviating the others‘ distress. Self-recognition is typically assessed by a task in which the
toddler is placed in front of a mirror with a red mark on his face; this test for self-recognition
is called ―rouge test‖ and was developed by Asendopf and Baudonnière (1993). If the toddler
touches or refers to the mark on his face, this is viewed as evidence for self-recognition.
Zahn-Waxler et al. (1992) found that self-recognition in 18-20 month-old infants was related
to prosocial behavior in response to another person‘s distress at 23-25 months. Congruently,
Bischof-Köhler (1994) found that only children aged 15 to 24 months who passed the ―rouge-
test‖ showed prosocial behavior to another person‘s distress. These findings support the
notion that self-recognition and self-other differentiation play a pivotal role in the
development of empathic concern. Alternatively, these findings could suggest simply that
these functions develop on closely related timetables. Additionally, it should be noted that
 The Development of Empathy in Early Childhood 123

this result has not always been replicated. Kärtner and colleagues (Kärtner, Keller, &
Chaudhary, 2012) reported no relationship between self-recognition in the mirror task and
prosocial responding in Eastern cultures, questioning whether self-recognition is a culture-
independent and universal precondition. Finally, others have reported that other-directed
empathic concern can occur at an age earlier in life, at which the mirror task is normally not
passed. For example, Ungerer et al. (1990) investigated 12-month-old infants and found that
advances in cognitive development in the second year of life were not necessary in order to
show other-oriented reactions.
Moreover, during the second year of life there is also a steep increase in children‘s joint
attention and social referencing, which can also be regarded as precursors for perspective-
taking abilities (Moll & Meltzoff, 2011). Between 9 and 12 months of age, the capacity for
joint attention, which refers to the ability to direct or follow another person‘s attention to an
object, emerges (Carpenter, Nagell, & Tomasello, 1998). This early social-cognitive
competence can be seen as clear precursor of a Theory of Mind (e.g., Kristen, Sodian,
Thoermer, & Perst, 2011) and is likely to support the development of an ability to form
mutual ideas about the characteristics of people and objects. Moreover, infants develop the
so-called capacity of social referencing, which refers to the ability to learn what an object is
like by reading the adult‘s attentional focus and his emotional reaction to it (Hornik,
Riesenhoover, & Gunnar, 1987). Supporting the idea of a relation between empathy and
ToM-development, Ibanez et al. (2013) found a positive relation between empathy and
Theory of Mind skills in young adolescents.
More direct evidence for a relation between perspective taking and empathy is provided
in a study by Vaish, Carpenter, and Tomasello (2009). They presented 18- and 25-month-old
infants either with an adult who was harmed by another person (e.g., by destroying his items;
―harm event‖) or with an adult to whom nothing happened (―neutral event‖). Importantly, in
both situations the adult did not show any emotional expression, but kept a neutral face.
Following this manipulation, infants were presented with a prosocial situation during which
the adult lost a balloon he was playing with. The authors assessed infants‘ behavior towards
the adult in the prosocial situation (e.g., whether the infant showed distress and shared his
balloons with the adult) as well as their looking behavior during the two events. The analyses
showed that the infants were more inclined to act prosocially towards the adult who had been
harmed previously. Moreover, the analyses revealed not only that children showed more
concerned looks to the other in the harm condition, but also revealed a relation between
children‘s concerned looking during the harm event and their subsequent inclination to
behave prosocially. In sum, the study suggests that, although the harmed adult did not show
any sign of emotional expression, children understood the situation and reacted empathically.
Whereas this study provided evidence that children react empathically, even when no clear
emotion is displayed, another recent study examined children‘s responses to ―unjustified‖
emotional distress. More concretely speaking, Hepach and colleagues (Hepach, Vaish, &
Tomasello, 2013) presented 3-year-old children with an adult person who displayed distress.
Importantly, they manipulated whether the distress was justified (as he was harmed),
unjustified (being an overreaction with respect to a minor inconvenience), or displayed
without any clear reason. Children showed lower rates of concerned looks and intervening
behavior when the adult‘s distress represented a case of overreaction, suggesting that their
empathic behavior – at least from the preschool age onwards – is not an inflexible and
automatic process, but rather modulated by cognitive evaluations of the others‘ situation.
124 Maria Licata, Amanda Williams and Markus Paulus

Additionally, and not mutually exclusive with the former interpretation, the results could
indicate that even children lose empathy when people are labile and show poor affective
regulation.
In addition to these specific relations with social-cognitive abilities, some researchers
have reported associations between more general cognitive abilities such as language and
individual differences in concern and disregard for others (e.g., Eisenberg-Berg, 1979; van
der Mark et al., 2002). For example, Rhee et al. (2013) found evidence for a relationship
between language skills and empathy development: Examining the associations between
language skills and concern and disregard for others in 14, 20, 24 and 36 months old children,
the authors found that higher language skills at 14 months predicted higher concern and lower
disregard for others at 36 months, even when controlling for more general cognitive abilities.
Yet, general cognitive abilities were not related to empathy when controlling for language
skills.

Neural Correlates of Early Empathy

A widely unexplored question surrounding early empathy development concerns the

neural correlates of early empathy. Knowledge pertaining to neural correlates is interesting as
it allows us to differentiate the components and mechanisms related to empathy and its
development (cf. Decety & Meyer, 2008). Moreover, findings on genetic contributions to
empathy development (e.g., Knafo & Plomin, 2006; Knafo, Zahn-Waxler, Van Hulle,
Robinson, & Rhee, 2008) might point to the existence of specific neural structures.
A recent study by Paulus and colleagues (Paulus, Licata, Kühn-Popp, Sodian, &
Meinhardt, 2013a) employed a longitudinal design to assess the neurophysiological
correlates, which support the developmental origins and emergence of empathy and
comforting behavior as well as instrumental helping. To this end, at 14 months, infants‘
resting state brain activation asymmetries were assessed by means of EEG and the authors
analysed individual differences in the frontal activation asymmetries (i.e., whether the left or
the right frontal cortex were relatively greater activated). Frontal cortical activation
asymmetries have been interpreted to be important markers for individual differences in
emotion regulation and motivational processes in adults (Harmon-Jones, Gable, & Peterson,
2010) and young children (Davidson & Fox, 1982; Smith & Bell, 2010). In particular, the
results indicate in that relatively greater left frontal cortical activity is typically related to
positive affect and approach-motivation, whereas right frontal cortical activity is typically
associated with certain negative affect and withdrawal motivation. At 18 months, the authors
examined infants‘ instrumental helping, and at 24 months infants‘ empathic reactions in a
comforting task, during which the infants‘ mother simulated pain. The results revealed a
positive relation between relatively greater left hemispheric frontal activation and infants‘
performance in the comforting task, evident in higher levels of distress understanding (more
cognitive empathy) and empathic reactions (more affective empathy). ―Greater left frontal
cortical activation was associated with infants‘ understanding of the other‘s distress as well as
empathic responding in the comforting task, whereas greater right temporal activation was
related to infants‘ instrumental helping‖ (p. 522). Subsequent analyses of the locus of effect
showed that understanding distress (i.e., the cognitive component of empathic responding)
was related to increased left frontal activation, whereas global empathy (i.e., a compound
 The Development of Empathy in Early Childhood 125

measure of affective empathic reactions and prosocial behaviour) was specifically associated
with decreased right frontal activation. Based on these results Paulus and colleagues
suggested that the different aspects of empathy (i.e., understanding others‘ distress, global
empathy) — albeit correlated on a behavioral level — might be subserved by distinct
neurocognitive processes, which may be related to the left and right frontal cortex. These
findings of a relation between prefrontal network activation asymmetries and empathic
behavior are further supported by clinical research showing that preschool-aged children of
depressed mothers as well as children prenatally exposed to cocaine showed greater right
frontal EEG asymmetry associated with less prosocial behavior (e.g., Field, Pickens, Fox, &
Nawrocki, 1995; Jones, Field, Davalos, & Hart, 2004).
In another recent study, Decety, Michalska, and Kinzler (2011) presented 4 to 37 year old
participants with scenarios showing incidentally or accidentally harming actions. Amongst
other findings, the results showed that intentional compared to accidentally harming actions
evoked stronger empathic reactions by all age groups and were related to activations in the
amygdala and the insula, two brain regions well-known to be associated with emotional
processing (Singer, 2006). Moreover, the results revealed that with increasing age, activity in
the prefrontal cortices increased as well as the interconnectivity of the prefrontal cortex with
the amygdale, suggesting that in the course of development, more ventral and more dorsal
brain systems become increasingly interactive, perhaps part of the substrates for how
emotional and cognitive processes become more interactive with each other. Given a working
definition that empathy may involve ―an affective response that stems from the apprehension
or comprehension of another‘s emotional state or condition, and which is identical or very
similar to what the other person is feeling or would be expected to feel‖ (Eisenberg & Fabes,
1998, p. 702), it would be of pivotal interest to highlight the neural mechanisms that subserve
this apprehension of the others‘ affect. Researchers have suggested that a mirroring-type
process could underlie this phenomenon and research with adults has indeed provided
evidence that the affective neural components of pain processing are associated with empathy
for another‘s pain (Singer, 2006). The idea of a mirroring-type process as basis of empathy
gets further support by developmental study reported by Pfeifer, Iacoboni, Mazziotta, and
Dapretto (2008). The authors showed activity in a part of the mirror neuron system when
children observed and imitated emotional expressions. Activity in frontal mirror neuron
regions as well as in the anterior insula and amygdala (areas not part of MNS but with insular
activity commonly found in many empathy functional imaging probes – see chapter by Watt
and Panksepp for discussion) was significantly correlated with behavioral measures indexing
children‘s empathic behavior (during both imitation and observation) and interpersonal skills.
Taken together, these studies – albeit conducted with children of different age groups – paint
a complex picture of empathy development, which suggests that 1) the affective response of
empathic feelings is based on mirroring-like mechanisms (basic affective contagion or
affective resonance) that should not be conflated with mirror neuron networks but that shares
important features with these networks in terms of close linkages between more executive and
sensory systems, 2) that a complex interplay of the left and right frontal hemisphere might
subserve the processing of the (mostly negative) feelings into active and solution-oriented
behaviors (e.g., trying to understand the others‘ distress, comforting), and 3) that the interplay
between emotional reactions and cognitive processes becomes stronger and more
differentiated in the course of development, suggesting that cognitive factors gradually come
to play a greater role in empathic reactions.
126 Maria Licata, Amanda Williams and Markus Paulus

The Parent-Child Relationship

The relation between the quality of the parent-child relationship and children‘s empathy
is based upon social learning and attachment theory, supposing that parents serve as role
models for their children‘s empathic skills (Barnett, 1987; Eisenberg, Spinrad, & Sadovsky,
2006). Evidence suggests that the presence or absence of such basic models exercise a large
influence in the relative development of empathy in children. Obviously, children who are
treated empathically develop better empathy capacities than children who are not (e.g.,
Berkowitz & Grych, 1998; Chase-Lansdale, Wakschlag, & Brooks-Gunn, 1995; Soenens,
Duriez, Vansteenkiste, & Goossens, 2007). It is also believed that parent foster secure
attachment by satisfying their children‘s emotional needs, and free children form self-
preoccupation, which allows truly empathic behavior (Hoffman, 2000; Kestenbaum, Faber, &
Stroufe, 1989; Laible, Carlo, & Roesch, 2004; van der Mark et al., 2002).
Constructs measuring the quality of a parent-child relationship include measures of child
attachment as well as parenting style and interaction quality. Attachment refers to one specific
aspect of the relationship between child and parent with its purpose being to make a child feel
safe, secure and protected, and is mainly based upon the quality of interaction experiences
with their caregivers (conf. Ainsworth et al., 1978; Bowlby, 1969). Studies have found that
children who were securely attached to their mothers were more responsive to their peers‘
distress (Kestenbaum et al., 1989) as well as toward an experimenter‘s distress simulation, but
not toward their mothers‘ distress (van der Mark et al., 2002). A relation between attachment
and empathy was also demonstrated by Bischof-Köhler (2000), showing that securely
attached children exhibited more empathic behavior than insecurely attached children. In a
more recent study, Panfile and Laible (2012) were able to identify an important role of
emotion regulation regarding empathy (measured through maternal reports): The authors
found that children‘s attachment style predicted empathy through mediation of emotion
regulation. Specifically, securely attached children had better emotion regulation and,
consequently, higher empathy. Thus, the link between attachment and empathy can also be
indirect via emotion regulation skills. Milkulincer and Shaver (2005) argue that securely
attached individuals are able to recognize other person‘s feelings more accurately than
insecurely attached individuals. This can be explained by Fonagy‘s hypothesis that only when
a child feels secure in the relationship with their caregiver will they develop capacities to
focus on other peoples‘ mental states (Fonagy & Target, 1997).
Moreover, parenting style has been linked to children‘s empathy. Investigating primary
school pupils, Antonopoulou, Alexopoulos and Marodaki-Kassotaki (2012) showed that a
father‘s parenting style as perceived by the pre-adolescents was related to their self-reported
empathy: If the pupils perceived their fathers as predominantly supportive, they had rather
high empathy. Another study identified an interaction effect between preschoolers‘
temperament and parenting: an inconsistent parenting style was associated with lower
empathy (rated by the parents), but only in temperamentally uninhibited children (Cornell &
Frick, 2007). A study investigating the impact of parents‘ discourse about others‘ emotions
during a picture-book task on toddlers‘ instrumental and empathy-based helping behavior
(Brownell, Svetlova, Anderson, Nichols, & Drummond, 2013) found that children who
helped and shared more had parents who asked them to label and explain the emotions in the
books more frequently. This was especially the case in tasks requiring more complex emotion
understanding. In particular, it was parents‘ elicitation of children‘s emotion talk, and not
 The Development of Empathy in Early Childhood 127

their own production of emotion labels and explanations that had a positive effect on
children‘s prosocial behavior toward an adult. Interestingly, parents‘ encouragement to label
others‘ emotions was only related to empathic and altruistic helping, but not to instrumental
helping. Those findings indicate that the quality of parent-child discourse about emotions
fosters young children‘s prosocial behavior, even at a stage when children have only just
begun to understand and talk about emotions meaningfully. One possible mechanism behind
this relationship could be that parents‘ talk about emotions with their children influences the
degree in which children attend to and develop concern about others‘ emotions, which is in
turn associated with the amount of prosocial behavior generated by the child in reaction to
others distress. Thus, parents focusing on others‘ emotions, and encouraging their children to
reflect about emotions, might foster children‘s interest in emotions, and also their motivation
to respond to other people‘ affective states, trying to help the other person with his negative
emotions (Brownell et al., 2013).
Another feature of the quality of mother-child interaction, specifically mothers‘
responsive and sensitive reactions toward the child, has also been linked to children‘s
empathy. ‗Maternal sensitivity‘ is commonly defined as a mother‘s capacity to recognize the
infant‘s/child‘s emotional state, and to react in an appropriate, contingent, and prompt way
(Ainsworth, Bell, & Stayton, 1971), suggesting a construct close to but certainly not identical
with many current definitions of empathy. Studies have demonstrated that children with
highly sensitive/responsive mothers showed higher levels of empathic, prosocial behaviors
(e.g., Kestenbaum et al. 1989; Volland & Trommsdorff, 2003; Zahn-Waxler et al., 1979).
Consistent with those findings, Kiang et al. (2004) found that maternal sensitivity (assessed
through the Emotional Availability Scales, Biringen, Robinson, & Emde, 1994, focusing on
emotional responsiveness and genuine affect of the mother) toward the 15-months-old infant
was positively correlated with children‘s prosocial behavior toward their mother when
children were 21-24 months old. However, authors who linked maternal responsiveness
(measured by a coding system focusing on contingent, infant-centered reactions of the
mother) with children‘s prosocial behavior at an earlier age found no direct link between
maternal responsiveness at ten months and later prosocial behavior at 18 months (Spinrad &
Stifter, 2006). The authors explained their findings by arguing that prosocial behavior is not
shown very frequently before two years of age. These findings are supported by van der Mark
et al. (2002), who found a link between maternal sensitivity and toddlers‘ empathic concern
for their mother‘s distress at 22 months, but not at 16 months of age. Furthermore, Kiang et
al. (2004) found both direct and indirect effects of mothers‘ preconceptions about parenting,
which refer to underlying beliefs reflecting a person‘s own experience with being parented,
on children‘s prosocial reactions: Maternal preconceptions, which were assessed using a
questionnaire about a range of attitudes about parenting and childrearing (e.g., including
empathy towards children‘s needs, and developmentally appropriate expectations about
children‘s abilities) had a direct effect on children‘s empathic behavior, such that negative
preconceptions were related to more indifference in children‘s reactions towards their
mothers‘ distress. Further, indirect effects were also identified, as maternal sensitivity was
found to mediate the link between maternal preconceptions and children‘s prosocial responses
to mothers‘ distress. Thus, also in this study, maternal sensitivity was associated with higher
empathic behavior in children.
A recent study (Licata, Kristen, Thoermer, Perst, & Sodian, 2013) explored the link
between a specific facet of maternal behavior in the interaction with her infant, namely
128 Maria Licata, Amanda Williams and Markus Paulus

maternal mind-mindedness, and children‘s empathy at two years of age. Mind-mindedness

refers to the mother‘s tendency to treat her infant as psychological agent and to comment
appropriately or in a non-attuned manner, respectively, upon the infant‘s mental states, and is
also referred to as ‗social-cognitive trait‘ of the mother (Meins, 1997, 1999). The authors
found that mothers who frequently commented in a non-attuned manner on their 7-month-old
infant‘s mental states had children who showed less empathy (operationalized through a
combined rating of affective concern and prosocial behavior) towards their mother in a pain
simulation situation at two years of age. This study provides first evidence that, besides
maternal sensitivity, other, more specific aspects of maternal behavior in the mother-child
interaction can play an important role in children‘s empathy development.
In contrast to children who grow up in a sensitive caregiving environment, children who
experience maltreatment have difficulties in social understanding, in particular with Theory of
Mind (Cicchetti, Rogosch, Maughan, Toth, & Bruce, 2003) and emotion recognition
(Fishbein et al., 2009), and tend to attribute hostile intentions to others in ambiguous
situations more frequently (Price & Glad, 2003). Accordingly, Main and George (1985) found
that abused toddlers (battered children who had suffered skull fractures, severe punishment,
broken bones or severe burns) did not note the distress of others; indeed, no abused toddler
responded to the distress of other toddlers with empathy, sadness, or concern. This link could
be attributed to the parenting behavior of maltreating parents. For example, maltreating
mothers talk less about mental states of themselves and of other persons (Edwards et al.,
2005), which leads to deficits in mental state language in toddlers (Beeghly & Cicchetti,
1994). Furthermore, abusive mothers‘ facial expressions are less recognizable by naive raters,
which could be shown in a study applying facial expression posing and recognition tasks
(Camras et al., 1988), which could account for children‘s poor emotion recognition skills
(Fishbein et al., 2009), whereas frequent exposure to the expression of anger could account
for better anger recognition in abused children (Pollak, Messner, Kistler, & Cohn, 2009). In
accordance with the last finding, Radke-Yarrow, Zahn-Waxler, Richardson, Susman, and
Martinez (1994) found that children of severely depressed parents who frequently showed
parentified, role-reversed behavior, such as taking care of the parent, exhibited highest
frequencies of caring.
In sum, the link between the parent-child relationship and children‘s empathy could be
explained as follows: parents who interact positively with their child in terms of affectionate
and playful behaviors, and who manage child distress empathetically show their children that
they support them and that they care for them, and thus serve as models for empathic
behavior (Spinrad et al., 1999). Furthermore, sensitive, authoritative parents create a positive
family climate where children‘s efforts are supported and praised, which helps children to
develop a general sense of competence and emotional safety (Baumrind, 1971), enabling
them to focus on other peoples‘ feelings (Fonagy & Target, 1997; Hoffman, 1982; Radke-
Yarrow, Zahn-Waxler, & Chapman, 1983). However, in children with parents suffering from
mental illness or in children experiencing maltreatment, the associations are more complex,
with some children showing more empathic behaviors, while others exhibit less empathy.
However, in order to better understand the complexities of these relationships, these
associations need to be investigated more comprehensively.
 The Development of Empathy in Early Childhood 129

Siblings

Most research has focused on the role of parents, and has thus overlooked other family
members, such as siblings. In the complementary nature of sibling relationships, a child can
learn about perspective taking and emotionally intense exchanges (Katz et al., 1992). It is
supposed that especially younger children can benefit from older siblings, as older siblings,
like parents, can serve as role models, thus acting as socialization agents for their younger
siblings‘ social and cognitive development (Dunn, 2002). Tucker Updegradd, McHale and
Crouter (1999) showed that sibling warmth was associated with higher levels of self-reported
empathy for second-born siblings, but not for firstborn siblings. These results imply that older
siblings enhance younger siblings‘ empathy rather than vice versa. With respect to the role of
sibling conflict, Ross, Ross, Stein, and Trabasso (2006) demonstrated that sibling disputes
allow children and youths to practice persuasive negotiation and see another‘s point of view.
Lam, Solmeyer, and McHale (2012) found that self-reports of empathy were related to more
sibling warmth and less sibling conflict in firstborns and second-borns, even when controlling
for parental responsiveness and marital love.
Another study reported a link between the number of siblings and children‘s empathy at
two years of age. However, in this study, the effect was of an inverse nature: Licata et al.
(2013) found a negative link between the number of siblings and children‘s empathy. The
authors attribute their findings to the fact that the children in their study exclusively had older
children. They further argue that young children do not have to care for others, as older
siblings take over this role. This interpretation is supported by findings that firstborns are
more inclined to develop parentification behaviors (e.g., taking over the caretaker role,
comforting the parent) than children with another birth-order position (Herer & Mayseless,
2000). As a result, younger siblings might not feel responsible and might not be used to
comforting their mother, and thus might not show empathic reactions toward the mother.
In sum, there is some evidence that siblings can contribute to empathy development, with
most of the findings pointing to a positive effect of older siblings on empathy development of
younger siblings.

Relations between Empathy and Social Behaviors

In the following chapter we report factors that commonly have been associated with
empathy. One such aspect that is regarded as frequent consequence/concomitant of empathy
is prosocial behavior. Research has also demonstrated that certain psychiatric disorders, such
as conduct disorders, autism, and psychopathy have fundamental deficits in empathy.

Prosocial Behavior

Several studies have found evidence that both empathy and sympathy are positively
related to various aspects of socially appropriate behavior. For example, Zhou et al. (2002)
found that children‘s observed and reported empathy in 5th grade was positively related to
parents‘ and teachers‘ concurrent reports of social competence.
130 Maria Licata, Amanda Williams and Markus Paulus

Through the years, many researchers have specifically been interested in the relationship
between empathy and prosocial behavior. Results have varied, with some researchers
reporting positive associations, and others failing to identify a relationship. These divergent
findings are believed to be (at least partly) due to inconsistencies in the way that empathy is
defined and measured (Eisenberg & Miller, 1987) and perhaps other methodological issues as
well. Often, especially in earlier research, affective empathy, cognitive empathy, sympathy,
and personal distress/contagion were not clearly differentiated. Nonetheless, there is a body of
research demonstrating relations between forms of empathic responding and various aspects
of prosociality (e.g., Eisenberg, McCreath, & Ahn, 1988; Malti, Gummerum, Keller, &
Buchmann, 2009; Strayer & Roberts, 1997; Zahn-Waxler & Radke-Yarrow, 1990; see also
Eisenberg, Spinard, & Sadovsky, 2006).
Traditionally, picture/story assessment procedures were used to assess empathy in
children. Following this approach, children were shown pictures, told brief stories about
another child in an emotionally distressing situation, and then asked to report how they
themselves felt. If their self-reported emotion matched the emotion displayed by the story‘s
character, this was characterized as empathy (Eisenberg & Miller, 1987). The Feshbach and
Roe Affective Situations Test for Empathy (FASTE), which includes eight vignettes, was
developed in 1968 by Feshbach and Roe, and variations of the task have been widely used by
researchers‘ exploring this relationship in young children. In some cases, positive
relationships have been found between FASTE scores and various aspects of prosociality,
such as caring (e.g., Roe, 1981) however a review of research exploring this approach found
little evidence of a consistent relationship between empathy assessed using the picture/ story
method, and prosocial behavior (see Eisenberg & Miller, 1987, for a review). In recent years,
this approach has been replaced by other methods, and problems with this task have been
noted by various researchers. Specifically, the potential for creating demand characteristics by
asking the child how they feel has been identified as problematic (Eisenberg & Lennon,
1983), as well as the fact that it traditionally included a range of emotions - as empathy may
be more readily experienced for some emotions, such as sadness more so than happiness
(Hoffman, 1982). Finally, same-sex experimenters have been found to elicit higher scores
from participants in comparison to opposite sex experimenters (Eisenberg & Lennon, 1983;
Lennon, Eisenberg, & Carroll, 1983).
Children‘s facial or gestural responses while watching videos, or hearing stories of
another child in distress have also been of interest, with researchers using this approach more
often reporting significant findings. For example, sympathetic facial expressions or gestures
have been correlated with later spontaneous prosocial behaviors (Eisenberg, et al., 1988) as
well as helping (e.g., Howard, 1983; Peraino & Sawin, 1981) and more generous donations to
the distressed individual, or an unrelated peer (e.g., Leiman, 1978; Sawin, Underwood,
Weaver, & Mostyn, 1981). Affective concern while watching an emotionally evocative video
has also been related to prosocial responding (Eisenberg, et al., 1989). These findings,
however, are not always consistent, as other studies fail to report relationships between
certain facial or gestural responses to others in distress, and different aspects of prosociality
(see Eisenberg & Miller, 1987 for a review).
Longitudinal associations between empathic responding and prosociality have also been
of interest. In one study, how typically developing 8-16 month old infants responded to the
distress of another, and whether early empathic responses were related to later prosocial
responding, was explored. As mentioned previously, researchers have found evidence of both
 The Development of Empathy in Early Childhood 131

cognitive (e.g., hypothesis testing) and affective empathy (e.g., empathic concern expressed
through facial expression, gestures, and vocalizations) present before one year of age,
gradually increasing with age (Roth-Hanania et al., 2011). They also found that while
prosocial behaviors of comforting and concern before age one were uncommon, they
increased substantially in the second year. Importantly, both cognitive and affective empathy
assessed early on at ten months of age, was not only correlated with prosocial behavior at that
time point, but also predicted later prosocial behavior at 12, and 14 months of age (Roth-
Hanania, et al., 2011). The findings of this study not only demonstrate the predictive value of
early empathy with regards to prosocial behavior, but also suggest that both cognitive and
affective empathy begin to emerge in the first year of life, and illustrate the differential
trajectories of prosocial behavior, and empathy.
Much of the research that has explored the link between prosocial behavior and empathy
is correlational. Therefore, the results support the notion of a relation by generally suggesting
that children who are more prone to experiencing empathy are also more likely to exhibit
prosocial behaviors. More recent research however, has taken the approach of experimentally
manipulating sympathetic or empathic experiences. In one experiment, which was discussed
preciously in relation to the role of perspective taking in empathic concern, it was found that
toddlers assigned to a harm condition (in which they witnessed one experimenter destroying
or breaking an item of value to a second experimenter) showed more prosocial behavior
towards the second experimenter in comparison to children who has witnessed the first
experimenter destroy something not of value to experimenter two (Vaish et al., 2009). That
children witnessing the harm condition showed concern for the ‗harmed‘ individual, even
when no behavioral distress cues were exhibited, demonstrates the importance of adopting the
other‘s perspective in a distressing situation when contagion mechanisms in a sense ―have
nothing to work with‖ to drive a more affective response, suggesting that theory of mind may
fill this gap. However, this research demonstrates that witnessing another individual in
distress increases prosocial behavior.
Similarly, it was found that five and six-year-old children who watched a video of a
young girl in a distressing situation (e.g., upset that her dog had run away), shared more, and
exhibited less envy towards the video‘s protagonist in a subsequent resource allocation task,
when compared to children who had watched the same girl in a neutral situation (e.g ,
preparing for a yard sale). Further, while perceptions of the video‘s protagonist‘s feelings
were correlated with participants ratings of their own emotions, prosociality was correlated
with ratings of the protagonists emotion alone (Williams, O‘Driscoll, & Moore, 2013).
Interestingly, the degree to which empathy induces prosocial behavior has been shown to vary
depending on the observed emotion one is empathically responding to. Specifically,
witnessing another exhibiting sadness has been shown to elicit more prosocial behavior than
witnessing another experiencing pain (Bandstra, Chambers, McGrath, & Moore, 2011).
Together, these recent studies demonstrate that witnessing another individual in a distressing
situation facilitates positive social behaviors (e.g., helping and sharing) and mediates negative
social behaviors (e.g., envy).
In sum, though in the past, definitions and measures of both empathy, and prosociality
have varied, a large body of research conducted over the past several decades supports the
link between empathy, and prosocial behavior in children. The nature of this relation
continues to interest researchers, with explorations of how empathy is differentially
influenced by various emotions, and novel approaches emerging.
132 Maria Licata, Amanda Williams and Markus Paulus

Psychopathology

In addition to positive links between empathy and social competent behavior, several
studies have reported negative links between empathy and different kinds of problem
behavior, especially aggressiveness (Eisenberg & Strayer, 1987; Kaukiainen, Björkqvist,
Österman, & Lagerspetz, 1996; Richardson, Hammock, Smith, Gardner, & Signo, 1994).
Research exploring the relationship between empathy and aggression has yielded mixed
results (see Lovett & Sheffield, 2007 for a review). For example, while some research reports
no relationship between empathy and aggression in children (e.g., Gonzalez, Field, Lasko,
LaGreca, & Lahey, 1996; MacQuiddy, Maise, & Hamilton, 1987; Marcus, Roke, & Bruner,
1985), most research reports the expected negative relationship (de Wied, Goudena, &
Matthys, 2005; Strayer & Roberts, 2004). For example, besides a negative link to aggression,
de Kemp, Overbeek, de Wied, Engels, and Scholte (2007) also found a negative relation
between self-reported empathy and delinquent behavior. In a longitudinal study by Hastings,
Zahn-Waxler, Robinson, Usher, and Bridges (2000), children with high levels of behavior
problems showed a decline in concern for others from 4 to 5 and 6 to 7 years of age, whereas
scores for children with low rates of problem behavior remained stable with regards to
concern for others. These findings indicate that children with behavior problems, and
especially aggressive behavior, show less empathic behaviors than children who do not have
behavior problems. However, some studies suggest that only affective, but not cognitive
empathy is negatively associated with problem behavior. Caravita, Di Blasio, and Salmivalli
(2009) investigated the relationship between adolescents‘ empathy and involvement in
bullying situations. They found that especially high levels of affective empathy
(operationalized through items about sharing others‘ feelings, e.g., ―When somebody tells me
a nice story, I feel as if the story is happening to me‖) inhibited bullying among adolescent
boys. Moreover, the authors found a positive relation between the cognitive components of
empathy (operationalized through items about understanding of others‘ feelings, e.g., ―I am
able to recognize, before many other children, that other people‘s feelings have changed‖)
and bullying in adolescence, which is in line with the hypothesis regarding ‗competent
bullies.‘ This hypothesis argues that at least some aggressive children (‗ringleader bullies‘)
have strong theory of mind skills. Regarding the underlying explanatory mechanism, Sutton
(2003) has argued that school bullies might be well aware of others‘ emotions but unable or
unwilling to share them, suggesting a potential dissociation between theory of mind on the
one hand, and contagion, and prosocial behavior on the other. Thus, competent bullies might
use their comprehension to manipulate and bully peers while feeling little genuine distress or
concern for the distressful impact of their behavior on others.
Moreover, empathy, and particularly empathy deficit, has also been linked to more severe
psychopathologies. A lack of empathy is viewed as explanatory mechanism in some
psychiatric disorders, in particular in autistic spectrum disorders and conduct disorders (Blair,
2005). However, it is not yet clear which aspects of empathy are impaired in those disorders.
Adolescents with conduct disorder seem to have lower levels of situational empathy (affective
and cognitive responses to an emotionally evocative vignette) and dispositional empathic
concern (assessed using self-report questionnaires) than a healthy control group. Furthermore,
they also tend to score lower in cognitive empathy (Cohen & Strayer, 1996). Consistent with
these findings, another study found that incarcerated boys showed less empathic reactions
than community boys (Robinson, Roberts, Strayer, & Koopman, 2007). In another study,
 The Development of Empathy in Early Childhood 133

structural brain parameters associated with emotion processing in male youth with conduct
disorder were compared to a control group. Not only did researchers find the volume of grey
matter for the youth with conduct disorder was significantly reduced in the bilateral anterior
insular cortex as well as the left amygdala, but they also found that grey matter volume in the
bilateral anterior insular cortex was significantly correlated with lower levels of empathy
(Sterzer, Stadler, Poustka, & Kleinschmidt, 2007), suggesting a possible structural or
neuroanatomical basis for empathy deficits in this population.
Additionally, there are findings showing that psychopaths have deficits in recognizing or
processing other people‘s emotional expressions of fear and sadness, but not of happy, angry,
surprised, or disgusted expressions (Blair & Coles, 2000). In the Diagnostic and Statistical
Manual of Mental Disorders, 4th edition, psychopathy is subsumed under the heading of
antisocial personality disorder (APD). It is characterized by antisocial behavior (frequent
violations of social rules), poor impulse control, and deficits in remorse and empathy for
others, among other features that emerge in childhood or adolescence, and persist into
adulthood (DSM-IV; American Psychiatric Association, 1994). Though these characteristics
are present throughout childhood or adolescence and into adulthood, a ‗psychopath‘ would
meet the criteria for a diagnosis of conduct disorder (CD) in childhood, and APD in adulthood
(Blair, 2001). It is important to note however, that most children with CD, or adults with APD
would not meet the criteria for psychopathy, as they do not demonstrate the same extreme
degree of callous/unemotional characteristics present in psychopathy (Hart & Hare, 1997;
Viding, Blair, Moffitt, & Plomin, 2005).
In one study, the relationship between psychopathic characteristics and empathy in male,
juvenile delinquents was explored. Psychopathic characteristics were measured by the
Psychopathy checklist, screening version (PCL-SV; Hart, Hare, & Forth, 1994) while
empathy was measured by self report using the Empathy Index (EI; Bryant, 1982). Deficits in
empathy were linked to callous/unemotional characteristics of psychopathy, but not
characteristics related to impulsivity or conduct problems (Holmqvist, 2008). Interestingly, in
a study looking at psychopathic characteristics in 7-year-old twins it was found that antisocial
behavior in children high in callous/unemotional characteristics was strongly influenced by
genetics. Conversely, they found that antisocial behavior in children low in callous or
unemotional characteristics was moderately influenced by both genetics, as well as the
influence of the shared environment (Viding et al., 2005). It has been suggested that this
genetic vulnerability may be linked to an emotion-related dysfunction in the amygdala and
orbitofrontal cortex that has been implicated in adult psychopathy (Abbott, 2001; Blair, 2001,
2003), and could also be present in children with psychopathic characteristics (Blair, 2001).
With regard to autism spectrum disorders, it is well known that people suffering from this
disorder are characterized by severe deficits in social interaction and communication as well
as stereotyped patterns of interest and behavior (DSM-IV-TR, APA, 2000). Autistic
individuals often have severe problems, especially with the cognitive component of empathy,
including emotion recognition and Theory of Mind (Baron Cohen, Wheelwright, Hill, Raste,
& Plumb, 2001; Pelphrey et al., 2002) as well as perspective taking (Castelli, Frith, Happé, &
Frith, 2002; Schwenck et al., 2012; Yirmiya, Erel, Shaked, & Solominica-Levi, 1998). Most
empirical investigations exploring emotional empathy in persons with ASD have not found
impairments (Blair, 2008; Decety & Moriguchi, 2007; Magnée, de Gelder, van Engeland, &
Kemner, 2007). In contrast, individuals with conduct disorder, which is characterized by
persistent patterns of behaviors which violate the basic rights of others as well as age-
134 Maria Licata, Amanda Williams and Markus Paulus

appropriate norms (DSM-IV-TR, APA, 2000), have deficits in the emotional component of
empathy (in other words poor contagion/affective resonance), whereas their cognitive
empathy (theory of mind and related perspective taking) is not clearly deficient (Jones et al.,
2010).
To summarize, challenges in identifying consistent patterns of results may be accounted
for by the fact that measures of both empathy (e.g., behavioral; self/ teacher/ parental reports)
and psychopathology (self/other reports or ratings; clinical diagnosis; recruitment status) vary
from study to study. Despite these variations however, research suggests that a deficit in
empathy related concern and responding is related to various psychopathologies, including,
but not limited to conduct disorder, autism spectrum disorder, antisocial personality disorder,
and psychopathy. More research however, is necessary to better understand what aspects of
empathy are inhibited, and the cause of this deficit in relation to these specific
psychopathologies.

Can Empathy Be Trained?

As empathy is known to be related to various positive developmental outcomes,

researchers and clinicians have tried to develop programs in order to train empathy and
empathy-related constructs, such as sympathy and prosocial behavior. One such program is
called ―Roots of empathy,‖ targeting children from kindergarten through 8th grade (Gordon,
2005). The program is conducted in the classroom and aims at improving children‘s social
and emotional understanding, promoting prosocial behavior, decreasing aggressive behavior,
and increasing children‘s knowledge about infant development as well as effective parenting
practices. Investigating the effectiveness of this program, Schonert-Reichl, Smith, Zaidman-
Zait, and Hertzman (2011) found that children participating in this program improved their
understanding of infant crying, showed increases prosocial behaviors – as reported by peers,
and showed decreases in proactive and relational aggression- as reported by teachers, when
compared to a control group. These findings indicate that a classroom-based intervention,
which does not focus exclusively on disturbed children, improves children‘s cooperative
behavior and decreases aggressive behavior.
Furthermore, empathy training as intervention program on bullying also seems to be
effective in terms of reducing bullying behavior (Sahin, 2012). Moreover, Dadds, Cauchi,
Wimalaweera, Hawes, and Brennan (2012) demonstrated that an emotion-recognition training
program geared towards improving the accuracy of children‘s perceptions and interpretations
of emotions fostered affective empathy and reduced conduct problems in ten-year-old
children, (but only in children with high levels of callous-unemotional traits) when compared
to a control group that instead received an integrative family intervention (―treatment as
usual‖). Thus, these children specifically seem to benefit from an emotion-focused training.
However, the effects were rather small, and many children remained in the clinical range even
after training. Another study investigated the effect of acting, an activity in which one must
step into the shoes of others, on empathy in elementary school aged children and adolescents.
Children received either one year of acting or other arts training (visual arts, music). The
authors demonstrated that both children and adolescents who received acting (but not other
arts) training showed significant gains in empathy scores (Goldstein & Winner, 2012). These
findings imply that empathy can be fostered by a non empathy-specific training, namely role-
 The Development of Empathy in Early Childhood 135

playing. Further, an empathy training program (―Second Step‖) with sixth graders which
aimed at improving social skills learning, prosocial behavior, and socio-emotional skills in
empathy, reported improvements in children‘s social skills knowledge and understanding, but
not in empathy (Angelone, 2008). Conversely an empathy training with adult male sex
offenders, Wastell, Cairns, and Haywood (2009) found that their program was successful in
improving offenders‘ scores on empathy measures (general empathy, emotional arousal, and
cognitive empathy), however it did not improve their ability to recognize affective cues in
other people. The authors discuss their findings by arguing that this specific inability to
recognize emotional state indicators is a crucial factor of re-offense.
In sum, it seems that empathy, and constructs close to empathy, respectively, can be
trained through various different programs, but that the effects of such programs may be
limited (Angelone, 2008; Dadds et al., 2012; Wastell et al., 2009). Further research is needed
to clarify more effective versus less effective interventions and their timing.

CONCLUSION
In summary, empathy is a complex concept, distinct from, yet intricately related to, basic
emotional contagion and personal distress emerging from contagion mechanisms, and
prosocial behavior. Empathy is influenced by both genetics, as well as environmental factors,
and basic affective precursors to more complex empathy (affective contagion/resonance) are
present from birth. Within the first years of life, empathy is apparent in young children‘s
interactions, with empathic responding becoming increasingly sophisticated with age.
Throughout the lifecycle, empathy remains vitally important with regards to social
functioning and the promotion of stable attachments, with deficits in empathy often being
linked to various psychopathologies.
Numerous researchers have theorized about the development of, and nature of empathy,
as well as the relationship between empathy and many factors such as temperament, gender,
and prosocial behavior. A multitude of research exploring a wide range of influences exists,
and though varying definitions of empathy often lead to mixed findings, results shows that
empathy is indeed linked to many aspects of our social behaviors, interactions, and
relationships with others. Recently, novel approaches to exploring empathy have been
emerging, such as looking at the neural correlates of empathy, and experimentally
manipulating the experiences of empathy or sympathy, which brings us closer to
understanding causal effects on prosocial behaviors. Researchers have also been paying closer
attention to more consistently defining their measures, and better differentiating between
empathy and other concepts such as personal distress, and sympathy. With these
developments, and an increasing interest in this area, we hope to continue to expand our
understanding of the influence empathy has on our lives, especially in the critical early years
of development.
136 Maria Licata, Amanda Williams and Markus Paulus

ACKNOWLEDGMENTS
We thank Jutta Kienbaum and Douglas Watt for constructive feedback on earlier versions
of this chapter. This work was supported by a DFG grant (SO 213/27-1, 2).

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prosocial initiations toward victims of distress. Child Development, 50, 319-330.
Zahn-Waxler, C., Radke-Yarrow, M., Wagner, E., & Chapman, M. (1992). Development of
concern for others. Developmental Psychology, 28, 126-136.
Zahn-Waxler, C., Robinson, J., & Emde, R. N. (1992). The development of empathy in twins.
Developmental Psychology, 28, 1038–1047.
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Zahn-Waxler, C., Schiro, K., Robinson, J., Emde, R., & Schmitz, S. (2001). Empathy and
prosocial patterns in young MZ and DZ twins: Development and genetic and
environmental influences. In R. Emde & J. Hewitt (Eds.), Infancy to Early Childhood:
Genetic and Environmental Influences on Developmental Change (pp. 141-162). Oxford
University Press: New York, New York.
Zhou, Q., Eisenberg, N., Losoya, S., Fabes, R. A., Reiser, M., Guthrie, I. K., Murphy, B.,
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In: Psychology and Neurobiology of Empathy ISBN: 978-1-63484-446-8
Editors: Douglas F. Watt and Jaak Panksepp © 2016 Nova Science Publishers, Inc.

Chapter 5

EMPATHY IN CHILDREN:
THEORY AND ASSESSMENT

María Cristina Richaud de Minzi1, PhD,

Viviana Noemí Lemos2, PhD,
and Laura Beatriz Oros2, PhD
1
Director of the Interdisciplinary Center of Research
in Mathematic and Experimental Psychology-
National Council of Scientific and Technical Research (CONICET),
Buenos Aires, Argentina
2
Researcher of Center of Research in Mathematical
and Experimental Psychology (CIIPME)-National Council
of Scientific and Technical Research (CONICET).
Professor in River Plate Adventist University (UAP), Argentina

ABSTRACT
Empathy is the ability to perceive, share, and understand the emotional states of
others, and it is crucial to succeeding in society. This social and emotional competence
underlies some of the most significant human interactions from the first bonds between
mother and child all the way to more complex forms of prosocial behavior (Batson,
2009), all of which may even be essential for survival. Empathy is critical to social
bonds, especially mother and child (Plutchik, 1987). The field of child mental health is
especially focused on emotional development (Shore, 2001). Therefore, the
neuropsychological understanding of attachment and empathy may create a more
accurate and comprehensive model of the normal development of the human body, brain,
and mind in the early stages of development and, consequently, lead to more accurate
definitions of the adaptive basis for mental health of children (Shore, 2001).
Most models of empathy emphasize that helping behavior is motivated by emotional
states activated by the emotional states of others, a capacity which develops in the
context of parental care and other social bonds (Hrdy, 2009). The resulting sense of
security that leads children to adopt a more empathic attitude not only in intimate
relationships but also toward others with whom they do not have such close relationships.
150 María Cristina Richaud de Minzi, Viviana Noemí Lemos and Laura Beatriz Oros

Despite the importance of empathy as a basic socioemotional development process,

it has been difficult to develop a theory that integrates its emotional and cognitive aspects
as well as to create adequate operational definitions in order to test theories more
empirically. This challenge is especially evident when trying to assess empathy in
children through self-reports that provide a multidimensional measurement.
This chapter will discuss the different theoretical perspectives of empathy and its
manifestation in children and will introduce a multidimensional empathy questionnaire
developed for children between 9 and 12 years of age that is based on models proposed
by social cognitive neuroscience. This questionnaire integrates four aspects of empathy:
a) emotional contagion, which is an affective reaction to another person that typically
involves sharing the emotional state of that person; b) self-consciousness, which protects
the boundary between self and other despite a transient identification with that person; c)
perspective taking, which implies the cognitive ability to put oneself in the place of the
other; and d) emotional self-regulation, which occurs through self-regulatory and control
mechanisms that regulate and modulate personal emotional states.

INTRODUCTION
The concept of empathy has a long history within the psychological literature. The term
empathy is Titchener‘s (1909) translation of the German term einfühlung, which is a feeling
of placing oneself inside something or someone that was perceived. It was originally
introduced into the German field of aesthetics near the end of the 19th century and was also
used in the field of experimental psychology in the United States at the beginning of the 20th
century (López, Arán & Richaud, 2014; Wispé, 1987). Definitions of empathy often
encompass a wide spectrum of processes, from feeling concern or caring for others to
experiencing emotions that coincide with those of other people, as well as the accurate
perception and recognition of what another person is thinking or feeling to drawing a line or
clear distinction between oneself and the other (Hodges & Klein, 2001). Additionally,
relationships between these various potential components of empathy are poorly understood
with little empirical work on the question of their potential interconnections.
Regardless of the specific definition, empathy is an essential ability for humans, whose
entire lives take place in complex social contexts. The intrinsically social nature of humans
makes the recognition and comprehension of the mental states of others, as well as the
capacity to share these mental states and respond to them properly, one of the most important
abilities necessary for living in such complex contexts (López, et al., 2014). The expanded
use of the concept of empathy in the fields of psychology and neuroscience has led to the
proliferation of theories on this topic as well as the emergence of a series of terms that share
conceptual aspects and are often used interchangeably (López, et al., 2014; Preston & de
Waal, 2002).

THEORIES OF EMPATHY
Among the numerous theories of empathy, there are two clear theoretical streams: a)
those that are derived from Lipps‘s (1903) idea of direct or vicarious perception and
associated affective resonance and b) those that accentuate the cognitive aspects of empathy,
 Empathy in Children 151

in which empathy is a synonym for perspective-taking and is limited to those individuals who
possess ―theory of mind‖ (Preston & de Waal, 2002). Models based on ‗automatic perception‘
recognize emotional contagion and resident/imitation as the basis for empathy and give
weight to the evolutionary continuity of this more affective type of phenomenon. The models
that emphasize the cognitive component, in contrast, stress basic differences between human
empathy and similar phenomena observed in animals (López, et al., 2014). Each of these
theoretical streams has found grounding in modern neuroscience. Direct-perception theories
of others‘ emotions have found empirical support from research on mirror neurons as an
example of an adaptive linkage between executive and sensory sides of the brain, although
recent work has also drawn increasing separation between action mirroring networks and
empathy networks (see introductory chapter by Watt and Panksepp). On the other hand,
theories that underline the cognitive aspects find empirical support from research showing
temporal and medial activation of the prefrontal regions during tasks that involve ―mind
reading.‖ The differential substrates do not necessarily imply that the two perspectives are
mutually exclusive; on the contrary, the two different aspects can be functionally integrated
through clarification of the relationships between these brain processes (López, et al., 2014;
Rameson & Lieberman, 2009).
Decety and Jackson (2004) propose a model that includes affective and cognitive
components of empathy and affirms that whereas resonating with others‘ emotions is a basic
affective process that can occur without the intervention of much deliberative conscious
effort, the more cognitive processes that constitute human empathy, such as perspective-
taking and self-regulation, require more conscious processing and conscious effort. This
multidimensional model comprises three components that interact dynamically to produce
human empathy: 1) emotions shared between the observer and the observed; 2) self-
consciousness and the consciousness of the other, which limits boundary confusion between
the self and the other despite a certain transient identification; and 3) self-regulation and
mental flexibility to adopt the other‘s subjective perspective. The mental flexibility to adopt
someone else‘s point of view is an effortful and controlled process.

―An essential aspect of empathy is to recognize the other person as like the self while
maintaining a clear separation between self and other. Hence, mental flexibility and self-
regulation are important components of empathy. One needs to regulate one‘s own
perspective that has been activated by interaction with others or even the mere
imagination of such an interaction. Such regulation is also important to modulate one‘s
own vicarious emotion so that it is not experienced as aversive.‖ (Decety & Jackson,
2004, pp. 85-86)

According to Decety and Jackson, none of the three components can individually account
for the full spectrum or complexity of human empathy; during normal empathic functioning,
they are proposed to be in constant interrelation. Decety and Jackson‘s definition of empathy
captures its multidimensional nature and makes explicit reference to a minimum capacity of
‗mentalizing‘ which refers to a broad social-cognitive capacity used by humans to explain and
predict their own behavior and that of others through theory of mind and related processes.
The organization of the human nervous system provides a basic biological mechanism to
resonate with the emotional states and behavior of others, created by extensive connectivity
and crosstalk between sensory and executive sides of the brain and between perception and
152 María Cristina Richaud de Minzi, Viviana Noemí Lemos and Laura Beatriz Oros

action, thus providing a primary means by we can relate implicitly with others and generating
a tendency to attribute our own characteristics and traits to others. The idea of continuity
between perception and action is not new. Indeed, this idea is already present in the work of
William James. Some years later, Sperry argued that the perception–action cycle is the
fundamental logic of the nervous system (Sperry, 1952). More recently, Prinz (1997) asserted
that perception and action share common computational ‗codes‘ and underlying neural
architectures. Common Coding Theory assumes that actions are ‗coded‘ in terms of the
perceivable effects they should generate (Hommel, Müsseler, Aschersleben & Prinz, 2001).
Watt (2007) basically agrees with this (also see chapter by Watt and Panksepp in this
volume), and suggests that an ‗action-perception cycle‘ must be ultimately based on extensive
connectivity between executive/motor systems and sensory/receptive systems. The principle
of mirror neurons (in this case, a sensory receptive processing of action kinetics is linked
directly to the more anterior brain systems organizing the motor aspects of that same process)
also broadly characterizes empathy networks. In this sense, the conflation of mirror neurons
with empathy is understandable because both phenomena reflect this adaptive linkage
between sensory and executive sides of the brain, but the ‗targets‘ of the process or the
adaptive basis of the process have to be seen as radically different. Mirror neuron networks
allow us to emulate skilled action while empathy networks allow us to sample the affective
states of conspecifics. One serves acquisition of skilled movement, the other social bonds and
social/group cohesion in general.
Gerdes and Segal (2009) add to the model of Decety and collaborators (Decety &
Jackson, 2004; Decety & Lamm, 2006) the concept of ‗empathetic action.‘ Gerdes and
Segal‘s model has three components: 1) the affective response to the emotions and actions of
others, 2) the cognitive processing of the other‘s perspective and one‘s own affective
response, and 3) the conscious decision making to undertake an empathetic or prosocial
action. Based on this model, the conscious empathy for bad feelings (pain, anguish) in others
should begin with actions directed to changing their situation, i.e., it should begin with
solidarity, help, or altruism. The resonance induction of at least one version of the suffering of
others within us and the intrinsic motivation to reduce the suffering or distress of others have
been considered by Watt (2007) as essential parts of empathy. Without them, the
phenomenon does not really meet the criteria to be considered full emotional empathy, as a
total indifference to the suffering of others in terms of no motivation to relieve suffering
clearly does not meet any kind of face validity test for empathy.

THE DEVELOPMENT OF EMPATHY

Perception and action are functionally interrelated from birth in such a way that
perception is a means for action and action is a means for perception (Bloch, 1997; Sperry,
1952). Observations of preterm-born infants and fetuses indicate that sensory and motor
activities are tied together and that such connections are prewired (Bloch, 1997). Gallese,
Rochat, Cossu, and Sinigaglia (2009) hypothesize that ‗…the ability to understand other‘s
intentional behavior relies primarily on the motor cognition the underpins one`s own capacity
to act… Goal-directed motor acts are the nuclear building blocks around which action is
produced, perceived and understood. Taking advantage of the motor system‘s functional
 Empathy in Children 153

organization in terms of motor goals and motor intentions, the mirror neuron matching
mechanism enables a direct comprehension of the actions of others. Such comprehension is
prereflexively accomplish because the behavior of others consists of a goal-directed motor
acts and is recognized as such by virtue of the activation in the observer‘s brain of the
neurons presiding over the motor accomplishment of the same act. The motor cognition
hypothesis emphasizes the crucial role of the motor system in the phylogeny and ontogeny of
basic aspects of social cognition.‘ (p. 110). However ―…social cognition cannot be reduced to
motor-based action understanding‖ (p. 103).
Meltzoff and Decety (2003) assert that imitation in newborns is behavioral evidence of
the innate association between perception and action (Meltzoff & Decety, 2003). However,
Watt (2007) advocates for a clearer distinction between more primitive contagion
mechanisms and forms of imitation that might require more cognitive processing. Contagion
is a primitive proto-empathic capacity that is a critical part of building the social brain and
promotes group and social cohesion, attachment, and prosocial behavior (Watt & Panksepp in
this volume). Imitation does not merely constitute an automatic behavioral resonance
mechanism, i.e., neuronal activity generated spontaneously during the perception of the
movements, gestures, and actions of others; it also requires a certain level of identification
with the agent of these actions. Based on this viewpoint, newborns perhaps experience
contagion but probably not imitation.
Between 18 and 72 hours after birth, newborns who hear other children cry often show
distress reactions, suggesting more automatic or reactive contagion-type mechanism (Martin
& Clark, 1982; Sagi & Hoffman, 1976; Simner, 1971). Newborns respond with greater
strength to the cries of other children than to a variety of control stimuli, including silence,
background noise, synthetic crying noises, nonhuman crying noises, and their own crying
(Martin & Clark, 1982; Sagi & Hoffman, 1976; Simner, 1971). This response suggests that
children‘s distress reactions when hearing other children crying are not simply responses to
an aversive noise but reflect contagion mechanisms and a very early precursor of more
complex empathetic responses (McDonald & Messinger, 2011).
Clearly, empathy requires more than contagion; the induced state of suffering has to
actually promote a cooperative or comforting response rather than overwhelm the subject,
further implying that affective regulation should remain to some extent intact within the
empathizer, as well as evidence for maintained boundary between the self and other. In
addition, an affirmative affective attitude toward the sufferer should be present in terms of
intrinsic motivation to relieve the suffering in some way. In this sense, empathy cannot be
explained by mere contagion but the presence of a fundamental contagion would constitute or
act as one of its main components (Watt, 2007).
Feelings of personal distress in response to negative emotional experiences during
childhood would be precursors to empathetic concern (Hoffman, 1975; Zahn-Waxler &
Radke-Yarrow, 1990). Young children cannot yet differentiate themselves from others (see
Watt & Panksepp, this issue). They tend to be bewildered and potentially flooded
(presumably largely due to relatively uninhibited contagion mechanisms) by the negative
emotions of others, and they can develop a variety of self-comforting behaviors to reduce
their own distress. However, during the second year of life, throughout the development of
the self-other differentiation, perspective-taking, and emotional regulation, a transformation
from self-concern to concern for others occurs (Knafo et al., 2008). By two years of age,
children begin to exhibit the basic behaviors of empathy by having emotional responses that
154 María Cristina Richaud de Minzi, Viviana Noemí Lemos and Laura Beatriz Oros

correspond to other people‘s emotional states and by manifesting more organized prosocial
behaviors (e.g., helping, sharing, or comforting) indicative of concern for others (Hoffman,
2000; Decety & Jackson, 2004). During this period of development, children increasingly
experience emotional concern ―on behalf of the victim,‖ comprehend others‘ difficulties, and
act constructively by providing comfort and help (ZahnWaxler, Radke-Yarrow, Wagner &
Chapman, 1992). Almost all two-year-old children develop some helping behavior in
response to real or simulated distress, such as providing verbal comfort and advice, sharing,
or distracting the person in distress (Zahn-Waxler et al., 1992). Even during the second year
of life, children can play games of falsehood or ―pretend‖ to attempt to deceive others, which
require that the child know what others think before he or she can manipulate these beliefs
(Zahn-Waxler & Radke-Yarrow, 1990), suggesting at least emerging theory of mind
capacities. At three years of age, children already show the development of a variety of
empathetic behaviors, including expressing verbal and facial concern and interest in another‘s
distress.
The understanding that others have of the difference in their own mental worlds from
one‘s own is a critical step in the development of human beings that generally takes place at
approximately 4 years of age (Wimmer & Perner, 1983). Humans are capable of inferring
different types of mental states, such as intentions, beliefs, or lies, using key types of
information, such as facial expressions, body kinetics, the direction of gazes, and prosody
(Frith & Frith, 2006). However, a fundamental aspect of successful mentalizing is
perspective-taking, i.e., the ability to consider a situation from different points of view. In the
preschool years (4-5 years old), children are capable of taking the perspective of the other in
pretend tasks that are frequently used as indicators of the development of a theory of mind
(Wellman, Cross & Watson, 2001; Wimmer & Perner, 1983). A theory of mind helps to shift
the early development of the affective experience of contagion and empathy in a more
organized and sustained sympathetic direction centered on others, i.e., the transformation
from being more completely connected to one‘s own feelings to a conceptualization of the
experience of the other over one‘s own experience. The ability to understand others‘
perspectives implies the complete and successful identification with others‘ experience and
involves the ability to infer and comprehend that other people can have different beliefs from
one‘s own beliefs (Baron-Cohen, 2003). Growth in the ability to identify oneself with the
experience of others permits children between 7 and 12 years of age to show a natural
inclination to feel empathy for others who suffer pain (Decety, Michalska & Akitsuki, 2008)
and to develop more effective helping strategies (McDonald & Messinger, 2011).

Genetic and Environmental Determinants of Empathy

A trait approach to empathy maintains that in both aspects of empathy (cognitive and the
affective aspects), an underlying common empathy disposition may be recognized (Gill &
Calkins, 2003; Volbrecht et al., 2007; Young, Fox & Zahn- Wexler, 1999; Zahn-Waxler et
al., 2001). In addition, the longitudinal stability of children‘s empathy reveals that empathy,
seen as a trait, shows clear continuity across time (van der Mark, van Ijzendoorn &
Bakermans Kranenburg, 2002; Volbrecht, et al., 2007; Zahn-Waxler, Robinson & Emde,
1992; Zahn-Waxler et al., 2001). Consistent with this, cross-situational consistency becomes
another essential characteristic of empathy as a trait (Knafo et al., 2008). Certainly, there
 Empathy in Children 155

exists a correlation between a child‘s empathic concern and perspective assumed toward an
unfamiliar examiner and the similar behavior the child will have toward his/her mother
(Moreno, Klute & Robinson, 2008; Zahn-Waxler, et al., 2001; Young et al., 1999) as well as
in response to hearing other children crying (Gill & Calkins, 2003). The significant influence
of situational variables cannot be ignored however, despite the existence of an underlying
empathy factor, and the expected consistency in the child‘s behavior toward both the mother
and an unfamiliar examiner should not be expected to be always heavily correlated as
children may manifest their own dispositions in different ways in different contexts (Mischel
& Shoda, 1995; Knafo et al., 2008).
Innate emotional ties with others facilitate the development of dyadic mother-father-child
relationships; each part of the dyad is behaviorally and physiologically affected by the other,
and both contribute to this relationship. Physical and emotional contact coordinated between
mother, father and child allows for the child‘s development of emotional regulatory abilities,
which will help determine his/her future emotional competency. The child‘s cry or smile in
turn modifies the affective and emotional responses of caregivers, guiding their attention and
action. Children‘s emotional contagion in relation to their caregivers act as an unconditional
stimulus motivating caregivers to act before a stressful event occurs (Preston & de Waal,
2002).
These emotional ties are also the basis of empathy and the successful demand for help
outside of the dyadic parent-child relationship (Preston & de Waal, 2002). Screams, cries, and
other distress signals can serve to generate empathy in others and gain help from non-familiar
individuals. Just as within the basic family relationships, outside of these relationships,
screams and cries are capable of generating stress in others and motivating them to act.
Aversive signals are developed in relation to contagion toward negative emotions because
there is intrinsic motivation to terminate or at least delimit those signals. Positive emotions
also generate contagion effects beyond the immediate family nucleus and thereby help to
generalize various prosocial processes involved in the obtaining of support, affection, and
care (Preston & de Waal, 2002).
Through reciprocal interactions with others, children develop an increasing consciousness
of themselves as separate individuals and social agents. As they internalize social values and
are more capable of controlling and modulating their behavior and emotional states, they
become more capable of involving themselves in relationships that are self-sustaining and, to
some extent, self-regulating and repairing (Sroufe, 1995), thereby gradually acquiring the
capacity to function independently. These early experiences are formative, in addition to
supportive, in the development of emotional control. Humans are intrinsically social, and
most of our behaviors, as well as most thoughts, desires, and feelings, are directed toward or
are produced in response to others (Batson, 1990). Our survival depends critically on
interactions with others. Emotions are increasingly blended with complex cognitive processes
because emotion increasingly depends on processes of evaluation, appraisal, and attribution
(Decety & Moriguchi, 2007), suggesting deeper interpenetration of emotion and cognition in
development.
156 María Cristina Richaud de Minzi, Viviana Noemí Lemos and Laura Beatriz Oros

PARENTING
Children‘s emotional development is heavily influenced by early parent-child
interactions. These early interactions with primary caregivers are the means by which
children first learn to express and interpret emotions. In infancy, caregivers influence
emotional development through the extent to which they provide emotionally arousing stimuli
at appropriate times, reinforce and encourage emotional displays, and respond to subtle
variations in the child‘s expressions (Bronson, 2000; Eisenberg, Cumberland & Spinrad,
1998; Nagin & Tremblay, 2001). Predictive relationships between the mother‘s empathic
caring and children‘s resultant altruism have been found in some studies (Zahn-Waxler,
Radke-Yarrow & King, 1979). Studies with preschool children have also found that the
children of non-authoritarian and non-punitive mothers have higher levels of affective and
cognitive empathy and pro-social behavior. Eisenberg, Lennon, and Roth (1983) examined
the relationship between the prosocial moral judgments of children aged 4 to 6 years, using a
longitudinal methodology, and both prohibition-oriented moral judgment and maternal child-
rearing practices. According to their conclusions, prosocial reasoning is related to non-
authoritarian, non-punitive, empathetic, and supportive maternal behaviors. It was also
observed that parental modeling of empathic relationships toward children and other
individuals predicted the development of pro-social attitudes and behavior in children. Zahn-
Waxler, Radke-Yarrow, and King‘s (1979) work examined maternal child-rearing behaviors
as they related to children‘s reparations for transgressions as well as to altruism as bystanders
to situations of distress experienced by others. Both mothers and researchers stimulated
distress. Mothers‘ empathic caregiving was rated during home visits and also predicted based
on children‘s reparations and altruism. In apparent contradiction to these findings, however,
other studies have shown little correlation between parents‘ and children‘s empathy, despite
an overlap in parent and child empathy measures (Bernadett-Shapiro, Ehrensaft & Shapiro,
1996; Hunter & Schmidt, 1990; Kalliopuska, 1984; Strayer & Roberts, 1989).
Considering that children exposed to models of specific behavior are more likely to
emulate those acts (especially if the model is admired or closely identified with) (Bandura,
1986), we have proposed that providing children with hands-on experiences in empathetic
acts may facilitate future empathetic behaviors by providing rehearsal and practice
opportunities. In line with the hypothesis that a child‟s perception of his parents‟ behaviors
may be more related to his adjustment than is the actual behavior of his parents (Schaefer,
1965, p. 413), one would clearly expect that parents who model and encourage empathetic
behaviors may promote empathetic behaviors in their children (Richaud, 2013). Despite the
active nature of children‘s development of their own emotional self-regulation, they need
assistance and guidance from their caregivers and culture (Sroufe, 1995). Specifically,
children benefit from observation of and hands-on experiences in empathetic acts from
parents (Bandura, 1986). For this reason, we hypothesized that it may be necessary to study
children‘s perceptions of parental empathy, reflecting parents‘ modeling, because there is
likely a disjuncture between what parents advocate for and what they actually do (Richaud,
2013).
 Empathy in Children 157

GENDER
Abundant evidence has been identified regarding the difference in empathy between
males and females, the latter being generally viewed as consistently more empathetic
(Garaigordobil & García, 2006; Litvack, McDougall & Romney, 1997; Mestre, Frías &
Samper, 2004). Because of cultural norms, parents‘ expectations for girls and boys typically
differ. In general terms, girls are expected to be more nurturing and concerned with the social
evaluation of others, whereas boys are expected to be more autonomous. Consequently,
stereotypical gender socialization leads to a lower sense of mastery and control and more
acute concern for external evaluation in girls than in boys (Blehar & Oren, 1999; Ruble,
Greulich, Pomerantz & Gochberg, 1993). These different expectations are likely to
differentially modulate the development of empathy in boys and girls (Richaud, 2013).
Studying empathy in boys and girls aged 9 to 12 year, we found significant differences
between the two genders. Specifically, girls were generally more empathic than boys, in both
cognitive and affective aspects (Richaud, 2013). These results coincide with those of all
previous studies on the subject (see, among others, Broidy et al., 2003; Carlo et al., 1996;
Carlo, Raffaelli, Laible & Meyer, 1999; Eisenberg & Lennon, 1983; Eisenberg, Zhou &
Koller, 2001; Mestre, Samper, Frías & Tur, 2009; Toussaint & Webb, 2005). As such, gender
is an important consideration when examining how parents‘ empathy influences children‘s
empathy, especially when taking cultural patterns into account that influence the gender roles
of children and parents.

RELATIONSHIPS BETWEEN FATHERS‟ AND MOTHERS‟ EMPATHY

AND BOYS‟ AND GIRLS‟ EMPATHY

Cultural norms, which establish the role of each parent in children‘s socialization, are
often quite different between cultures. Gender differences in attachment and such related
behaviors as empathy are expected due in large part to the differences in parents‘ expectations
for girls and boys (Blehar & Oren, 1999; Kerns & Barth, 1995; Ruble, Greulich, Pomerantz &
Gochberg, 1993). Families develop means of interaction with their children based in part on
the beliefs and values promoted by and embedded in their cultural contexts (Reebye, Ross &
Jamieson, 1999). It is thus essential to examine the relationship patterns between children‘s
perceptions of maternal and paternal empathy and son and daughters‘ empathy separately in
developmental studies. This approach is particularly important for identifying patterns
between perceived parental empathy and children‘s empathy that are unique to the father and
child and to the mother and child (Richaud, 2013).
When comparing boys and girls with respect to their perception of their mothers‘ and
fathers‘ empathy, they coincide in their perception of their mother‘s empathy and differ in
their perception of their father‘s empathy. Girls perceive more perspective-taking and
empathic concern in their fathers than do boys. Boys do not tend to perceive empathic
concern in their father, only perspective taking. These results coincide with previous studies
on this topic (Drevets, Benton & Bradley, 1996; Harter, 1990; Siegal, 1985) that indicate that
both girls and boys perceive more empathic concern and perspective taking in their mothers
than in their fathers, whereas girls perceive more of their father‘s empathic concern. Not only
158 María Cristina Richaud de Minzi, Viviana Noemí Lemos and Laura Beatriz Oros

are women more empathic, they are also broadly perceived by both genders as more empathic
and, at the same time, are more capable of perceiving empathy. Therefore, there appears to be
relatively strong data suggesting a basic connection between empathy and gender (Richaud de
Minzi, 2006, 2010, 2013).
Regarding the relationship between parents‘ and children‘s empathy, we found not only
that the empathy that children perceive in their parents explains, to a significant extent, the
development of their own empathy but also that this influence varies greatly according to the
gender of both parents and children. Thus, boys‘ perception of their fathers‘ perspective-
taking is related to their own perspective-taking; of their fathers‘ fantasy to their own fantasy;
and of their mothers‘ empathic concern to their own empathic concern; i.e., boys do not tend
to perceive the more affective components of empathy in their fathers, only the cognitive
components. Regarding girls, maternal and paternal perspective-taking influences girls‘
perspective-taking, maternal and paternal fantasies influence girls‘ fantasies, and maternal
and paternal empathic concern influences girls‘ empathic concern. Therefore, girls are
influenced by both components of empathy as perceived in both parents (Richaud, 2013).

EMPATHY MEASUREMENT IN CHILDREN

Empathy, due to its complex dimensionality, is obviously a difficult construct to
operationalize and accurately measure, perhaps especially so in children. A number of
different scales have been developed based on the various and previously outlined
conceptualizations of empathy. There are classic measures of empathy in children, such as
those identified by Bryant (1982) and Mehrabian and Epstein (1972), which operationalize
the more affective aspects of empathy, and by Hogan (1969), which are based on the more
cognitive aspects of empathy. This last scale was critiqued as by Froman and Peloquin
(2001), who concluded that the model suffered from questionable test-retest reliability, low
internal consistency, and poor replication of factor structure. Social developmental
psychology suggests that empathy must have multiple dimensions (Cliffordson, 2002; Davis,
1996), including components such as awareness of self and others (Batson et al., 1997) and
emotional regulation (Eisenberg et al., 1994). Davis (1983) defined empathy as a
multidimensional construct and built the Interpersonal Reactivity Index (IRI), a scale
comprised of cognitive components (perspective-taking and fantasy) and emotional
components (empathic concern and personal distress, i.e., experiencing feelings of discomfort
and anxiety when witnessing the negative experiences of others). In studies of this instrument
in Argentinean and Spanish children (Mestre, Frias & Samper, 2004, Richaud, 2007), it was
determined that the Perspective-Taking Factor, a more cognitive factor, included items in
both samples that gave it more of an emotional comprehension nature than one of cognitive or
theory of mind reasoning. Due to this finding, it was proposed that this factor be called
comprehension of others given that it combines cognitive and affective aspects. The same
result occurred for Fantasy, the other factor considered cognitive by Davis, given that more
than simple identification with fictitious people or imagining oneself in their place,
―enthusiasm‖ with fictitious people role appeared to be involved in these situations. In other
words, there was not only a cognitive assessment of but also an affective involvement with
characters. When assessing the correlations between factors, statistically significant
 Empathy in Children 159

relationships were found between empathic concern (affective) and fantasy (cognitive),
fantasy (cognitive) and personal distress (affective), and perspective-taking (cognitive) and
empathic concern (affective), contradicting Davis‘ model, according to which there should be
significantly weakened correlation between the cognitive and affective components. It was
thus concluded that it would be important to study which processes were really involved in
empathy and whether affective and cognitive factors are independent or if the affective and
cognitive aspects are intimately related with respect to empathy and other related processes
(Richaud, 2007). Moreover, Cliffordson (2002) criticized the IRI, determining that personal
distress (contagion) and fantasy factors were inadequate to assess levels of empathy. In
addition, the IRI was not validated by further statistical analysis.
Hoffman (2000) added to this discussion and suggested that empathy was not simply
multidimensional but may also represent a developmental process, progressing from
automatic mimicry (Iacoboni, 2009) to the cognitive processing that involves the ability to
imagine the experiences of others. More recently, Decety and Jackson (2004) and Decety and
Moriguchi (2007) demonstrated that observable brain activity was linked to four subjectively
experienced components of empathy. The first component is affective sharing or contagion,
which comprises automatic reactions based on a person‘s observation of another. The second
component, self-awareness, is a person‘s ability to differentiate the experiences of another
individual from his or her own experiences. The third component is perspective-taking, which
is the cognitive process of adopting the subjective perspective of another individual to
understand his/her feelings. The fourth component is emotion regulation, defined as a
person‘s ability to sample another person‘s feelings via a contagion-type mechanism without
becoming overwhelmed by the intensity of this experience. With the exception of Lietz et
al.,‘s (2011) scale for social workers based on the Decety and Jackson model, to our
knowledge, there are currently no empathy scales constructed for children. Generally, when
attempting to study different processes in children, observations and reports from third parties
(parents or teachers) are employed. With respect to the observation technique frequently used
to study the empathic behavior of children, Light et al., (2009) and Sallquist et al., (2009)
identified several limitations:

1) The results of observation depend on the observer and the type of codification,
2) Observation requires individual evaluation and is thus costly in terms of time,
3) Reliance on skilled observation is a methodological variable that precludes large-
scale evaluation and large cohorts or longitudinal studies.

Finally, evidence for the psychometric properties of this type of measure is often limited
to the particular study for which it was designed, which hampers the standardization of tests
needed to compare and integrate results through different studies. There are also measures
that study empathy in children based on hetero-evaluation (Rieffe, Ketelaar & Wiefferink,
2010). However, children‘s self-reports about their own behavior tend to be the most reliable
measure compared with the reports of adults, given that children do not always show certain
behaviors in front of their parents or teachers and because they know their behavior in
different situations.
160 María Cristina Richaud de Minzi, Viviana Noemí Lemos and Laura Beatriz Oros

A NEW QUESTIONNAIRE ABOUT EMPATHY IN CHILDREN

Based on our earlier considerations, we proposed to construct a self-report measure that
would allow one to obtain a multidimensional measure of empathy for children aged 9 to 12
years using the Decety and Jackson (2004) model as a base and adding the previously
mentioned Gerdes and Segal (2009) measure of empathetic action. Thus, our first objective
was to operationalize five aspects of empathy in children: contagion, self-consciousness,
perspective-taking, affective self-regulation, and empathic attitude. Using the
operationalization for adults developed by Lietz et al., (2011), which also used the models
developed by Decety and Jackson as well as Gerdes and Segal, these items were redeveloped
with the intention of adjusting them to the base model and maintaining clear and simple
expressions that are used in common speech in Argentinean children between the ages of 9
and 12 years. Alternative expressions were proposed for certain items, and the best
expressions were selected in accordance with the opinions of experts in this field. In this way,
the measure remained a scale comprising 47 items: 7 on contagion (e.g., When I am with
someone who is sad, I also get sad); 10 on self-consciousness (e.g., I realize right away when
someone is feeling badly); 10 on perspective-taking (e.g., Even if someone thinks differently
than me, I can understand them); 11 on emotional regulation (e.g., When I get angry, I have
trouble calming down); and 9 on empathic or prosocial attitude (e.g., We should share what
we have with those who have less than we do).
After analyzing psychometric functioning in relation to the answers provided by 417
children, we observed that the items were centered around four basic factors rather than five
as was originally proposed. The items corresponding to the empathic attitude dimension did
not fit clearly into a different factor; some items presented as factorially complex, and others
did not have weight in any factor. Given the progression in the development of empathy, we
will explain why it is reasonable that the first four dimensions (contagion, self-
consciousness, perspective-taking, and self- regulation), but not the last dimension
(empathetic action), have clearly emerged in children of this age range (9-12 years).
Contagion (first questionnaire dimension) appears quite early in development (Decety &
Jackson, 2004), meaning that it was expected that 9-12-year-old children would not have
difficulty responding to the corresponding items on the new questionnaire.
Regarding self-consciousness and perspective-taking (second and third questionnaire
dimensions, respectively), as was mentioned in the above section, at 4 to 5 years of age,
children begin to express and recognize themselves as enduring entities and at the same time
to demonstrate significant advances in their understanding of others. At that age, children
begin to have multiple representations and perspectives of objects and people (Callaghan &
Rochat, 2003). This ability is related to the ability to build false beliefs in others and to
understand the representational aspect of graphs and other symbolic elements such as maps,
photos, or scaled models (Callaghan & Rochat, 2003; DeLoache, 1991; Olson & Cambell,
1993; Perner, 1991). When children understand that another person has a false belief, they
necessarily understand that they have the correct belief. In the same way, when children show
that they comprehend the permanence of an object, they also demonstrate their own
permanence in relation to objects (Rochat, 2001).
With regard to emotional self-regulation (fourth questionnaire dimension), it was not
expected that children 9-12 years old would have difficulties responding to the corresponding
 Empathy in Children 161

items. Emotional regulation encompasses a group of strategies employed to adjust one‘s own
emotional state to a level of intensity that allows for adequate functioning (Berk, 1999). Self-
regulation refers, in general terms, to the ability to control and moderate one‘s emotional
expressions (positive and negative) and to interact with others in ways that are increasingly
more complex in accordance with social rules. It also refers to the ability to adapt to
emotionally challenging situations, to inhibit behaviors perceived as inappropriate in a given
context, and to promote behaviors that are perceived as socially desirable. Emotional
regulation abilities are ―processes used to manage and change if, when, and how (e.g., how
intensely) one experiences emotions and emotion-related motivational and physiological
states, as well as how emotions are expressed behaviorally‖ (Eisenberg, Gollust, Golberstein
& Hefner, 2007, p. 288).
The emergence of emotional regulation is a gradual process. At first, children trust
completely in the mediation of external parties, such as primary caregivers, to co-regulate
their emotions, such as when they are upset and need the attention of their mothers to calm
them. At 6 months, children begin to exhibit the first signs of self-regulation as a result of the
internalization of the self-regulation ―programs‖ of their caregivers (Schore, 2003). Between
1 and 2 years of age, children distract themselves from distressing stimuli, increasingly
avoiding fixation of their attention on them (Kopp, 1989; Mangelsdorf, Shapiro & Marzolf,
1995). Still, however, they cannot regulate fear (Buss & Goldsmith, 1998), which they
express in such a way that they attract the attention of their caregivers, who try to comfort
them (Bridges & Grolnick, 1995). Several years later, children manage their negative
emotions by speaking with others and negotiating methods of resolving situations,
demonstrating more sophisticated methods of emotional regulation. Emotional regulation is
very important for children‘s moral development, such as, for example, when parents attempt
to have children sympathize with other people to whom they have caused distress and to also
feel guilt for having hurt them (Dunn, Brown & Maguire, 1995; Kochanska, 1991). This
maturing of self-regulation is accompanied by neurological changes, particularly the maturing
of the frontal lobes, which are essential for attention and for the inhibition of thoughts and
behaviors (Siegler, 2006).
Contrary to the first four dimensions of the questionnaire, on which children had no
difficulty in responding, the fifth dimension involves the conscious decision to undertake an
empathetic action. The ability to undertake an empathetic action would imply the
internalization of certain values (solidarity, help, or altruism) for which it is necessary to
comprehend certain abstract concepts that are associated with the development of logical
thinking, which is not fully realized until adolescence. Indeed, the items that operationalize
this dimension (empathetic action) include a type of reasoning that is quite complex and
evolved for children 9-12 years old because it involves (a) a set of generalized beliefs and
causal attributions about the misfortune of others and (b) the evaluation of whether it is
appropriate to assist them. For example, if it appears that the misfortunes of others are the
result of their own voluntary decisions or their ineffectiveness (item example: It is wrong to
give things to beggars; they ask because they do not want to work), these actions may be less
likely to elicit empathic action, whereas if the misfortune is attributed to causes beyond the
control of the individual (item example: I think we all have to help kids in need), the child is
more likely to have an empathetic and caring disposition.
Eisenberg (2000) notes that children‘s growing capacity to feel empathy for others
contributes in large part to the development of mature prosocial reasoning and the
162 María Cristina Richaud de Minzi, Viviana Noemí Lemos and Laura Beatriz Oros

development of disinterested concern for the good of other people in need of help, but this
mature prosocial reasoning is only achieved in adolescence (Eisenberg & Miller, 1987;
Eisenberg, Carlo, Murphy & Van Court, 1995; Eisenberg et al., 1987; Eisenberg, Shell,
Pasternak, Lennon, Beller & Mathy, 1987). Beginning in late elementary school, some
children begin to verbalize reasoning that reflects abstract principles; internalized affective
reactions, such as culpability or positive feelings about the consequences of their own
behavior; and self-reflective sympathy, even if this reasoning is not dominant during early
and middle-adolescence. Reasoning relative to the internalization of norms, rules, and values;
internalization of affective reactions based on concern about the consequences of one‘s own
behavior for others; and positive feelings related to values and living up these values all
increase with age until late adolescence (Eisenberg, Cumberland, Guthrie, Murphy &
Shepard, 2005).
Based on these theoretical principles and empirical evidence, we found that the four-
factor model obtained through exploratory factor analysis coincided with progression in the
predicted development of empathy. In any case, this model was tested through confirmatory
factor analysis, revealing satisfactory adjustment indices that corroborated the proposed
model (χ2(98) = 187.814, χ2/df = 1.92; GFI = .952; AGFI = .933; RMSEA = .045). The four
factors showed indices that were moderately adequate with regard to internal consistency
(between .54 and .62), as did the complete scale (.65). All of the items were discriminative.
Finally, to contribute evidence on the validity of the construct of the scale, the new
questionnaire was used to test the repeatedly tested hypothesis (Garaigordobil & García de
Galdeano, 2006; Mestre, Frías Navarro & Samper García, 2004) that empathy has a positive
influence on the development of positive social behavior during childhood and adolescence.
The results indicated significant differences in social abilities as related to empathy (F(2,402)
= 37.12; p < .000), confirming the proposed hypothesis (Oros & Fontana Nalesso, 2015).

CONCLUSION
In this chapter, we have considered empathy to be a multidimensional construct that
explains the sense of sharing and the comprehension of the subjective experience of others,
indexing a fundamental prosocial process in the human mind and brain that shares a basic
evolutionary continuity with other mammals that clearly demonstrate primitive forms of
proto-empathy or basic contagion. Empathy in humans includes aspects of emotional
contagion, self-consciousness and theory of mind, and perspective-taking. Humans, similar to
other species, share emotions and sentiments with other people, but the capacity to feel for
and act intentionally in the place of another individual whose experiences can differ a great
deal from their own may be significantly more restricted (Batson & Shaw, 1991; Decety &
Hodges, 2006). This phenomenon, called empathic concern, is often associated with prosocial
behavior, such as helping, and has been considered quite important for the development of
altruism. Empathy involves not only shared affective experience of the real or inferred
emotional state of others but also some minimum cognitive comprehension of the emotional
state of others. Empathetic individuals are also typically less aggressive because of their
emotional sensitivity and their ability to understand the potential negative consequences for
themselves and others that can result from aggression. Thus, empathy appears to be
 Empathy in Children 163

negatively related to predispositions toward aggressive behavior and positively related to

prosocial and altruistic behavior.
The complex reentry between sensory and executive sides of the brain provides a basic
neurobiological mechanism for resonating with the affective states of others. This
mechanism, driven by a common ‗coding‘ between perception and action, provides a
fundamental channel for sampling the emotions of others and helps build continuity between
the self‘s and others‘ experiences. Empathy, when considered in this way, structures
development from birth to adolescence and adulthood in a way that builds upon simple
contagion toward more complex forms of empathy, through perspective-taking and theory of
mind, accompanied by progressive emotional self-regulation, to ultimately reach a level of
conscious decision-making in late adolescence that promotes empathic actions.
Although empathy presumably has a genetic basis that is still only minimally understood,
interaction with others through early relationships provides a critical social scaffolding and
context for the development of empathy. In this sense, early relationships with primary
caregivers are fundamental. The child‘s sociocultural environment also provides a ―cultural
toolbox‖ of meaning and methods that guide and support cognitive growth, the development
of self-regulation, and adaptation to the entire social environment (Bruner, 1986, 1990).
Because of this, which most likely sustains different cultural patterns of role expectations for
children, critical differences have consistently been found in empathy according to gender.
These differences, in turn, may promote different interactional patterns between parents and
children that influence children‘s development of empathy. Finally, we have addressed the
topic of measuring empathy in children, considering the difficulties of conventional measures
and proposing a new measure.

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In: Psychology and Neurobiology of Empathy ISBN: 978-1-63484-446-8
Editors: Douglas F. Watt and Jaak Panksepp © 2016 Nova Science Publishers, Inc.

Chapter 6

EMPATHY IN ADOLESCENCE:
FAMILIAL DETERMINANTS AND PEER
RELATIONSHIP OUTCOMES

Holly Ruhl1 and Chong Man Chow2,

1
University of Texas at Dallas, Richardson, TX, US
2
Eastern Michigan University, Ypsilanti, MI, US

During the past 30 years, research has explored the determinants and outcomes of
empathy in adolescence (Davis, 1983). In this chapter, we adopt a socialization perspective
(Staub, 1979) and extend the dialogue on adolescent empathy with the hope of highlighting
the familial factors that contribute to the emergence of empathic capability. We also review
the body of literature that establishes a connection between empathy and relational
competence and functioning in adolescent peer relationships. The overarching theoretical
model that guides the current chapter is presented in Figure 1. Taken as a whole, this model
shows that specific factors influence adolescent empathy and social outcomes of empathy in
adolescent friendships and romantic relationships. Specifically, empathy is impacted by
familial factors, such as the intergenerational transmission of empathy, parenting styles, and
parent-child relationship quality (Laible, 2007; Padilla-Walker & Christensen, 2010; Walter,
2012). Adolescent empathy leads to social competences, such as intimacy skills, the ability to
manage and resolve conflicts with peers, and prosocial behaviors (Chow, Ruhl, &
Buhrmester, 2013; Fraser, Padilla-Walker, Coyne, Nelson, & Stockdale, 2012). In general,
these competences lead to more positive peer relations, including better friendship quality,
higher status within peer networks, and better romantic functioning (Čavojová, 2012;
Soenens, Duriez, Vansteenkiste, & Goossens, 2007). In addition to the core model, we will
also discuss the ―dark side‖ of empathy—the potential for empathy to have deleterious
psychological and social outcomes during adolescence (Smith & Rose, 2011). Finally, a
summary of the literature and future directions for research on adolescent empathy are
discussed.


All correspondence concerning this article should be addressed to Chong Man Chow, Psychology Department,
Eastern Michigan University, 341 MJ Science, Ypsilanti, MI, 48197 [email: cchow@emich.edu].
172 Holly Ruhl and Chong Man Chow

Figure 1. Proposed theoretical model of determinants and outcomes of empathy during adolescence.

DEFINING AND MEASURING EMPATHY IN ADOLESCENCE

Early studies of empathy characterized this construct as the cognitive ability to put
oneself in the position of others, and anticipate their reactions, feelings, and behaviors
(Dymond, 1949; Gladstein, 1983; Kerr & Speroff, 1954). This characterization is consistent
with the idea of theory of mind, or mentalizing, in that these processes involve understanding
the mental states of others (Singer, 2006). However, this conceptualization solely focused on
the cognitive aspect of empathy and did not address the affective component of empathy.
Several years later, researchers began considering the affective side of empathy, or the
emotional response of an individual to the perceived feelings of others (Stotland, 1969).
Amongst contemporary researchers, a general consensus is maintained that empathy is
most aptly defined as a multidimensional process, consisting of both affective and cognitive
aspects. Indeed, neurological evidence supports this theory in that cognitive aspects of
empathy appear to be represented in the temporal lobe and pre-frontal cortex, whereas
affective aspects of empathy are represented in the sensorimotor cortices and the limbic and
para-limbic structures (Singer, 2006). Recent conceptualizations of cognitive empathy (e.g.,
Devoldre, Davis, Verhofstadt, & Buysse, 2010) describe it as the ability to accurately
perceive and experience others‘ internal states (perspective taking). In contrast, affective
empathy is described as the ability to feel sympathy, compassion, and concern for others, or
the induction of emotion due to witnessing a congruent emotion in another (empathic
concern; Devoldre et al., 2010; Fraser et al., 2012; Singer & Lamm, 2009). Further, the
concept that an adolescent may excessively share in others‘ stress and experience it as their
own is referred to as empathic distress (Smith & Rose, 2011). Within both the cognitive and
affective domains, there has been much debate regarding the most accurate conceptualization
and definition of empathy. In the cognitive domain, terms such as theory of mind, perspective
taking, and mentalizing are often used with little differentiation (Frith & Frith, 2006; Singer,
2006). In the affective domain, terms such as sympathy, emotional contagion, affective
resonance, and empathic concern are often used (Singer & Lamm, 2009). This chapter will
refer to the cognitive aspect of empathy as perspective taking and the affective aspect as
empathic concern. These terms are rooted in the developmental literature on empathy and in
 Empathy in Adolescence 173

self-report measures of empathy. Although the current chapter will primarily utilize these
terms, the lack of a consistent conceptualization of empathy across developmental, social, and
neuroscience backgrounds is an important shortcoming that will be discussed in the final
section of this chapter.
Because empathy is now conceptualized as a multidimensional construct, modern
methods of measuring empathy have combined previous efforts to measure cognitive insight
and role-taking (Dymond, 1949; Hogan, 1969) and affective empathy (Mehrabian & Epstein,
1972). For instance, the Interpersonal Reactivity Index (IRI; Davis, 1983) was developed to
measure empathy as four related but distinct constructs, including two cognitive aspects and
two affective aspects. The cognitive aspects include a perspective taking component, or the
ability to adopt the internal viewpoints of others, and a fantasy component, or the ability to
transpose oneself into the feelings and behaviors of fictitious others. The affective aspects
include an empathic concern component, or feelings of concern and sympathy toward the
unfortunate circumstances of others, and a personal distress component, or feelings of anxiety
within the self regarding stressful interpersonal circumstances. The measure of personal
distress is similar to Smith and Rose‘s (2011) conceptualization of empathic distress, or the
intense emotional involvement in a close other‘s distressed feelings to the point of perceiving
the distress as one‘s own. With regard to the IRI, researchers commonly utilize the subscales
of interest to their specific hypotheses, typically empathic concern and perspective taking
(e.g., Chow et al., 2013; Fraser et al., 2012; Gleason, Jensen-Campbell, & Ickes, 2009; Smith
& Rose, 2011; Soenens et al., 2007). The IRI is often considered the gold standard for
measuring empathy (Baron-Cohen & Wheelwright, 2004; Jolliffe & Farrington, 2006),
having good validity in a late adolescent and young adult sample (Davis, 1983). Empathic
concern and perspective taking in this measure are related to other measures of cognitive and
affective empathy, social functioning, sensitivity toward others, less loneliness, and a
beneficial interpersonal style (Davis, 1983).
Although a commendable measure, the IRI is in no way the only effective measure of
empathy. The Empathy Scale (EM) is a measure that assesses the ability to be ―socially acute
and sensitive to nuances in interpersonal behavior‖ (Hogan, 1969). The EM has shown good
validity and test-retest reliability in young adolescents and young adults. However, because it
does not take into account the multidimensional nature of empathy, this measure may have
potential methodological flaws. More recently, measures such as the Empathy Quotient, the
Basic Empathy Scale, and the Adolescent Empathic Tendency Scale have been developed as
alternative methods of assessing empathy in adolescents and adults (Baron-Cohen &
Wheelwright, 2004; Dereli & Aypay, 2012; Jolliffe & Farrington, 2006). The Empathy
Quotient (EQ) conceptualizes cognitive and affective empathy as one cohesive construct, due
to the co-occurrence of these related aspects. This measure was found to have good construct
and internal validity in both normative and clinical samples. Taking a two-dimensional
approach, the Basic Empathy Scale (BES) assesses the cognitive and affective aspects of
empathy by measuring individuals‘ abilities to understand (cognitive) and share in (affective)
others‘ emotional states (Jolliffe & Farrington, 2006). Confirmatory factor analyses suggested
that, although related, the cognitive and affective constructs are separate factors. Further, the
validity of this measure was rigorously examined in adolescents and was found to be
commendable. Lastly, for examining empathy outside of English-speaking populations, the
Adolescent Empathic Tendency Scale is a measure created specifically for Turkish
adolescents (Dereli & Aypay, 2012). Similar to measures given in English, exploratory and
174 Holly Ruhl and Chong Man Chow

confirmatory factor analyses both indicate that this measure consists of two factors (emotional
and cognitive empathy; Dereli & Aypay, 2012). Thus, several effective measures of empathy
exist, and should be considered based on researchers‘ specific populations of interest and
hypotheses.

FAMILIAL FACTORS AND ADOLESCENT EMPATHY

Although numerous studies have focused on the socialization of empathy in a familial
context in young children (Eisenberg, Fabes, Schaller, Carlo, & Miller, 1991; Eisenberg et al.,
1993), research on the link between familial factors and the development of adolescents‘
empathy is relatively scarce. However, the body of research on the associations between
familial factors and empathy in adolescence is growing (e.g., Carlo, Knight, McGinley, &
Hayes, 2011; Miklikowska, Duriez, & Soenens, 2011; Padilla-Walker & Christensen, 2010).
In general, research on the link between familial factors and adolescents‘ empathy can be
broadly organized into three areas: (a) the intergenerational transmission of parental empathic
ability to adolescents, (b) the association between parenting styles and practices and
adolescents‘ empathy, and (c) the association between parent-child relationship quality and
adolescents‘ empathy.

INTERGENERATIONAL TRANSMISSION OF EMPATHY

Research on young children has consistently provided support for the link between
parents‘ and children‘s empathy-related characteristics, particularly within same-sex dyads
(Eisenberg et al., 1991; Fabes, Eisenberg, & Miller, 1990). Similarly, recent research has
documented the concordance between parents‘ and adolescents‘ empathy (e.g., Hawk et al.,
2013; Soenens et al., 2007). Soenens et al. (2007) demonstrated that adolescent empathic
concern was moderately related to mothers‘ empathic concern. It is important to note that this
study showed that perspective taking was only weakly related between adolescents and their
mothers.
Naturally, researchers are interested in the mechanisms that may account for the
concordance between adolescent and parent empathy, and one obvious candidate is genetic
contribution (for a review, see Walter, 2012). A recent meta-analysis of twin studies reviewed
the genetic contribution to empathy during early childhood and adulthood. This study found
that genetic factors accounted for approximately 35% of individual variation in empathy
(Knafo & Uzefovsky, in press). Furthermore, research has revealed that the heritability of
empathy may differ for cognitive and affective components of empathy (Davis, Luce, &
Kraus, 1994). Specifically, higher heritability estimates were found for empathic concern than
perspective taking. Indeed, these results shed light on Soenens et al.‘s (2007) findings that
adolescent-mother dyads are more similar in empathic concern than perspective taking. This
finding suggests that affective components of empathy may be more inheritable than the
cognitive components, which may be more attributable to one‘s environment.
PARENTING PRACTICES AND ADOLESCENT EMPATHY
 Empathy in Adolescence 175

The fact that genetic factors can only account for some of the variance in empathy
highlights the importance of the socialization process in determining adolescent empathy. For
instance, social learning theory suggests that children may rely on their parents as role models
for their empathic skills (e.g., Eisenberg, Spinrad, & Sadovsky, 2006). However, other
theorists argue that behavioral and psychological mechanisms, such as parenting styles and
practices, may underline the concordance between parent and adolescent empathy (Carlo,
Mestre, Samper, Tur, & Armenta, 2011; Miklikowska et al., 2011; Padilla-Walker &
Christensen, 2010). For instance, some theorists argue that experiencing supportive and warm
parenting is the root of empathic capability in adolescents (Miklikowska et al., 2011; Soenens
et al., 2007). Parents who are more empathetic may be better at recognizing their children‘s
needs and subsequently respond to their children in a warm, affectionate, and involved
manner. Indeed, research has consistently demonstrated that adolescents exhibit more
empathic concern and perspective taking when they have parents who encourage positive and
warm parent-child communication (Eisenberg & McNally, 1993; Laible & Carlo, 2004;
Miklikowska et al., 2011; Soenens et al., 2007). With regard to disciplining practices,
research suggests that parents who use inductive verbal reasoning to enhance their children‘s
awareness of behavioral consequences to themselves and others have adolescents who display
more empathic concern toward others (Carlo, Knight et al., 2011; Laible, Eye, & Carlo,
2008). Furthermore, adolescents with parents who are more involved in their lives (e.g.,
participating in school activities) also display more empathy (Padilla-Walker & Christensen,
2010). Not surprisingly, however, parents who are either reluctant to discipline or who are
overly strict and controlling have children who are less empathic (Carlo, Mestre, et al., 2011;
Eisenberg & McNally, 1993; Laible et al., 2008). These negative parenting styles (either too
lax or firm) place unrealistic demands on children that can produce negative affect and more
self-centered thoughts in children, leading to less empathic capability (Carlo et al., 2010).

PARENT-CHILD RELATIONSHIP QUALITY

AND ADOLESCENT EMPATHY

Whereas many studies have focused on the roles of parenting styles and practices on the
emergence of empathy in adolescence, another line of research has investigated the
importance of parent-child relationship quality. For instance, adolescents who perceive that
their relationships with their parents are more ―connected‖ and intimate display more
empathy (Padilla-Walker & Christensen, 2010; Van der Graaff, Branje, de Wied, & Meeus,
2012). In contrast, adolescents who experience more conflict with parents tend to display less
empathic concern and perspective taking (Batanova & Loukas, 2012). In addition to the
positive and negative qualities of parent-child relationships, some researchers have adopted
an attachment theory approach to investigate the link between attachment security and
empathy during adolescence. Attachment theory suggests that sensitive and responsive
caregiving from parents fosters secure attachment representations by satisfying a child‘s
emotional needs. Secure children are confident about the availability of their parents and are
better at regulating their emotions (Cassidy, 1994). Thus, it is believed that securely attached
children are freed from self-preoccupation and are, therefore, better able to express empathy
toward others (Laible, 2007). Consistent with this notion, research suggests that adolescents
176 Holly Ruhl and Chong Man Chow

with secure attachment to parents exhibit more empathic concern and perspective taking
(Laible, 2007; Laible, Carlo, & Roesch, 2004).
Overall, research has consistently demonstrated the importance of the familial
socialization process, especially through various parenting styles and practices, in the
emergence of adolescent empathy. Previous studies have also highlighted the role of parent-
adolescent relationship quality (e.g., support, conflict, attachment security) in fostering
adolescents‘ empathic capabilities. However, it is crucial to note the possibility that links
between parenting styles or parent-child relationship quality and adolescent empathy might be
attributable to a broader genetic factor; this possibility should be further examined as it could
certainly undermine the socialization hypothesis (Harris, 1998). Therefore, we argue that
future research should examine how genetic and parental factors might interact to predict the
development of empathy during adolescence.

EMPATHY AND PEER RELATIONSHIPS:

THE ROLE OF SOCIAL COMPETENCE
Empathic concern and perspective taking skills are central to healthy peer relationships
during adolescence. An adolescent‘s ability to accurately perceive the thoughts of, and
identify with, a peer is a valuable tool that can be used to maintain positive friendships and
romantic relationships during this period in life (Franzoi, Davis & Young, 1985; Smith &
Rose, 2011). Perspective taking skills and empathic concern for others during adolescence
contribute to social competences, such as intimacy and conflict management skills, as well as
prosocial behaviors. These social competences allow adolescents to maintain well-adjusted
peer relationships and favorable peer networks (Čavojová, 2012; Chow et al., 2013).

Empathy and Adolescent Friendships

Empathic concern and perspective taking skills play an important role in helping
adolescents develop healthy friendships. By understanding peers‘ intentions, goals, and
emotions, adolescents are better equipped to engage in effective social support with friends
and are more comfortable engaging in self-disclosure of personal information to friends
(Burleson, 2003; Chow et al., 2013). Additionally, empathic concern for friends promotes
good communication and makes it possible to be accommodating of a friend‘s needs during
conflict. Indeed, research suggests that adolescents who are high in affective empathy engage
in more compromise-based and less anger-based conflict management with peers (de Wied,
Branje, & Meeus, 2007). Further, adolescents high in cognitive and affective empathy engage
in more prosocial behaviors, such as willingness to intervene on behalf of victimized peers,
more honesty and tolerance, more helping behaviors, and less psychological and physical
bullying (Dereli & Aypay, 2012; Fraser et al., 2012; Hektner & Swenson, 2012). When
adolescents engage in empathic concern for others and prosocial behaviors such as these, they
perceive their close friendships as higher quality and are seen as more popular with their peer
group as a whole (Čavojová, 2012; Oberle, Schonert-Reichl, & Thomson, 2010; Soenens et
al., 2007).
 Empathy in Adolescence 177

Although ample research has investigated the role of empathy in determining adolescent
friendship outcomes at the individual level, limited research has examined the role of
empathy in impacting friendship quality at the level of the friend dyad. Because the
cognitions, emotions, and behaviors of friends are often mutually interdependent, this
research is crucial for gaining a better understanding of how empathy impacts the quality of
friendships (Hatfield, Cacioppo, & Rapson, 1993). This research indicates that taking the
perspective of a friend during times of distress predicts more positive perceptions of
friendship quality on the part of the friend, even when controlling for the friend‘s perspective
taking skills (Smith & Rose, 2011). Furthermore, adolescents‘ empathy, as well as
understanding and expectations of friends‘ empathic concern, increase and become more
similar to their friends‘ expectations from early to mid-adolescence (Clark & Bittle, 1992).
Gender differences in this research indicate that girls have higher expectations of empathy,
and also perceive more empathy, from friends than boys (Clark & Bittle, 1992). This is
consistent with research suggesting that females are higher in empathy than males during
adolescence (de Wied et al., 2007; Garaigordobil, 2009). These gender differences may be
due to differences in social priorities of girls and boys during adolescence. Specifically,
adolescent girls may be concerned with developing close interpersonal relationships, whereas
adolescent boys may be most concerned with dominance hierarchies and competition with
peers (Kobak, Cole, Ferenz-Gillies, Fleming, & Gamble, 1993; Panksepp, 1998). Because
males are attempting to establish dominance in their peer groups, they may try to prove their
resilience by avoiding emotional displays of empathy with peers.
Recent research has investigated the dyadic impacts of empathic concern and perspective
taking on closeness and discord in adolescent friendships. This research examined how these
relationships might be explained by adolescents‘ abilities to engage in emotional support and
conflict resolution, which are aided by their empathic perspective taking skills (Chow et al.,
2013). Specifically, this study examined empathy (measured as the average of empathic
concern and perspective taking), intimacy and conflict management competence, and
friendship closeness and discord in adolescents and their same-sex friends. Actor-Partner
Interdependence Model (APIM) analyses showed that adolescents high in empathy held more
intimacy competence, which led to perceptions of more closeness in friendships, from both
adolescents and their friends. Further, adolescents high in empathy demonstrated more
conflict management competence, which led to perceptions of less discord in friendships,
from both adolescents and their friends. These findings indicate that adolescents high in
empathy are more skilled in engaging in self-disclosure, emotional support, and conflict
management, which leads to more closeness and less conflict in their friendships.
Furthermore, this research suggests that adolescents are perceptive of their friends‘
willingness to engage in these intimate behaviors, which leads to perceptions of more
closeness and less discord for both adolescents and their friends.
Although the majority of research on empathy and perspective taking skills during
adolescence suggests that these traits are related to positive relational outcomes, some
findings indicate that perspective taking may have certain drawbacks in adolescent
relationships. Specifically, perspective taking has been found to be related to more empathic
distress in girls‘ friendships (Smith & Rose, 2011). This relationship was found to be
mediated by co-rumination over friends‘ problems. In other words, when adolescent girls
become preoccupied with their friends‘ stressors, due to excessive discussion about the
stressors, they may feel more distress on behalf of their friends. These distressed feelings may
178 Holly Ruhl and Chong Man Chow

include worrying about their friends, feeling upset because their friend is going through a
difficult time, or having trouble feeling okay if their friend is not feeling okay. It is important
to note, however, that regardless of the mediating effect of co-rumination found on distress, it
is difficult to establish causality in this scenario. For instance, it is also possible that co-
rumination is a commonly occurring behavior in female adolescents that may actually emerge
from empathic distress over a friend‘s stressors (Rose, 2002). With regard to the outcomes of
empathic distress, an unpublished study on friendship quality during adolescence suggests
that adolescents‘ reports of personal distress in a friendship predict negativity and conflict
within the friendship (Buhrmester, 1992). Taken together, these findings indicate that
empathy can at times have negative psychological and relational outcomes during
adolescence. Thus, it is important to consider all facets of empathy in friendships during
adolescence, rather than presupposing only positive outcomes of empathy during this period
in life. Because these negative outcomes of empathy have only begun to be explored, more
research is necessary to determine the extent to which empathy may be detrimental to
friendships, especially because no research has examined the role of empathic distress in male
relationships. Further, research should consider the causal processes of stressors, co-
rumination, and empathic distress to determine which of these constructs begets the others.

Empathy and Adolescent Romantic Relationships

Although the emergence of romantic relationships represents an important developmental

milestone during adolescence, limited research has examined the role of empathic concern
and perspective taking in determining romantic relationship outcomes during this time period.
Although some research indicates that individuals often show even more empathic concern
for romantic partners than friends (Pinkus, Lockwood, Schimmack, & Fournier, 2008),
existing findings on the role of empathy and perspective taking in romantic relationships are
mixed. For instance, some research has found no relationship between perspective taking and
relationship satisfaction at the individual or dyadic level (Steins, 2006). Similarly, some
research suggests no relationship between empathic concern and relational support, or
between empathy and relational responsiveness in romantic relationships (Devoldre et al.,
2010; Ebesu Hubbard, 2001). Interestingly, some research has found that perspective taking,
as opposed to objectively attending to cues from a partner, causes individuals to overestimate
their own transparency to their partners regarding their own feelings, values, and preferences,
which can actually lead to decreased relationship satisfaction (Vorauer & Sucharyna, 2013).
In contrast, some research has found evidence that perspective taking is related to
relationship satisfaction in adolescent and young adult romantic relationships, even after
accounting for disclosure of personal information in the relationship (Franzoi et al., 1985).
These findings suggest that perspective taking contributes to more positive romantic
relationship experiences because it helps adolescents anticipate partners‘ responses to their
behaviors before they engage in such behaviors, which contributes to a smoother intercourse
between romantic partners (Franzoi et al., 1985). Similar to perspective taking, some research
suggests that empathic concern is also an important determinant of romantic relationship
quality and satisfaction in the relationship (Cramer, 2003; Davis & Oathout, 1987). This is
likely because empathic concern contributes to adolescents‘ and young adults‘ warmth,
 Empathy in Adolescence 179

communication skills, and positive outlook in their romantic relationships (Davis & Oathout,
1992).
Research on romantic dyads suggests that partners‘ perceptions of perspective taking in
the relationship may be even more important in determining relationship satisfaction than
young adults‘ own perceptions of their perspective taking skills, in that perceptions of
partners‘ perspective taking contribute to more relational satisfaction, whereas an individual‘s
own perspective taking does not (Meeks, Hendrick, & Hendrick, 1998). This may be because
perspective taking is related to positive relational behaviors such as affective support,
sensitivity, even-temperedness, warmth, and willingness to forgive partners, which may be
received positively by partners (Brown, 2003; Davis & Oathout, 1992; Devoldre et al., 2010).
Because romantic relationships most commonly consist of opposite-sex partners, the
possibility of gender differences exists. Indeed, some research has found gender differences in
empathy in romantic relationships. Specifically, research suggests that females report more
perspective taking and empathic concern in their romantic relationships than males (Britton &
Fuendeling, 2005; Davis & Oathout, 1987). Furthermore, research on romantic dyads
suggests that females‘ abilities to take the perspective of their romantic partner play a
significant role in their male partners‘ relationship satisfaction, whereas males‘ perspective
taking abilities do not significantly impact their female partners‘ relationship satisfaction
(Franzoi et al., 1985). Because females have been found to endorse affective relational
support more so than males, this gender difference in relationship satisfaction may be
explained by findings that perspective taking skills predict more affective relational support,
but not instrumental relational support (Burleson, Kunkel, Samter, & Werking, 1996;
Devoldre et al., 2010). It is important to note, however, that not all research has shown gender
differences in empathy and relationship satisfaction in romantic relationships. For instance,
Haugen, Welsh, and McNulty (2008) found that empathic accuracy in understanding partners‘
conflict and feelings of discomfort predicted more relationship satisfaction for adolescent
boys and girls, as perceived by both the adolescent and their romantic partner. These
differences in findings may be due to differences in the conceptualization of empathy as the
distinct constructs of empathic concern and perspective taking.
Overall, research on the role of empathy in adolescent peer relationships consistently
demonstrates the importance of empathic concern and perspective taking in developing
positive peer relationships, especially with regard to friendships. This research indicates that
these skills enable adolescents to effectively offer support and manage conflict with peers,
which promotes more positive perceptions of relationships from both adolescents and their
peers. Further, females appear to be higher in empathy than males, and the impact of partners‘
empathy may play differing roles for males‘ and females‘ relationship satisfaction during
adolescence. It is important to note that the role of empathy in adolescent friendships should
not be viewed through rose-colored glasses. In fact, recent research indicates that certain
aspects of empathy (i.e., perspective taking, empathic distress) can inadvertently lead to
decreases in romantic relationship satisfaction, as well as co-rumination, conflict, and
negativity in adolescent friendships (Buhrmester, 1992; Smith & Rose, 2011; Vorauer &
Sucharyna, 2013). Thus, it is important that research continue to examine the circumstances
that surround negative outcomes of adolescent empathy.
180 Holly Ruhl and Chong Man Chow

EXISTING SHORTCOMINGS AND FUTURE DIRECTIONS

Since the initiation of research on adolescent empathy, developmental psychologists have
learned a great deal about how familial factors contribute to the development of adolescent
empathy, and how empathy may have implications for the development of social competence.
In this final section, we will discuss several common shortcomings in existing literature on
adolescent empathy and how future research may address these issues.
First, most existing research has relied on questionnaire methods to capture empathy-
related constructs. Although questionnaire assessments are the most convenient and direct
way to measure empathy, self-report measures are subject to individual biases. Some research
efforts have attempted to address this issue by examining cross-informant data (e.g., Chow et
al., 2013); however, this approach cannot completely resolve the issue of self-report bias. We
suggest that developmental psychologists begin to utilize innovative paradigms that have
been developed by social psychologists to capture empathy. An approach that integrates
different types of measures (e.g., behavioral observations of empathy skills) could be useful
for obtaining more accurate reports of empathy-related constructs. For instance, Ickes (1993)
developed an experimental procedure, the empathic accuracy paradigm, which captures how
accurately individuals infer their partners‘ feelings and thoughts by comparing reports from
both members. Whereas Ickes‘ empathic accuracy paradigm has been widely used in social
psychology research, there are few developmental studies that have utilized this paradigm to
measure empathy among adolescents (see exceptions, Gleason et al., 2009; Haugen et al.,
2008). We believe that such an approach may help to achieve a more objective assessment of
empathy, which should be fruitful for developmental research.
Another avenue for measuring empathy lies in autonomic measures of affective arousal
and neurological measures of empathy. A review of methods for measuring empathy suggests
that empathy consists of distinct processes that are represented differently in the brain and
that neuroimaging and physiological measures of empathy can be extremely useful in
assessing these processes (Gerdes, Segal, & Lietz, 2010). For instance, fMRI imaging has
shown that empathic accuracy and the ability to cognitively process others‘ feelings are
represented in two distinct areas of the brain (Gerdes et al., 2010; Zaki, Weber, Bolger, &
Ochsner, 2009). This study also found significant correlations between this brain activity and
subjective feelings of empathy. Research using physiological measures of empathy (e.g.,
heart rate, skin conductance) has also found high correlations between empathic accuracy and
physiological signals (Gerdes et al., 2010; Levenson & Ruef, 1992). However, this study did
not find evidence that physiological signals are related to self-reports of empathy. In contrast,
similar research has found correlations between patient-therapist skin conductance
concordance, patient-perceived therapist empathy, and self-reports of positive social-
emotional interactions (Gerdes et al., 2010; Marci, Ham, Moran, & Orr, 2007). Although
these measurement methods have only recently been used in conjunction with self-report
measures, they show much promise in helping researchers to understand how empathy is
represented in the developing adolescent brain. It is important to note, however, that before
researchers can truly begin to fuse methods from different backgrounds in studying empathy,
it is imperative that a consensus is formed regarding the mere conceptualization and
operationalization of empathy. Because neurological evidence supports, and augments, the
theory that empathy consists of affective and cognitive components, we recommend that
 Empathy in Adolescence 181

researchers consider this line of research in their attempts to advance the concept of empathy
in the future (Singer, 2006; Zaki et al., 2009).
Second, most of the studies reviewed in this chapter are based on cross-sectional data.
The lack of innovation in research design, namely longitudinal methods, may prevent
developmental psychologists from understanding the complex developmental nature of
empathy during adolescence. For instance, we know little about whether empathy-related
constructs continue to develop over the normative course of adolescence. Furthermore, we
know little about individual differences in the stability and change in empathy, and how these
individual differences may be explained by early familial factors, including parenting styles
and parent-child relationship quality. Although the model that guided the current chapter
(Figure 1) implies a causal chain from familial factors to social competence through empathy,
bidirectional influences between these variables are certainly possible. For example, it is
possible that adolescent empathic concern and perspective taking may promote better parent-
child relationship quality and encourage warm and supportive parenting styles. It is also
possible that well-adjusted peer relationships, above and beyond parent-child relationships,
may lead to the development of empathic capability during adolescence. We believe that
utilizing longitudinal methods will be a vital step toward addressing these bidirectional
hypotheses.
Finally, most research on adolescent empathy has focused on the ―positive‖ components
of empathy: empathic concern and perspective taking. As previously mentioned, the concept
of personal distress, or empathic distress, has been largely ignored (Smith & Rose, 2011). To
our knowledge, only one study has investigated the link between parenting and the
development of adolescent personal distress (Eisenberg & McNally, 1993). Furthermore,
developmental psychologists have only recently begun to examine the paradoxical effects of
empathy on relational and psychological functioning (Smith & Rose, 2011; Vorauer &
Sucharyna, 2013). Given that empathic distress might represent a uniquely important
component of empathy, future research should focus on the developmental precursors and
outcomes of this construct. Before considering the precursors and outcomes of empathic
distress, however, research should further examine the true nature of empathic distress.
Although most developmental research presumes that this construct is distinct from other
empathy components (i.e., empathic concern and perspective taking), it is possible that
empathic concern is a negative artifact of the more normative empathic concern component of
empathy. In support of this idea, research has found that empathic concern and empathic
distress are positively correlated for males (Davis, 1983). It is possible that this extreme form
of empathic concern depends upon the extent to which adolescents are insecurely attached to
their partners, engage in an overinvolved support-giving style, or perceive that their partner is
vulnerable and in need of help (Chow & Buhrmester, 2011; Erlanger, 1996; Watt, 2007). For
instance, an adolescent who engages in overinvolved and enmeshed support-giving may take
on a friend‘s problems and subsequently feel burdened by them (Chow & Buhrmester, 2011).
Thus, it is important that future research consider the source of empathic distress and the
extent to which it is truly distinct from empathic concern.
182 Holly Ruhl and Chong Man Chow

SUMMARY
From a developmental viewpoint, the current chapter reviewed the socialization of
empathy during adolescence and the relational corollaries of empathy in peer relationships. In
general, adolescent empathy appears to be due to several familial factors, including genetic
contributions, parenting practices, and parent-child relationship quality. Further, dispositional
empathy during adolescence is related to a number of relational competencies, such as
support-giving skills, conflict resolution skills, and prosocial behaviors. These competencies
appear to primarily support positive social interactions, leading to more relationship
satisfaction with friends and more peer acceptance.

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In: Psychology and Neurobiology of Empathy ISBN: 978-1-63484-446-8
Editors: Douglas F. Watt and Jaak Panksepp © 2016 Nova Science Publishers, Inc.

Chapter 7

GENDER ROLES, NOT ANATOMICAL SEX, PREDICT

SOCIAL COGNITIVE CAPACITIES, SUCH AS EMPATHY
AND PERSPECTIVE-TAKING

Jennifer Vonk1,, Patricia Mayhew2

and Virgil Zeigler-Hill1
1
Oakland University, Rochester, MI, US
2
University of Southern Mississippi, Hattiesburg, MS, US

ABSTRACT
Sex differences have not been examined thoroughly with regard to cognitive skills of
typically-developed adults in both social and non-social domains. Furthermore, studies
that do examine the effects of anatomical sex rarely simultaneously examine the possible
role of psychological gender role orientation. This gap in the literature exists despite
commonly held notions about possible sex differences in perspective-taking, empathy,
and causal reasoning. We examined the associations between sex, gender roles, and self-
esteem, and aspects of social and non-social cognition (e.g., perspective-taking, empathy,
emotional intelligence, social and physical causal reasoning, systemizing) in two college
student samples. These indicators of social and non-social cognition were more closely
associated with masculine and feminine gender roles than anatomical sex.
Undifferentiated individuals (i.e., those with low levels of both masculinity and
femininity) displayed deficits in social and non-social cognition. In addition, men with
low levels of masculinity showed decreased perspective-taking and increased personal
distress. These findings support the idea that the influence of psychological gender roles
extends beyond anatomical sex with regard to social cognitive abilities.

Keywords: gender role, sex, empathy, perspective-taking, causal reasoning, social cognition


Corresponding Author: Jennifer Vonk, Department of Psychology, Oakland University, 2200 N. Squirrel Rd,
Rochester MI, 48309, vonk@oakland.edu.
188 Jennifer Vonk, Patricia Mayhew and Virgil Zeigler-Hill

INTRODUCTION
There is a paucity of research connecting gender roles and gender identity, rather than
anatomical sex, to well-known cognitive constructs such as theory of mind, cognitive
empathy, and emotional intelligence, of which empathy may be a key component.
Admittedly, ‗sex‘ itself is a nebulous construct that involves a myriad of factors, including
genetics, anatomy, hormones, and brain development (see Panksepp & Biven, 2012). We do
not attempt to elucidate what is surely a complex relationship between anatomy, genetics,
brain ‗genderization,‘ and gender role socialization in this chapter. Rather, we are interested
in comparing the contributions of one‘s anatomical sex and one‘s psychological gender role
orientation to various aspects of social cognition, given that previous investigations have
focused on anatomical sex alone (Eisenberg & Lennon, 1983). We wish to make clear from
the outset that we do not imply that anatomical sex tells the complete story of one‘s biological
identity, nor that gender identity is completely independent of biology. Such determinations
are beyond the scope of the current work. However, it is of interest to examine potential
differences in social cognitive skills in individuals who (a) differ in anatomy but share gender
orientations or (b) share anatomical features of a particular sex but differ in gender
orientation. We focus on gender as a psychological construct in which individuals identify
more strongly with a set of traits defined as masculine or feminine using somewhat traditional
definitions that we admit may soon become antiquated. We are not particularly concerned
with whether these gross labels really map on to anatomical, genetic, or biological aspects of
sex, but we examine whether such traits, regardless of their etiology, are predictive of social
cognitive skills such as empathy, theory of mind, and emotional intelligence. Empirical tests
of such hypotheses are important given common ‗popular‘ notions about sex differences in
empathy and perspective-taking (Eisenberg & Lennon, 1983).
The glaring omission in the literature on social cognition is surprising given the potential
importance of gender roles to social cognitive skills. Prior research has focused on the
possible advantage for androgynous individuals in self-esteem (Bem, 1974; Buckley &
Carter, 2005; Lamke, 1982; Spence, Helmreich, & Stapp, 1975), and social competence
(Heilbrun, 1981), whereas others have focused on differences in masculine and feminine traits
with regard to psychological traits such as empathy (Jose, 1989; Karniol, Gabay, Ochion &
Harari, 1998; Lauren & Hodges, 2009), openness to diversity (Miville et al., 1999), and
instrumental versus expressive behavior (Holmbeck & Bale, 1998). However, researchers
have not fully investigated differences in cognitive ability, particularly with regard to
different realms of reasoning such as social and non-social reasoning. This is potentially
important because of observations concerning sex differences in the degree to which
individuals engage in systemizing (i.e., concern for rules and structures) and empathizing
(i.e., concerns with the thoughts and feelings of others) such that males are more likely to
systemize, whereas females are more likely to empathize (Auyeung et al., 2009; Carroll &
Yung, 2006; Vorachek & Dressler, 2006). Individuals with autism spectrum disorder (ASD)
tend to report high scores on measures of systemizing but show deficits in empathy (e.g.,
Baron-Cohen, Knickmeyer, & Belmonte, 2005). These findings have led Baron-Cohen (2000)
to suggest that autism may represent an extreme form of the typical male brain. It is important
to determine whether these trends are determined by one‘s sex (which is a culmination of
anatomy, genetics, and hormones) or may be a function of the differential socialization of
 Gender Roles, Not Anatomical Sex, Predict Social Cognitive Capacities … 189

males and females to embrace masculine versus feminine gender roles (c.f. Bem, 1974;
Karniol et al., 1998). Notably, we are not suggesting that biological and sociocultural factors
are independent, nor that the expression of masculine and feminine traits are independent of
underlying physiology, but rather that the extent to which an individual displays traits that
have been historically typified as masculine or feminine may be more predictive of their skills
in social and non-social aspects of reasoning, relative to contributions of their biological or
anatomical sex as male or female. That is, we expect that the extent to which males and
females show high levels of empathy, perspective-taking, and emotional intelligence may
depend more on the extent to which they embody psychological traits that have previously
been identified as masculine or feminine (Bem, 1974).
We are particularly interested in social reasoning as it pertains to theory of mind, also
known as perspective-taking – the ability to reason about the mental states of others. Empathy
– the ability to share and relate to the feelings of others is a closely related construct.
Although empathy is comprised of multiple facets – an affective component, which includes
emotional contagion/affective resonance and sympathy toward another‘s emotional state, as
well as a cognitive component, which includes the capacity to recognize the emotional states
of others, and reflect upon those states, here we focus on the cognitive aspect, namely the
tendency to focus attention on and relate to others‘ thoughts and feelings. Furthermore, the
ability to assess one‘s own capabilities in these domains of both empathy and theory of mind,
taken together with high levels of social functioning comprise the construct of emotional
intelligence. Thus, here we assess theory of mind, social reasoning, empathy, and emotional
intelligence together as part of an overarching construct of social cognition. We assess
systemizing and physical causal reasoning as comparable components of non-social
cognition.
Despite a rapidly growing literature concerning domains of reasoning, few studies have
directly addressed differences in reasoning about psychological causes or social events and
reasoning about physical causes or events in analogous tasks in typically-developed
populations. Wakabayashi, Sasaki, and Ogawa (2012) compared performance on the
empathizing quotient and the intuitive physics task, and found sex differences only with
empathizing such that women had higher scores than men. However, the two tasks were not
comparable. Differences in social and non-social reasoning have been explored primarily in
atypical populations such as individuals with autism spectrum disorder or schizophrenia
(Langdon et al., 1997) but in many of these studies the tasks that were designed to measure
the two processes were not perfectly analogous and thus not easily compared (Apperly,
Samson, Chiavarino, Bickerton, & Humphreys, 2007; Apperly, Samson, & Humphreys, 2005;
Iao, Leekam, Perner, & McConachie, 2011; Zaitchik, 1990) and individual differences in
healthy adults have been generally neglected. It is important to note that Russell, Tchanturia,
Rahman, and Schmidt, (2007) found a somewhat surprising advantage for men on both the
social and non-social versions of Happe‘s stories. Others have recently found that women are
better at recognizing emotions from both expressions and bodily posture in point-light
displays (Alaerts, Nackaerts, Meyns, Swinnen, & Wenderoth, 2011), which extends the
advantage for females in assessing emotion from the eyes (Baron-Cohen, 2001) to the
interpretation of body language. Recognition of another‘s emotional state, either from
outward expressions, postures, or from an inference to underlying mental states, is a
necessary component of cognitive empathy, and also rests upon perspective-taking capacities.
Thus, it is important to develop comparable tests of social and non-social reasoning and
190 Jennifer Vonk, Patricia Mayhew and Virgil Zeigler-Hill

examine the contribution of psychological gender roles, as well as sex, in non-clinical

populations.
The relatively small but robust findings of sex differences that have emerged suggest the
existence of sex-based differences in social and non-social reasoning that may have their
origins in biology, socialization, or both. It is difficult to tease apart the effects of biology and
differential socialization as many established sex differences could be the result of a complex
interaction between biological and social environmental factors (see Panksepp & Biven,
2012). However, our goal for the present study was to provide an initial investigation
concerning these sex differences by using sex and gender role endorsement as unique
predictors of various aspects of social and non-social cognition. Here we utilize a new, more
detailed measure to assess causal reasoning in both social and non-social domains (Vonk et
al., 2013) in a non-clinical adult population and determine whether their performance is
predicted by their sex, their psychological traits of masculinity or femininity (i.e., gender
roles), or an interaction of the two.
We expected that women would outperform men on tasks concerning social reasoning
and that men would outperform women on tasks concerning non-social reasoning. We also
anticipated that the degree to which an individual was characterized as either masculine or
feminine might have greater influence on their theory of mind, empathy, emotional
intelligence, and social and physical reasoning skills than sex alone. We expected individuals
with a high degree of feminine traits – regardless of their sex – to show greater empathy,
emotional intelligence, and theory of mind. If gender roles are important for the development
of social skills, then psychological traits of gender role may have a greater impact on social
cognition than underlying biology. At the same time, it is important to note that biology
undoubtedly plays a role in the expression of gender-typed traits– a topic that has often been
ignored in the discussion of gender role and psychology (Berenbaum, Blakemore, & Beltz,
2011; Blakemore, Berenbaum, & Liben, 2009). Although genetics certainly play a role in the
expression of various traits (e.g., assertiveness, empathy), it is also likely that these traits are
also influenced to a large extent by experiences in both the social and physical environments.
Thus particular characteristics may arise as a result of a complex dyadic relationship between
genetic and environment. As an example, Pollack (1999) has written about the detrimental
effects of the ―boy code‖ in which males are socialized to repress their feelings and assert
their dominance. However, there is a growing trend to defy stereotypical gender roles by
fostering nurturance and emotional expression in boys at the same time that girls are being
taught to be more assertive and confident. Therefore, it is possible to obtain a sample in which
men and women vary in the extent to which they exhibit traditionally masculine or feminine
traits. If gender roles have an impact on social cognition beyond sex, then these results may
have important implications for gender-typing. In the studies described here, we were not able
to determine genetic or hormonal differences in our participants and refer to sex only with
regard to the external anatomy of the participants. We were not concerned with differences in
underlying hormone levels or with sexual orientation, but merely in the relationship between
gender-typical psychological characteristics and social cognitive traits.
 Gender Roles, Not Anatomical Sex, Predict Social Cognitive Capacities … 191

STUDY 1
Method

Participants and Procedure. Participants were 152 undergraduate psychology students

(114 women, 38 men) at the University of Southern Mississippi who participated in exchange
for course credit. Participants responded to a series of online questionnaires via a secure
website.
Measures. Our predictions concerned sex and gender roles, which we assessed using the
well-known Bem Sex-Role Inventory (BSRI; Bem, 1974). We included a measure of self-
esteem (Rosenberg Self-Esteem Scale; Rosenberg, 1965) to control for feelings of self-worth
in our analyses. In addition, we included impression management (IM) and self-deceptive
enhancement (SDE) from the Balanced Inventory of Desirable Responding (BIDR, Paulhus,
1984) to control for socially desirable response distortion. We included a number of
instruments that captured aspects of social and physical cognition as our criterion measures,
including theory of mind (Reading the Mind in the Eyes Test; Baron-Cohen, Wheelwright &
Hill, 2001), empathy (Empathizing Quotient [Baron-Cohen & Wheelwright, 2004] and
Interpersonal Reactivity Index [Davis, 1983]), systemizing (Systemizing Quotient; Baron-
Cohen, Richler, Bisarya, Gurunathan & Wheelwright, 2003), and emotional intelligence
(Self-Report Emotional Intelligence Scale; Schutte et al., 1998).
Bem Sex-Role Inventory. The BSRI consists of 60 traits, including 20 masculine traits, 20
feminine traits, and 20 neutral traits. Participants were asked to indicate the extent to which
each trait described them using a seven point scale, ranging from ―almost never describes me‖
to ―almost always describes me.‖ Masculinity ( = .87) and femininity ( = .88) were
assessed by summing the scores on the masculine items and the feminine items, and dividing
by the number of items to reach an average masculinity and femininity score. The factor
structure of the BSRI has been well validated over the years in both North American (Choi,
Fuqua, & Newman, 2007; Holt & Ellis, 1998; Walkup & Abbott, 1978) and international
samples (Reed-Sanders, Dodder, & Webster, 1985; Wilson et al., 1990), although the ability
of the two dimension model to capture the complex nature of masculinity and femininity has
been questioned by other researchers (Choi & Fuqua, 2003). However, some of the debate
surrounding modern use of the scale centers around the finding that masculinity and
femininity may not be orthogonal, and is not a problem if individuals are considered
androgynous when scoring high on both factors.
In our sample, a score of 4.9 was used as a cut-off in determining whether someone was
scored as high in feminine or masculine traits, as proposed by Bem (1974). Participants who
scored lower than 4.9 on both scales were considered undifferentiated. Participants who
scored higher or equal to 4.9 on both scales were considered androgynous for classification
purposes, although we treated masculinity and femininity as continuous variables in our
study, with undifferentiated individuals being those who scored low on both and androgynous
individuals being those who scored high on both femininity and masculinity.
Rosenberg Self-Esteem Scale. The Rosenberg Self-Esteem Scale (Rosenberg, 1965)
served as the measure of self-esteem. The Rosenberg Self-Esteem Scale is a well-validated
measure of global self-esteem (Blascovich & Tomaka, 1991) that consists of 10 items (e.g.,
―I feel that I have a number of good qualities‖). Participants were instructed to report how
192 Jennifer Vonk, Patricia Mayhew and Virgil Zeigler-Hill

they typically feel about themselves on scales ranging from 1 (strongly disagree) to 5
(strongly agree). For the present study, the internal consistency of this measure was  = .88.
Balanced Inventory of Desirable Responding. The BIDR (Paulhus, 1984) is a 40-item
measure that was designed to detect socially desirable response distortions. This instrument is
comprised of two subscales referred to as self-deceptive enhancement (20 items; e.g., ―I have
not always been honest with myself‖;  = .83) and impression management (20 items; e.g., ―I
have received too much change from a salesperson without telling him or her‖;  = .82). The
self-deceptive enhancement subscale captures an unintentional distortion of self-image,
whereas the impression management subscale captures a deliberate distortion of one‘s public
image. Participants were asked to respond on scales ranging from 1 (not true) to 7 (very true).
This instrument is counterbalanced such that there are equal numbers of positively and
negatively keyed items and uses a dichotomous scoring system with responses of 6 or 7 being
assigned a score of 1and responses between 1 and 5 being assigned a score of 0. We included
this measure to control for the possibility that women might be more inclined to report higher
levels of empathy and femininity, for example, based on the idea that it would be desirable to
do so, rather than because these were truthful responses.
Eyes Test. The Reading the Mind in the Eyes Test (Baron-Cohen et al., 2001) was used to
assess underlying emotions, as one aspect of perspective-taking or theory of mind. It consists
of 36 images of eyes. Participants are asked to choose the best response to describe the
feeling or thought projected in the image from four alternatives,  = .70.
Interpersonal Reactivity Index. The Interpersonal Reactivity Index (IRI) is a 28-item
empathy scale consisting of four subscales measuring perspective-taking, empathic concern,
personal distress, and fantasy (Davis, 1983). The perspective-taking scale is the positive
aspect of cognitive empathy and contains such statements as ―I sometimes try to understand
my friends better by imagining how things look from their perspective,‖  = .71. Empathic
concern is the positive aspect of emotional empathy and is measured based on statements
including ―I often have tender, concerned feelings for people less fortunate than me,‖  = .77.
Fantasy represents the negative outcome of cognitive empathy,  = .70, while personal
distress represents the negative outcome of emotional empathy,  = .60. Personal distress can
also be seen as reflecting contagion/resonance and is a necessary component of empathy,
despite its potentially negative consequences. Although not without detractors, the IRI is thus
an inclusive measure of empathy.
Empathizing Quotient. An additional measure of empathy, the Empathy Quotient (EQ),
developed by Baron-Cohen and Wheelwright (2004), consisted of 40 statements, such as ―I
can pick up quickly if someone says one thing but means another‖ and ―Seeing people cry
doesn‘t really upset me.‖ Participants were required to rate on a 4-point scale the degree to
which they agreed with the statements,  = .90. Thus, the EQ is a self-report measure that
captures the extent to which individuals believe themselves to be attuned to the feelings of
others. It is also believed to capture both cognitive and affective components of empathy.
Systemizing Quotient. Systemizing is focused on predicting behaviors of inanimate
objects based on the laws of the universe rather than predicting another person‘s behavior.
The Systemizing Quotient (SQ; Baron-Cohen, 2003) consists of 75 items measured on a 4-
point scale from strongly disagree to strongly agree (e.g., ―I like music or book shops
because they are clearly organized‖),  = .69.
 Gender Roles, Not Anatomical Sex, Predict Social Cognitive Capacities … 193

Emotional Intelligence Scale. The Emotional Intelligence scale (EIS; Schutte et al., 1998)
consists of 33 items and measures aspects of emotional intelligence including appraisal and
expression, regulation, and utilization of emotion (e.g.,‖ I find it hard to understand the non-
verbal messages of other people‖) and contains 33 items rated on a 5-point scale that ranged
from strongly disagree to strongly agree,  = .93.

Results

Sample Characteristics. Of the women, 39.1% were identified as androgynous, 27.0%

identified as undifferentiated, 27.8% identified as feminine and 5.2% identified as masculine,
according to the BSRI. Of the men, 31.6% were scored as androgynous, 34.2% as
undifferentiated, 34.2% as masculine and 0% as feminine. Thus, the BSRI was able to
identify both men and women that varied in degree of masculine and feminine characteristics,
indicating that the scale tapped into a construct that was more sensitive to the psychological
aspects of sex compared to determining anatomical sex alone. Although none of the men were
identified as feminine based on the median split method of scoring, we used a continuous
measure of masculinity and femininity in our analyses, and both men and women varied to
some extent on these measures. However, sex and gender roles were not completely
independent, as zero order correlations indicated that sex was correlated with masculinity but
not femininity (see Table 1).
Descriptive Statistics and Analyses. Table 1 presents the means, standard deviations, and
intercorrelations for the measures in the present studies (except for the control measures of
self-esteem and socially desirable responding). A series of hierarchical multiple regressions
were conducted in which each of the criterion variables was regressed on sex, masculinity,
femininity, self-esteem, impression management, and self-deceptive enhancement.
Masculinity, femininity and self-esteem were standardized for the purpose of testing
interactions. For these analyses, the main effect of sex was entered on the first step of the
model to remove effects of sex before identifying the influence of gender roles. Masculinity,
femininity, self-esteem, impression management, and self-deceptive enhancement were
entered on the second step of the model. The third step included the following interaction
terms: sex X masculinity and sex X femininity. The interaction between masculinity X
femininity and the three way interaction of sex, masculinity, and femininity were entered on
the fourth and final step. Examining the interaction between masculinity and femininity
allowed us to explore differences between individuals high in masculinity or femininity or
both (i.e., androgynous individuals), as well as individuals low in both masculinity and
femininity (i.e., undifferentiated individuals). A Bonferroni correction was made to adjust for
the number of analyses and the associated increase in the possibility of type 1 error. We
accepted as significant only results with p < .006. The results of these analyses are presented
in Table 2.
Systemizing. Masculinity was associated with higher levels of systemizing (β = .34,
t = 3.91, p < .001) as was self-deceptive enhancement (β = .25, t = 3.14, p =.002).
Empathy. Femininity was associated with higher levels of empathizing (β = .53, t = 6.38,
p < .001), as measured by the EQ.
Femininity was associated with higher levels of perspective-taking from the IRI (β = .52,
t = 6.05, p < .001) and fantasy (β = .50, t = 5.69, p < .001).
 Table 1. Correlations and descriptive statistics for the measures included in the present studies. Data from Study 1 is presented above
the diagonal and data from Study 2 is presented below the diagonal. Measures 8-11 are subscales of the IRI measure of empathy. Theory
of Mind represents scores from the eyes test

1 2 3 4 5 6 7 8 9 10 11 12 13
1. Sex — .22** -.29*** n/a n/a .13 -.18* -.10 -.15 -.24** -.22** -.01 -.04
2. Masculinity .12* — .41*** n/a n/a .41*** .18* .16* .09 .09 -.16* .53*** .18*
3. Femininity -.22*** .52*** — n/a n/a .19* .56*** .50*** .47*** .62*** .17* .63*** .27***
4. Social Reasoning -.03 .19*** .29*** — n/a n/a n/a n/a n/a n/a n/a n/a n/a
5. Physical Reasoning .01 .20*** .25*** .91*** — n/a n/a n/a n/a n/a n/a n/a n/a
6. Systemizing .07 .34*** .26*** .10*** .09 — .33*** .23** .09 .19* -.19* .38*** .11
7. Empathizing -.17*** .21*** .50*** .24*** .17*** .44*** — .67*** .39*** .72*** -.16* .58*** .29***
8. Perspective-Taking -.07 .21*** .46*** .22*** .21*** .29*** .60*** — .34*** .62*** .01 .45*** .10
9. Fantasy -.05 .12* .37*** .25*** .18*** .18*** .48*** .38*** — .52*** .28*** .35*** .21*
10. Empathic Concern -.13* .10 .52*** .26*** .21*** .28*** .69*** .69*** .52*** — .07 .48*** .30*
11. Personal Distress -.18*** -.10* .15*** .06 .04 -.08 -.05 -.04 .21*** .00 — -.09 -.15
12. Emotional -.05 .52*** .58*** .25*** .20*** .41*** .51*** .45*** .25*** .40*** -.02 — .25***
Intelligence
13. Theory of mind .01 .16** .24*** .33*** .31*** .14** .36*** .30*** .28*** .34*** -.13** .26*** —
Mean .24 5.00 5.15 247.23 202.97 53.53 36.66 2.49 2.44 2.68 1.90 3.74 22.96
Standard Deviation .43 0.87 0.88 47.08 43.30 17.46 13.61 0.65 0.71 0.72 0.61 0.57 4.93
*
p < .05; **p < .01; ***p < .001.
 Table 2. Hierarchical multiple regression analyses of social cognition onto sex, masculinity, femininity, self-esteem, and desirable
responding for Study 1. Perspective-taking, Fantasy, Empathic Concern and Personal Distress are subscales of the IRI measure of
empathy. Theory of Mind represents scores from the eyes test

Systemizing Empathizing Perspective- Fantasy Empathic Personal Emotional Theory

Taking Concern Distress Intelligence of Mind
Step 1 .02 .03* .01 .02 .06** .05** .01 .00
Sex .13 -.18* -.10 -.15 -.24** -.22** -.01 -.04
Step 2 .25*** .43*** .27*** .23*** .42*** .14*** .55*** .11*
Masculinity .34*** -.04 -.11 -.17* -.22** -.22* .29*** .05
Femininity .03 .53*** .52*** .50*** .66*** .25* .52*** .25*
Self Esteem .05 .09 .08 .14 .05 .03 .06 -.05
IM .02 .21** .10 .10 .06 -.02 .05 -.08
SDE .22** .14 .07 -.03 .11 -.20* .14 .17
Step 3 .27*** .48*** .28*** .24*** .44*** .22*** .56*** .12*
Sex X Masculinity .14 .33*** .15 -.07 .19* -.41*** .13 .04
Sex X Femininity -.21** -.15 -.15 -.01 -.12 .23* -.03 -.18
Step 4 .30*** .49*** .32*** .24*** .45*** .22*** .57*** .18***
Masculinity X .20* -.03 -.14 -.09 -.09 .18 -.16* -.29***
Femininity
Masculinity X -.23 -.16 -.27 .13 -.05 .07 .07 -.02
Femininity X Sex
*
p < .05; **p < .01; ***p < .001.
 Table 3. Hierarchical multiple regression analyses of social and physical cognition onto sex, masculinity, femininity, self-esteem, and
desirable responding for Study 2. Perspective-taking, Fantasy, Empathic Concern and Personal Distress are subscales of the IRI
measure of empathy. Theory of Mind represents scores from the eyes test

Social Non- Perspective- Empathic Personal Emotional Theory

Reasoning Social Systemizing Empathizing Taking Fantasy Concern Distress Intelligence of
Reasoning Mind
Step 1 .00* .00 .01 .03*** .01 .00 .02** .03*** .01 .00
Sex -.05 -.03 .09 -.18*** -.08 -.05 -.14** -.19*** -.07 -.02
Step 2 .08*** .06** .24*** .38*** .25*** .15*** .37*** .14*** .52*** .07***
Masculinity .02 .07 .29*** -.12* -.09 -.16* -.35*** -.28*** .21*** .06
Femininity .28*** .20** .03 .49*** .49*** .50*** .70*** .37*** .37*** .21**
Self Esteem -.04 -.04 -.10* -.09 -.06 -.11* -.07 -.04 .20*** -.10
IM .02 .03 .17** .10 .06 -.11 -.00 -.15* .03 -.04
SDE -.01 -.03 .21** .30*** .14* .15* .22*** -.07 .23*** .67
Step 3 .09*** .06** .24*** .38*** .25*** .15*** .37*** .15*** .53*** .09***
Sex X .14 .08 .03 .12 -.02 .04 .09 -.06 .13* .23**
Masculinity
Sex X -.11 -.03 .01 -.14* .06 -.09 -.06 -.04 -.02 -.07
Femininity
Step 4 .16*** .12*** .24*** .41*** .26*** .15*** .38*** .16*** .55*** .27**
Masculinity -.29*** -.26*** .08 -.10* -.08 -.07 -.13* .06 -.17*** -.44***
X Femininity
Masculinity -.05 -.02 -.03 -.10 -.08 -.06 -.00 .07 .06 -.06
X Femininity
X Sex
*
p < .05; **p < .01; ***p < .001.
 Gender Roles, Not Anatomical Sex, Predict Social Cognitive Capacities … 197

Higher levels of femininity were also associated with higher levels of empathic concern
from the IRI (β = .66, t = 8.59, p < .001) while higher levels of masculinity were associated
with lower levels of empathic concern (β = -.22, t = -2.85, p = .005).

Figure 1. Predicted values for Personal Distress from Study 1 are presented illustrating the interaction
of sex and masculinity (at values that are one standard deviation above and below its mean).

Figure 2. Predicted values for the Eyes Test from Study 1 are presented illustrating the interaction of
femininity and masculinity at values that are one standard deviation above and below their respective
means.

Sex interacted with masculinity to predict personal distress from the IRI (β = -.41,
t = - 3.84, p < .001). To probe this interaction, separate regressions were conducted for men
and women with masculinity, femininity, self-esteem, self-deceptive enhancement and
impression management as predictors. Men low in masculinity reported higher levels of
198 Jennifer Vonk, Patricia Mayhew and Virgil Zeigler-Hill

personal distress than men high in masculinity, (β = -.58, t = - 3.64, p = .001). As can be seen
in Figure 1, there was no effect of masculinity for females, who generally scored high on
personal distress.
Emotional Intelligence. Both Masculinity and Femininity predicted higher levels of
emotional intelligence (β = .29, t = 4.31, p < .001, and β = .52, t = 7.64, p < .001).
Theory of Mind. Femininity interacted with masculinity to predict performance on the
eyes test (β = -.29, t = -3.03, p = .003). Predicted values for this interaction are presented in
Figure 2. Simple slopes tests revealed that greater masculinity predicted higher scores for
those low in femininity, although the effect only approached conventional levels of statistical
significance (β = .30, t = 1.92, p = .06). In contrast, for those high in femininity, masculinity
had no significant effect. As can be seen in Figure 2, undifferentiated individuals scored more
poorly on the eyes test relative to those who were androgynous or masculine individuals who,
in turn, had lower scores than feminine individuals.

STUDY 2
In order to assess the reliability of our findings regarding the influence of gender roles on
social and physical cognition, we tested another larger sample with the same measures, along
with the addition of a novel measure of causal reasoning framed in both social and non-social
domains – the Social Physical Causal Reasoning Task (SPCRT; Vonk, Zeigler-Hill, Mayhew,
& Mercer, 2013).

Method

Participants were 390 undergraduate psychology students (296 women, 94 men) at the
University of Southern Mississippi who participated in exchange for course credit.
Participants responded to a series of online questionnaires via a secure website. This data is
part of a larger data set for which results were previously reported regarding the association
between narcissistic personality features and several of the social cognition measures reported
here (Vonk, et al., 2013).

Measures

We used the same measures as Study 1 with the addition of a measure of causal reasoning
in both social and physical contexts involving narratives that were loosely based on Happé‘s
stories (1994). Our measure (Vonk et al., 2013) was designed to tap into social and non-social
reasoning specifically with regard to the attention paid to predetermining events in the lives of
both humans and other objects or events. The measure consisted of 24 narratives (12 involved
a social context or mental state as the primary precipitating cause for the outcome and 12
involved a physical context with a mechanical or scientific cause for an outcome).
Participants were asked a series of analogous questions after each narrative that indicated
their propensity to attribute mental states as causes for actions, and to take past circumstances
 Gender Roles, Not Anatomical Sex, Predict Social Cognitive Capacities … 199

and characteristics into account, rather than considering only immediately precipitating
actions or events as causes for outcomes. Rather than having participants respond based upon
a single correct response (Bull, Phillips & Conway, 2008; Happé, 1994; Stone, Baron-Cohen
& Knight, 1998), our measure was concerned with differences in the type of cause attributed
to various events, with several possible attributions being correct, as well as the depth of
analysis displayed by participants.
Two raters independently scored the responses to the narratives. Narratives were scored
on the basis of inclusion of descriptive information (higher scores for more descriptive
content), attribution of mental state (higher scores to second order, then first order mental
state attributions versus other causal explanations), and attribution to immediate versus long-
term factors (higher scores for considering character‘s backstory and underlying traits versus
immediate precipitating event or action alone). Responses received the highest score if
participants took into account multiple factors that may have been responsible for the actions
of the character. The scores of the raters for four randomly sampled narratives including two
social and two physical scenarios (19 questions) for 67 of the 368 participants were correlated
to determine the reliability of the coding system. Their scores were highly correlated (r = .70,
p < .001) showing reasonable agreement.

Results

Sample Characteristics. Of the women, 44.9% were identified as androgynous, 24.7%

identified as undifferentiated, 22.6% identified as feminine and 7.4% identified as masculine,
according to the BSRI. Of the men, 39.4% were scored as androgynous, 25.5% as
undifferentiated, 23.4% as masculine and 11.7% as feminine. Thus, the BSRI was able to
identify men as feminine and women as masculine, indicating that the scale tapped into a
construct separate from sex. However, these measures were not completely independent, as
zero order correlations indicated that sex was correlated with masculinity but not femininity
(see Table 1), as with Study 1. In addition, independent samples t-tests indicated that males‘
and females‘ mean masculinity scores differed significantly, t = 4.48, p < . 001, CI = .26 - .66,
but their mean femininity scores did not, t = -1.73, p = .08, CI = -.38 - .02.
Descriptive Statistics and Analyses. Table 1 presents the means, standard deviations, and
intercorrelations for the measures in the present study (except for the control measures of self-
esteem, impression management, and self-deceptive enhancement). Social and non-social
causal reasoning were shown to be correlated, suggesting that the same reasoning processes
may have been evoked even when reasoning in different domains or contexts. This finding
suggests that either our task did not tap into two different domains of ability or that the ability
to reason in these two different domains will be highly correlated when the task is made to be
perfectly analogous. The same hierarchical multiple regressions from Study 1 were conducted
in which each of the criterion variables (with the inclusion of social and non-social or
physical reasoning) was regressed on sex, masculinity, femininity, self-esteem, impression
management, and self-deceptive enhancement. Once again, a Bonferroni correction was
applied such that alpha was set to .005.
Causal Reasoning. Masculinity and femininity interacted to influence social reasoning
(β = -.29, t =- 4.59, p < .001). An examination of Figure 3 reveals that those high in
femininity scored lower on the social reasoning task if they scored higher on masculinity
200 Jennifer Vonk, Patricia Mayhew and Virgil Zeigler-Hill

(β = -.17, t =-2.06, p = .04), whereas those low in femininity scored higher if they reported
high scores for masculinity (β = .18, t = 1.92, p = .06).

Figure 3. Predicted values for Social Reasoning from Study 2 are presented illustrating the interaction
of femininity and masculinity at values that are one standard deviation above and below their respective
means.

Masculinity and femininity interacted to influence physical (non-social) reasoning

(β = -.26, t =- 4.01, p < .001). An examination of Figure 4 reveals that those high in
femininity scored high on the physical reasoning task regardless of masculinity, whereas
those low in femininity scored higher if they possessed high levels of masculinity (β = .23,
t = 2.46, p = .01). Undifferentiated individuals performed more poorly on both types of causal
reasoning as compared to those high in masculinity, femininity, or both.

Figure 4. Predicted values for the Non-Social Reasoning Test in Study 2 are presented illustrating the
interaction of femininity and masculinity at values that are one standard deviation above and below
their respective means.
 Gender Roles, Not Anatomical Sex, Predict Social Cognitive Capacities … 201

Systemizing. Masculinity was associated with higher levels of systemizing (β = .29,

t = 4.53, p < .001) as was self-deceptive enhancement (β = .21, t = 3.12, p =.002), as in
Study 1.
Empathy. Femininity was associated with higher levels of empathizing (β = .49, t = 8.43,
p < .001) as was self-deceptive enhancement (β = .30, t = 4.95, p < .001), when empathy was
assessed with the EQ.
Femininity was associated with higher levels of perspective-taking (β = .49, t = 7.76,
p < .001) and fantasy (β = .50, t = 7.38, p < .001).
Higher levels of femininity were associated with higher levels of empathic concern
(β = .70, t = 11.92, p < .001) whereas higher levels of masculinity were associated with lower
levels of empathic concern (β = -.35, t = -6.02, p < .001). Self-deceptive enhancement also
predicted empathic concern (β = .22, t = 3.6, p < .001).
More feminine individuals reported higher levels of distress (β = .37, t = 5.45, p < .001)
whereas more masculine individuals reported lower levels of distress (β = -.28, t = - 4.19,
p < .001). Sex also predicted personal distress, with women reporting higher levels of distress
(β = -.19, t = - 3.60, p < .001).
Emotional Intelligence. Self-esteem (β = .20, t =5.07, p < .001) and self-deceptive
enhancement (β = .23, t = 4.19, p < .001) predicted higher levels of emotional intelligence.
Masculinity and femininity interacted to influence emotional intelligence (β = -.17, t = -3.74,
p < .001). Those high in femininity did not differ in terms of emotional intelligence as a
function of masculinity. However, those low in femininity reported higher emotional
intelligence if they were highly masculine, β = .27, t =4.26, p < .001 (Figure 5).

Figure 5. Predicted values for Emotional Intelligence in Study 2 are presented illustrating the
interaction of femininity and masculinity at values that are one standard deviation above and below
their respective means.

Theory of Mind. Femininity interacted with masculinity to predict performance on the

eyes test (β = -.44, t = -7.76, p < .001). Predicted values for this interaction are presented in
Figure 6. Simple slopes revealed that greater masculinity predicted higher scores for those
low in femininity (β = .28, t = 3.43, p = .001) but lower scores for those high in femininity
202 Jennifer Vonk, Patricia Mayhew and Virgil Zeigler-Hill

(β = -.25, t = -3.37, p = .001). Undifferentiated individuals scored more poorly on the eyes
test relative to those who were feminine, masculine, or androgynous.

Figure 6. Predicted values for the Eyes test in Study 2 are presented illustrating the interaction of
femininity and masculinity at values that are one standard deviation above and below their respective
means.

Figure 7. Predicted values for the Eyes test in Study 2 are presented illustrating the interaction of sex
and masculinity (at values that are one standard deviation above and below its mean).

Masculinity also interacted with biological sex to predict performance on the eyes test
(β = .23, t = 2.95, p = .003). Masculinity had no effect on performance for women but more
masculine men performed better on the eyes test than less masculine men (β = .39, t = 2.82,
p = .006).
 Gender Roles, Not Anatomical Sex, Predict Social Cognitive Capacities … 203

GENERAL DISCUSSION
In general, the results support our hypothesis that gender identity, or the extent to which
individuals possess what are stereotypically identified as predominantly masculine or
feminine traits, may be more closely associated with empathy and perspective-taking than the
anatomical sex of the individual. That is, even when sex was controlled for in our regressions,
we still obtained an influence of psychological gender role on aspects of social cognition such
as empathy, theory of mind, and emotional intelligence. The effects of sex were limited to
personal distress (contagion) and an interaction with masculinity regarding performance on
the eyes test in Study 2. The results across both studies were consistent in that masculinity
predicted higher scores on non-social scales, such as systemizing, whereas femininity
predicted higher scores on scales of social skills, such as empathy and theory of mind.
Femininity was consistently a strong predictor of variables associated with theory of mind,
self-awareness, and empathy, even when sex was controlled in the model. Both masculinity
and femininity predicted higher scores on emotional intelligence and causal reasoning in both
social and non-social contexts.
The importance of gender roles in influencing social cognition may not be terribly
surprising given prior findings (Lauren & Hodges, 2009) and the fact that feminine traits are
defined by Bem (1974) as those that exemplify nurturing and empathy (see also Gilligan &
Wiggins, 1988). Therefore, it is possible that the significant relationship between Bem‘s
gender roles and measures of empathy is explained solely by the overlap between the factors
assessed by the scales. However, the causal reasoning measure that we introduced in Study 2
and the eyes test assess abilities not measured by the sex role inventory, so the relationship
between gender identity and perspective-taking, as well as between gender role and causal
reasoning cannot be explained by similar overlap in the scales. Furthermore, it is somewhat
surprising that sex itself yielded such weak connections with social and non-social cognition.
Both highly masculine and highly feminine individuals, as well as androgynous
individuals reported greater causal reasoning, empathy (as measured by self-report assessing
both affective and cognitive components), and emotional intelligence. These individuals were
also better at assessing others‘ emotions using the eyes test. Although previous studies have
shown an advantage for more masculine women and more androgynous men in areas such as
self-esteem and psychological flexibility (Miville et al., 1999; Spence et al., 1975, although
see also Heilbrun, 1981 who found an advantage for androgynous males but not females),
there has been no prior evidence suggesting that such traits lead to better perspective-taking.
Undifferentiated individuals – who are low in both masculine and feminine traits (Bem, 1974)
– displayed difficulties with empathy, theory of mind, and causal reasoning, which again
suggests an advantage for both feminine and masculine traits. It is important to note that
including self-esteem in our analyses did not significantly alter the observed patterns. Thus,
the idea that greater self-esteem may contribute to higher levels of empathy and self-
awareness – especially in those who more fully endorse expected gender roles or show greater
androgyny – cannot fully account for our pattern of results. We did not examine the
possibility that empathy engenders greater self-esteem but the lack of zero order correlations
between self-esteem and any of our measures of empathy indicates that this is also not the
case. It is possible that individuals that are better at assessing the mental states of others are
both more likely to be nurturing and compassionate, thus exhibiting a high degree of
204 Jennifer Vonk, Patricia Mayhew and Virgil Zeigler-Hill

stereotypically traditional feminine traits, but are also more likely to be comfortable asserting
themselves with others and directing others, thus demonstrating a high degree of masculine
traits as well. With a correlational design, one simply cannot know much about causal
mechanisms and therefore can not speculate about the direction of the effects, but it seems
plausible that greater perspective-taking and empathic capabilities allow individuals to fully
express both masculine and feminine aspects of their personality.
We predicted that gender roles would interact with sex to produce these effects such that
feminine men might differ from masculine men in the extent to which they report feeling
empathy and demonstrating perspective-taking. We found minimal support for this prediction
in that sex interacted with masculinity alone, and solely with regard to personal distress in
Study 1 and theory of mind in Study 2. In both cases more masculine men were at an
advantage, relative to less masculine men – more masculine men had lower levels of personal
distress and higher scores on the eyes test. Advantages for feminine or masculine traits
appeared regardless of the sex of the individuals. Femininity was positively associated with
both cognitive and affective aspects of empathy as measured by Davis‘ (1983) IRI, whereas
masculinity was negatively associated with the affective components (empathic concern and
personal distress) but not associated with the cognitive components (perspective-taking and
fantasy). These results are consistent with earlier results suggesting a link between both
aspects of empathy and feminine characteristics. However, we have extended these findings
to an advantage for feminine characteristics on theory of mind tasks and measures of
emotional intelligence, as well as causal reasoning in both social and non-social domains.
Thus, the current findings suggest that the characteristics that are traditionally associated with
femininity are important for cognitive as well as emotional aspects of social cognition.
In addition, we found that gender roles as well as sex can explain differences in the
tendency to systemize rather than empathize. Stauder, Cornet, and Ponds (2011) examined
gender roles from the Minnesota Multiphasic Personality Inventory (MMPI) in relation to
individuals with ASD and control participants, but, although they examined empathizing and
systemizing (Baron-Cohen, 2009), they did not relate gender roles directly to these measures.
Our results demonstrate for the first time that such traits may be linked to psychological
gender as well as - or perhaps instead of - sex. We found a similar advantage for femininity in
social reasoning as well as non-social causal reasoning, which may indicate a greater attention
for detail in scenarios for those with more feminine traits. In addition, we found that feminine
individuals, regardless of sex and masculinity, performed better on the eyes test (Baron-
Cohen et al., 2001). Prior studies have found an advantage for females (Wakabayashi et al.,
2012) but gender roles have not been explicitly linked to tasks assessing theory of mind. Our
results may be consistent with prior research failing to find a link between digit ratio (a
biological marker and gender phenotype) and performance on Baron-Cohen‘s EQ, SQ and
Eyes test (Voracek & Dressler, 2006). However, it has also been noted that digit ratio may not
be the best test of prenatal hormone levels despite its common use as such (Dressier &
Voracek, 2011).
We also found that males who were low in masculinity performed relatively poorly on
the eyes test, which assesses perspective-taking – a critical aspect of theory of mind.
Furthermore, males who were low in masculinity exhibited much greater personal distress on
the IRI relative to males who were high in masculinity and even in comparison to females
who also had high scores for personal distress. Personal distress reflects the potential costs of
affective empathy where one may be overwhelmed by feelings of sadness for another‘s
 Gender Roles, Not Anatomical Sex, Predict Social Cognitive Capacities … 205

suffering, particularly in individuals who may have poor affective regulation and/or poor
boundaries. Thus, it may be more beneficial for perspective-taking for males to be masculine
and less beneficial for females to be feminine in the traditional sense – a finding that supports
gender stereotypes where feminine males face greater discrimination compared to masculine
females. It is well-known that male children who adopt female gender stereotyped behaviors,
such as playing with dolls, face greater derision and ostracism from their peers and parents,
relative to girls who adopt male gender stereotypes, such as playing with cars. The findings of
lower ability on a perspective-taking task go beyond consequences of negative feelings of
self-worth due to gender typing and suggest a real social difficulty for feminine males and
undifferentiated individuals in general.
We do not have a clear explanation for the difficulties faced by individuals low in both
masculinity and femininity – relatively ‗undifferentiated‘ individuals in terms of traditional
gender role definitions. However, by definition on Bem‘s scale, these individuals are lacking
traits that are advantageous for several of the measures we assessed in the current study, such
as empathy. In addition to scoring lower on typically feminine traits such as nurturing and
empathy, they score lower on typically masculine traits such as assertiveness, dominance and
control, which might be expected to relate to emotional intelligence and a sense of agency in
assessing and navigating social situations.
These findings are limited by the fact that we relied almost exclusively on self-report.
Although we included direct tests of theory of mind and causal reasoning, future studies
should explore whether individuals with high or low levels of masculine or feminine traits
exhibit greater levels of empathy and perspective-taking in their behavior, rather than simply
in their own self-evaluations of their capacity for these characteristics. It is possible that
feminine individuals are not really more empathic but are simply more likely to report
feelings that are consistent with this trait (c.f. Lennon & Eisenberg, 1987). Some evidence for
this concern exists in the contribution of self-deceptive enhancement to reports of empathy
and emotional intelligence. We found a greater contribution of self-deceptive enhancement in
Study 2, relative to Study 1. However, prior studies controlling for socially desirable
responding still found an impact of communion (helping behavior based on emotional support
and comfort) and empathy (feminine traits) on empathic accuracy (Lauren & Hodges, 2009).
Empathic accuracy refers to the ability to accurately describe the feelings of another
individual. In addition, performance on the Reading the Mind in the Eyes Test, like tests of
empathic accuracy, would be less likely to be accounted for by gender-dependent reporting
biases as this test assesses accuracy of perspective-taking rather than self-reports of desirable
behavior.
These results highlight an important relationship between gender-typed personality
characteristics and particular social skills. Although we cannot explicitly tease apart the role
of socialization versus the impact of genetics and biology, these results suggest that
anatomical sex may not be as important in determining social cognition as are personality
variables that are most likely shaped by the social and physical environment, as well as by
multiple genes and hormones. Future studies should also assess the contributions of
underlying neural networks, hormones, and genetics to differences in psychological traits
previously identified as predominantly masculine or feminine.
206 Jennifer Vonk, Patricia Mayhew and Virgil Zeigler-Hill

ACKNOWLEDGMENTS
We thank John D. Harry, Sara Hiegel, Robin McCoy, Rania Hannan, and Rob Ninowski
for assistance coding the narratives. This project was part of an undergraduate thesis in
Psychology completed by the second author under the supervision of the first author at the
University of Southern Mississippi.

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Editors: Douglas F. Watt and Jaak Panksepp © 2016 Nova Science Publishers, Inc.

Chapter 8

EMPATHY AND AGING:

MECHANISMS OF EMPATHY
THROUGHOUT ADULTHOOD

Tao Yang and Michael J. Banissy

Department of Psychology, Goldsmiths,
University of London, London, UK

ABSTRACT
In recent years, there has been growing interest in age-related differences in social
cognitive functions across the adult life span, such as emotion perception and theory of
mind. Empathy, the ability to both understand and share another person‘s feelings,
involves emotional and cognitive processes and is a fundamental aspect of social
interactions and relationships. However, systematic knowledge about the development of
empathy across the lifecycle is limited, including changes through adulthood. Several
questionnaire and behavioral studies have suggested that in typical aging, late adulthood
and advanced age is associated with reduced capacity for cognitive empathy, but the
developmental trajectory of empathy throughout adulthood remains a topic of debate.
Here, we summarize the latest results in this growing area of study, and discuss potential
neurocognitive mechanisms that might contribute to changes in empathy throughout
adulthood.

1. INTRODUCTION
Empathy is a complex multi-level construct, which describes the ability to understand
and share other people‘s emotional and mental states (Davis, 1983; Brothers and Ring, 1992;
Baron-Cohen and Wheelwright, 2004; Decety and Jackson, 2004). Most studies have agreed
that empathy may be comprised of two subtypes: affective and cognitive empathy (Baron-
Cohen and Wheelwright, 2004; Batson, 2009; Decety and Jackson, 2004). Affective empathy
refers to the ability to recognize, understand and particularly to share via some form of
212 Tao Yang and Michael J. Banissy

affective resonance the affective states, emotions or feelings of others (Brothers and Ring,
1992; Banissy, Kanai, Walsh & Rees, 2012; Kemp, Després, Sellal & Dufour, 2012).
Cognitive empathy relates to the ability to understand and predict the cognitive states, beliefs,
thoughts, or intentions of other people, which can be labelled as ‗perspective taking,‘ ‗theory
of mind‘ or ‗mentalizing‘ (Brothers and Ring, 1992; Shamay-Tsoory et al., 2010).
Evidence from functional neuroimaging (Hynes et al., 2006) and neuroanatomical studies
(Shamay-Tsoory et al., 2009) support that emotional empathy and cognitive empathy can act
on dissociable neutral pathways. Lesions to ventromedial prefrontal cortex are correlated with
disruption of cognitive empathy, whereas lesions to inferior frontal cortex are correlated with
impairment of affective empathy (Shamay-Tsoory et al., 2009). In brain imaging studies on
healthy younger adults, it has also been found that mentalising consistently activated medial
prefrontal cortex (MPFC), temporal-parietal junction (TPJ) and posterior superior temporal
sulcus (STS) (Frith and Frith, 2003), whereas affective empathy processing leads to activation
of the anterior insula and anterior cingulate cortex (Lamm, Decety & Singer, 2011).
While several studies have focused on the developmental patterns of empathy in children
(Perner & Davies, 1991) or impairments in clinical populations (e.g., Baron-Cohen,
Wheelwright, Stone & Rutherford, 2001; Bragado-Jimenez & Taylor, 2012; Shamay-Tsoory,
Tomer, Berger, Goldsher & Aharon-Peretz, 2005), less is known about changes in empathy in
throughout healthy aging. Empathy plays an important role in social interactions, as it can
motivate prosocial behaviour and prevent people from doing harm to others (Bragado-
Jimenez & Taylor, 2012). In addition, empathy also correlates with higher life satisfaction,
emotional intelligence, and self-esteem (Eisenberg & Fabes, 1998; Mayer, Caruso & Salovey,
2000; Richardson, Hammock, Smith, Gardner & Signo, 1994). It is therefore important to
track how empathy changes throughout the adult lifespan and what impact this may have on
broader social abilities.
To date, empirical studies conducted on age-related changes in empathy are fairly scarce
and differ greatly in their approach. In order to have a well-covered review of this area, here
we review studies on age-related changes in both cognitive and affective dimensions of
empathy, including self-reported questionnaires and behavioural tasks. The current review
will only focus on studying the effect of normal aging on empathy based on studies of using
normal aged population. However, up to date the separation of normal aging from early
prodromal stages or even preclinical stages of major neurodegenerative disorders is rarely
considered. With this in mind, patients with early clinical disease may also appear in
normative samples, which needs to be kept in mind as a potential confound in studies on the
relationship between healthy aging and empathy reviewed below.

2. SELF-REPORTED QUESTIONNAIRE STUDIES

In self-reported questionnaire studies, empathy questionnaires or scales were
administered to assess trait empathy in people with different ages. These scales contain
questions that are designed to measure cognitive empathy and emotional empathy [e.g.,
Emotional Quotient (EQ), Baron-Cohen & Wheelwright, 2004], overall empathy [empathy
subscale of the California Personality Inventory (CPI), Gough & Bradley, 1996], or just one
aspect of emotional or cognitive empathy (Emotional Empathy Questionnaire, Mehrabian &
 Empathy and Aging 213

Epstein, 1972). In theses self-reported questionnaire studies, participants were asked to rate
themselves for each statement. For example, questionnaire response choices range from ―not
at all like me‖ to ―very much like me.‖ Responses are coded and summed, such that typically
higher scores reflect more empathy (Schieman & Van Grundy, 2000). Below we review these
studies, but firstly we describe some commonly used measures.
The Empathy subscale of the CPI is one popular scale that has been used in self-reported
empathy studies (Grühn, Diehl, Rebucal & Lumley, 2008; Diehl, Coyle, and Labouvie-Vief,
1996; Helson, Jones & Kwan, 2002). The revised CPI (32-item) was designed to assesses
people‘s ―interest and resourcefulness‖ in understanding others. This one-dimensional scale
taps emotional and cognitive aspects of empathy conjointly (Grühn et al., 2008).
The EQ is another commonly used measure. It consists of sixty items in which fourty of
the questions measure empathy (test items), whilst the remaining twenty are distracter items.
Of the test items, five items are thought to correspond solely to cognitive empathy, whilst
another five items tap affective empathy (Muncer & Ling, 2006; Bailey, Henry & Hippel,
2008). Cognitive empathy questions include; ―I can easily work out what another person
might want to talk about‖ and ―I am good at predicting how someone will feel.‖ Affective
empathy questions include; ―Seeing people cry doesn‘t really upset me‖ and ―I usually stay
emotionally detached when watching a film.‖ The overall score reflects the overall level of
affective empathy and cognitive empathy (Muncer & Ling, 2006; Bailey, Henry & Hippel,
2008).
The 33-item Mehrabian and Epstein (1972) emotional empathy questionnaire has also
been used in studies of the impact of aging on empathy (e.g., Phillips et al., 2002). This is
commonly used to study affective empathy. Items include ―It makes me sad to see a lonely
stranger in a group‖ and ―Another‘s laughter is not catching for me.‖ (Phillips et al., 2002). A
further measure used is the Interpersonal Reactivity Index (Davis, 1983), which has been used
to measure empathic concern and cognitive empathy/perspective taking.

2.1. Aging and Affective/Cognitive Empathy

Most cross-sectional studies reported negative association between age and empathy.
That is to say older adults score lower than younger adults in self-reported levels of empathy.
This pattern has been observed in a number of cross-sectional studies (e.g., Bailey, Henry &
Hippel, 2008; Schieman & Van Gundy, 2000). It is important to note, these studies measured
empathy using different self-report scales (including some not discussed above), and different
aspects of empathy were measured. In Schieman & Van Gundy‘s study (2000), 1581
Canadians aged between 22 and 92 years (born between 1904 and 1965) were measured using
an eight-item subset of Mehrabian and Epstein (1972) emotional empathy questionnaire, and
found a significant negative association between age and affective/emotional empathy. The
negative association was found to be partly mediated by education. In Bailey et al.,‘s study,
80 younger adults (29% male) aged between 19 and 25 years and 49 older adults (33% male)
aged between 65 and 87 were measured using EQ questionnaire (described above) that
measures affective and cognitive empathy. They found that older people have significantly
lower cognitive empathy than young people (p = 0.02), whereas overall empathy (p = 0.23)
and affective empathy (p = 0.43) did not significantly differ between the groups. Phillips et
al., (2002) reported lower affective empathy in older people (60 – 80 years old, born between
214 Tao Yang and Michael J. Banissy

1919 and 1979) compared to younger people (20 – 40 years old) using Mehrabian and Epstein
(1972) emotional empathy questionnaire (described above). However, the age-related
empathy difference disappeared after education was controlled.
In contrast to the studies above, two cross-sectional studies have reported no relationship
between empathy and age (Eysenck, Pearson, Easting & Allsopp, 1985; Diehl, Coyle, and
Labouvie-Vief, 1996). Eysenck, Pearson, Easting, and Allsopp (1985) found no age
differences in self-reported empathy in 1320 British adults (born between 1919 and 1979)
ranging from 16 to 87 years using Eysenck‘s Impulsivity Inventory; Diehl, Coyle, and
Labouvie-Vief (1996) found no significant age differences in empathy in 363 Midwestern
Americans (born between 1903 and 1972) sample ranging from 15 to 87 years using CPI
questionnaire (described above), which taps both cognitive and affective empathy conjointly.
A cross-sectional longitudinal study conducted by Grühn and colleges (2008) tracked
self-reported empathy over the course of 12 years in people between 10 and 87 years of age.
The combined results suggested that older cohorts reported lower cognitive empathy than
younger cohorts, with affective empathy remaining relatively stable within cohorts. Another
longitudinal study (Helson et al., 2002) examined the developmental trajectory of empathy,
showing a fairly small but significant linear decline over the 40-year observation period.
Recently, an alternative view of the relationship between aging and empathy has been
suggested, based on postulation of a nonlinear effect of age; instead, there is an inverse-U
shaped pattern of self-reported empathy across the lifespan, in which the level of empathy
peaks in middle adulthood due to ―age related shifts in the efficiency and availability of
biological, cognitive, and social resources‖ (O‘Brien, Konrath, Grühn & Hagen, 2012). In
support of this, these authors found empirical evidence for this pattern in the case of both
empathic concern (more affective empathy) and perspective taking (more cognitive empathy)
measured by two subscales of Interpersonal Reactivity Index described above (O‘Brien,
Konrath, Grühn & Hagen, 2012).

2.2. Impacts of Other Factors

In addition to age, several other factors can mediate the general pattern of the effect of
aging on self-reported empathy. For example, questionnaire studies have revealed that
education, gender, interpersonal relationships and religious involvement of older people
might mediate self-reported empathy.
Some previous studies on age differences in empathy reported that higher education level
correlated with higher empathy, which suggested that education might mediate empathy level
(Phillips et al., 2002; Schieman & Van Gundy, 2000; Grühn et al., 2008). One explanation put
forward to explain this is the possibility that people with higher education typically live in
more complex social environments that ―require and stimulate the development of more
refined empathic abilities because of more complex relationships and interactions‖ (Grühn et
al., 2008). With regard to gender, empirical findings are mixed. Some studies reported that
women scored higher than men in empathic concern and perspective taking (e.g., O‘Brien,
Konrath, Grühn & Hagen, 2012), but some studies claimed gender was not related to empathy
(e.g., Grühn et al., 2008), and it was argued that the observed gender-difference in empathy
might due to motivational differences in self-report measurements (Zahn-Waxler, Cole &
Barrett, 1991). In addition, it was found that older people who have better interpersonal
 Empathy and Aging 215

relationships and greater religious involvement report higher empathy levels (Schieman and
Van Gundy, 2000).

2.3. Summary

Taken together, while prior research suggests some changes in empathy across the
lifespan, but the pattern for age differences in self-reported empathy are mixed. It is important
to note, however, that none of these studies suggest that empathy is higher in older adults than
in any other age group. In addition, other factors could moderate the association between
aging and empathy, such as gender, social involvement, and education.

3. BEHAVIOURAL STUDIES
As discussed earlier, empathy is comprised of two key components: affective and
cognitive empathy (Baron-Cohen and Wheelwright, 2004; Decety and Jackson, 2004; Banissy
et al., 2012). However, few experimental studies have included these two dimensions of
empathy into one study. Most studies have only assessed the effect of aging on one
component of empathy. Here, we review the impact of aging on cognitive and affective
empathy separately based on behavioural experiments.

3.1. Cognitive Empathy

One of the most well studied aspects of aging and empathy relates to cognitive empathy –
that is the ability to make inferences about the beliefs, thoughts and intentions of others. A
common method of assessing cognitive empathy is the use of verbal-based false belief stories:
these include tests that require subjects to understand a character‘s mental state in different
social scenarios, and tasks that require subject to detect a ―social blunder or lack of tact‖ in a
scenario (Duval et al., 2010). Perspective taking abilities, are normally assessed by two levels
(first- and second- order) of mental representations (Duval et al., 2010). The first-order
mentalizing questions requires participants to recognize the emotional or mental state of a
single character portrayed in the story, for instance, the questions were (‗A thinks or feels
X‘); second-order mentalizing questions examines participants‘ abilities to answer questions
regarding second-order beliefs (‗A thinks that B thinks or feels X‘) of two different characters
(McKinnon and Moscovitch, 2007).

Verbal Based-False Belief Stories Test

Theory of Mind (ToM) is often differentiated from empathy, but it is widely considered
to be the equivalent of the cognitive part of empathy (Davis, 1983; Baron- Cohen, 2003;
Bragado-Jimenez & Taylor, 2012). Theory of Mind (ToM) tasks measured the ability to infer
the thoughts, intentions, beliefs of others (Premack and Woodruff, 1978). Strange Stories
tasks are a popular test to measure theory of mind (ToM) functions. The task assesses
216 Tao Yang and Michael J. Banissy

understanding of faux pas, double bluffs, mistakes, and white lies, and normally involve
considering mental states of individual or multiple characters.
The first study to investigate age effects on ToM conducted by Happé, Brownell and
Winner (1998) showed intact or even improved mentalizing in older subjects compared to
younger subjects. In the study, participants were presented with two types of passages: theory
of mind stories and control stories. The theory of mind stories required an inference about the
characters‘ thoughts and feelings, whereas the control stories required an inference about
physical causality. The results showed that the older group outperformed a younger group in
the mental state inference condition, whereas the performance in the control condition that
tapped knowledge of physical events did not significantly differ. Their results led them to
conclude that mentalizing/perspective taking abilities remain intact and may even improve
over the later adult years. However, some researchers argued that Happe et al.,‘s study used
unusually high-functioning older adults (Maylor et al., 2002). Later replication studies by
Maylor, Moulson, Muncer, and Taylor (2002), Sullivan and Ruffman (2004) and Charlton,
Barrick, Markus, and Morris (2009), and Rakoczy, Harder-Kasten, Sturm (2012) found
contradictory results, with age-related decline in the ability to make theory of mind
inferences, when compared to control tasks. Charlton et al., (2009) studied the effect of aging
to ToM from middle age to older adulthood (aged from 50 to 90 years) and found that ToM
ability declined with age. However, the lack of young people‘s data makes it impossible to
determine when ToM starts to decline in adulthood. Later, Bernstein, Thornton &
Sommerville (2011) used a false belief task (the Sandbox task) to investigate the age-related
changes to ToM among younger, middle-aged, and older adults. They found that middle-aged
and older adults showed more false belief bias than did younger adults, ―irrespective of
language ability, executive function, processing speed, and memory.‖
Interestingly, it has also been found that ToM can be mediated by working memory
(Maylor et al., 2002), fluid intelligence (Sullivan and Ruffman, 2004) or other cognitive
abilities, such as performance intelligence and executive function (Charlton et al., 2009;
Rakoczy et al., (2012). For instance, Maylor et al., reduced the memory loads of the task by
including cartoon pictures with stories and by allowing participants to read back the story text
when answering the test question. They found that with reduced memory load, the
performances between the group aged 67 years and the young group did not differ
significantly. In Sullivan and Ruffman (2004)‘s study, after adding fluid intelligence as a
covariate into the analysis, the ToM performance between younger and older adults was no
longer significantly different. Recently, Rakoczy et al., (2012) found that the decline of
‗theory of mind‘ or cognitive aspect of empathy in older people might be mediated by
developmental changes in cognitive functioning, as evidenced in the results that the
performance of ToM stories was moderately correlated with the executive function (EF)
measures.
Unlike previous false-belief tasks that measure first- and second- order ToM altogether,
McKinnon and Moscovitch (2007) investigated the effect of aging on ToM by testing first-
and second-order ToM stories tasks separately. In the task, the first-order mentalizing
questions required participants to recognize the emotional or mental state of a single character
portrayed in the story, for instance, the questions were (‗A thinks or feels X‘). The second-
order mentalizing questions addressed participants‘ ability to answer questions regarding the
second-order beliefs (‗A thinks that B thinks or feels X‘) of two different characters
(McKinnon and Moscovitch, 2007). Whereas first-order questions require recognition of a
 Empathy and Aging 217

single perspective only, second-order questions require that participants not only recognize
the emotions and beliefs of individual characters, but also integrate these perspectives from
different individuals, which require a higher level of mentalizing. The results of McKinnon
and Moscovitch (2007) showed that older groups only have deficits in the second-order ToM
which require participants to consider the thoughts of two different characters, whereas their
first-order ToM, which involved consideration of only one character‘s perspective, was not
impaired with age.
In other studies, Phillips, MacLean & Allenonly (2002) and Slessor et al., (2007) used
first-order Strange Stories tasks, in which participants were only asked to tell the intentions of
the individual in each story. The results were consistent with McKinnon and Moscovitch‘s
findings (2007) whereby aged people are not impaired in answering first-order mental
inference questions. However, in further statistical analysis, Slessor et al. (2007) revealed a
significant age-related deficit on the ToM stories task after including vocabulary as a
covariate. This result may suggest that older adults‘ greater vocabulary knowledge may have
masked age-related declines in making first-order mental state judgments.

Visual Based ToM Tasks-Video and Cartoon Tasks

Overall, video tasks studies have showed consistent results that older people have
impairments in making first-order inferences on visual based stimuli (Sullivan and Ruffman,
2004; Slessor, 2007; Keightley, 2006; Duval et al., 2010). Only one study investigated
second-order ToM in older adults, and the results showed aging has a significant direct effect
on second-order ToM (Duval et al., 2010). Sullivan and Ruffman (2004) however have
argued that text story studies are heavily linguistically-based and involve a high working
memory demand, a domain that declines significantly with aging and also even more within
early-stage neurodegenerative disorders. Sullivan and Ruffman used a video task to assess
theory of mind, which reduced verbal processing and working memory demands. Their task
also only assessed first-order inferences tests, which asked subjects to label the correct
emotion or mental state of the person in the video. They found that the decline in social
understanding persists in the elderly, and the decline was found independent of changes in
fluid abilities. Slessor (2007) and Rakoczy et al. (2012) used color video clips adapted from
Sullivan and Ruffman (2004) that portrayed characters interacting. The results were in line
with the finding of Sullivan and Ruffman (2004), where older participants performed
significantly worse than the younger participants did on these tasks. Furthermore, Rakoczy et
al., (2012) found that the performance of ToM video-based task correlated with the speed and
the EF measures.
Cartoon stories are another visual stimuli readily adopted to study theory of mind.
Keightley (2006) used first-order cartoon mental inferences stories to investigate age
differences on theory of mind. They found younger participants had significantly better story
comprehension than did the older adults on both theory of mind and non-theory of mind
stories. However, the poor performance of older adults may reflect an age difference in
memory, as participants did not have access to the stimuli when answering questions about
them.
Duval et al., (2010) used both visual attribution of intention and verbal-to-visual false-
belief task to assess the effect of aging on both first- and second-order theory of mind
abilities. They observed an effect of aging on both first- and second-order theory of mind, and
also measured executive functions, processing speed, and memory. They analysed the
218 Tao Yang and Michael J. Banissy

potential association between these factors and first-order, and second-order, theory of mind
performance. The results showed that the significant effect of aging observed on first-order
theory of mind were indirect, mediated by execution functions. In contrast to first-order
theory of mind, the results of second-order ToM tasks were not mediated by executive
functions, processing speed, or memory, and age exerted a more significant direct effect on
second-order theory of mind.

Summary
Overall, both verbal and visual based theory of mind studies suggest older people have
significantly poorer performance than younger people in making second-order mental
inferences, which require them to mentalize the thoughts and intentions of someone from
another person‘s perspective. In other words, they experience difficulty when required to
adopt two perspectives simultaneously. The visual false-belief study by Duval et al., (2010)
suggested age exerted a significant direct effect on second-order theory of mind. However,
verbal stories theory of mind studies found that ToM can be mediated by working memory
(Maylor et al., 2002), fluid intelligence (Sullivan and Ruffman, 2004) or other cognitive
abilities, such as performance intelligence and executive function (Charlton et al., 2009). The
discrepancies of the results might be caused by the nature of the different stimuli used in
tasks, as verbal based theory of mind tasks may require higher demands of working memory,
executive function, and other cognitive abilities (Sullivan and Ruffman, 2004).
The findings of potential effect of aging on first-order theory of mind tasks are not
terribly consistent. To date, almost all studies that used visual-based stimuli found older
people‘s deficits in first-order tasks. In contrast, studies using verbal based stories task tended
to show that older people‘s ability in making first-order mentalizing were relatively
unaffected (Phillips, MacLean & Allenonly, 2002; Slessor et al., 2007; McKinnon and
Moscovitch, 2007). However, Slessor et al. (2007) revealed a significant age-related deficit
on the theory of mind story tasks after including vocabulary as a covariate. These results
suggest that vocabulary knowledge may mask some age-related declines in making first-order
mental state judgments.
In summary, age-related deficits have been shown on both more visually based theory of
mind tasks and second-order verbal theory of mind tasks and in more limited instances on
some first-order tasks.

3.2. Affective Empathy

In addition to cognitive empathy, other studies have examined affective empathy in more
detail – that is the ability to make inferences about emotions or feelings of others. Previous
studies have used faux pas, white lies and irony tasks to measure affective component of
empathy, as these tasks require the ability of understanding and sharing the character‘s
feelings or emotional states (Kemp et al., 2012; Shamay-Tsoory et al., 2006, 2007; Wang &
Su, 2013). In the affective irony task, the ironic utterance intends to express an affective
mental state (such as anger, for example, a wife telling her husband who forgot to pick up
their child from school ―you are such a good father,‖ Shamay-Tsoory et al., 2007).
Affective irony. Joe‘s dad was supposed to pick him up after chess club at 6 p.m. By the
time he recalled he had to pickup his son, it was 7 p.m. Dad found Joe standing tired and
 Empathy and Aging 219

frightened out in the rain. When they got home, Joe was crying and told his mom what had
happened. Mom said to dad ―You are such a good father!‖

1. Why did mom say that?

2. Did mom think dad was a good father?
3. Was dad a good father on this occasion?
4. What kind of club did Joe attend?

In one study researchers have used tasks involving faux pas, white lies and irony to test
affective empathy of three age groups (mean of age of each group, young: 27 years, SD =
3.90 years; young-old: 69 years, SD = 2.50 years; old-old: 79 years, SD = 3.07 years) (Wang
& Su, 2013). The results revealed that the performance of older adults was very similar to the
performance of young adults on affective theory of mind tasks.
Another study by Richter and Ute (2011) even reported that older adults have higher level
of affective empathy than younger adults. They investigated age differences in affective
empathy based on performance-based evidences of young and old adults, such as ―the ability
to perceive another‘s emotions accurately (suggesting more affective theory of mind), the
capacity to share another‘s emotions (indexing affective empathy), and the ability to
behaviorally express sympathy in an empathic episode‖ suggesting empathic concern)
(Richter & Ute, 2011). In the study, after presenting video-clips of different emotional
engaging topics portrayed by either younger or older adults, older subjects were observed
with higher level of sympathy while watching all video clips. They also showed better
understanding of the emotions of the target person in the video clips that were relevant to
older adults.
In contrast, a meta-analytic review of age differences in empathy by Henry, Phillips &
Ruffman et al., (2012) presented the results that both affective and cognitive empathy were
associated with significant age deficits across all modalities (verbal, visual and mixed of
both). However, in a sub-analysis that focused only on studies that included a matched control
task, the results revealed that older adults‘ cognitive empathy was substantially more
impaired than their respective control tasks, while their performance on affective empathy
tasks was relatively intact.
Shamay-Tsoory (2009) proposed that affective empathy also involves the component of
personal distress/contagion, and empathic concern, besides emotion recognition and sharing.
However, few studies have focused on this area and only one study appears to demonstrate an
effect of aging on empathic concern and personal distress/contagion. In the study by Sze,
Gyurak, Goodkind & Levenson (2012), empathic concern and personal distress were assessed
in older (average age 66 years, SD = 5.27 years), middle-aged (average age 45 years, SD =
2.90 years), and young adults (average age 23 years, SD = 2.62 years). In the study, two films
(one uplifting and one distressing) were presented to subjects, and subjects were asked to rate
their levels of emotional empathy after watching the film, and their physiological responses
(cardiac and electrodermal responding monitoring sympathetic arousal) were monitored
during the films. The results suggested that more affective empathy actually increased with
age, with older subjects exhibiting the highest levels of reported empathic concern and
physiological activation, middle-aged subjects exhibiting intermediary levels, and young
subjects exhibiting lowest levels across the uplifting and distressing films. However, the
220 Tao Yang and Michael J. Banissy

underlying mechanistic basis for this result is not clear, and further studies are required to
examine this relationship.

4. AGING AND AFFECTIVE RECOGNITION

While these results might suggest that older adults do not necessarily demonstrate
impairments on affective empathy, there is some literature suggesting that older adults show
declines on closely related processes of affect recognition for basic and complex emotions.
These are summarized below.

4.1. Aging and Basic Emotion Recognition

Emotion recognition plays an important role in social cognition and social competencies,
with emotions of course expressed through changes in facial expression, eye contact, tones of
voice, body posture and body kinetics (Ruffmana, Henryb & Livingstonec et al., 2008; Ryan,
Murray and Ruffman, 2010). Emotional expression through these various channels can alter
the ultimate meaning of verbal expressions, and the ability to accurately identify emotional
content is particularly important in social interaction (Ryan, Murray and Ruffman, 2010). It is
therefore not surprising that considerable research has focused on establishing how the
capacity for emotion recognition is affected as a function of normal adult aging, as well as the
extent and implications of any observed difficulties.
The overall pattern of results regarding age group differences in facial expression
identification is quite consistent. A recent meta-analysis by Ruffmana, Henry & Livingstone
et al., (2008) reviewed papers that examined age differences in emotion recognition, and
concluded that the predominant pattern is of age-related decline in identification of emotions
expressed across different modalities (faces, voices, bodies, matching faces to voices): Older
people are worse at identifying facial expressions of anger, sadness, and fear than younger
people, with age group differences in the same direction but substantially smaller for happy
and surprised faces. For example, Mc-Dowell, Harrison & Demaree (1994) asked older and
younger adults to identify the emotion and the intensity of the expression portrayed by facial
expressions. They found that the older adults could equally identify happy expressions
compared to younger subjects, whereas older adults had significantly greater difficulties
identifying negative and neutral expressions. The finding suggested that aging individuals
have difficulty in identifying negative facial expressions. This has been replicated by other
researchers (Brosgole & Weisman, 1995; Calder et al., 2003; Gunning-Dixon et al., 2003;
MacPherson, Phillips & Della Sala, 2002). In recent a study by Keightly‘s (2006), both
younger and older adults were exposed to color photographs, it was found that the reaction
time for recognizing negative faces was much slower than the reaction times for recognizing
neutral and positive emotions between the two age groups. In addition, further analysis
showed that the older adults were significantly less accurate at identifying facial expressions
of fear and sadness but were as accurate as younger adults in labeling happy, surprised, and
neutral faces.
 Empathy and Aging 221

Why might there be age group differences in facial expression identification, and why
might it be restricted to emotion subtypes? Although adult aging causes widespread gradual
changes in the brain, the frontal and temporal brain regions suffer the earliest and greatest
age-related deterioration (Kalpouzos, Chételat, Baron & Landeau et al., 2009; Allen, Bruss,
Brown & Damasio, 2005; Good, Johnsrude, Ashburner & Henson, 2001). Therefore the
volumetric reductions of white and grey matter in these regions may possibly account for
older adults‘ declined emotion recognition abilities. In particular, the brain volume of frontal
areas declines much earlier and more rapidly than other brain regions, and there is evidence
that the orbitofrontal cortex (OFC) degrades even more rapidly than other frontal areas (Raz,
Gunning, Head & Dupuis, 1997). In addition, the superior temporal sulcus (STS) has been
found to be subject to atrophic change with age. For instance, it was reported that 24% gray
matter density of the STS deteriorated between the ages of 40 and 87 (Sowell et al., 2003).
The STS has commonly been linked to affect recognition in several studies and reduced brain
volume in this region may contribute to declines in affect recognition found in typical aging.
In addition, age-related declines also occur in the gray matter density of the prefrontal brain
regions, which supports more complex social cognition (Raz & Rodrigue, 2006). In contrast,
the relative sparing of some structures within the basal ganglia with age may result in
preserved ability at identifying disgusted expressions in older adults (Calder et al., 2003;
Williams et al., 2006).

4.2. Aging and Complex Emotion Recognition

Basic emotions are recognized universally, and they can be recognized purely as emotion,
without the need to attribute a belief to the person (Baron-Cohen, Wheelwright & Hill et al.,
2001). In 1996, Baron-Cohen et al., found that in addition to recognition of basic emotions,
normal adults and children showed considerable agreement in recognizing a range of complex
facial expressions from images of faces. Moreover, this was true not only within any single
culture, but also across different cultures. They tested complex mental states (such as
‗revenge,‘ ‗guilt,‘ ‗threaten,‘ ‗regret,‘ and ‗distrust‘), as well as the basic emotions such as
fear (wariness) and surprise (astonishment). It was found that cross-culturally, mental state
recognition extends beyond the classic basic emotion categories Ekman (1992) documented.
It has been argued that older adults‘ difficulties and differences at evaluating facial
emotional expressions are not restricted to basic emotion stimuli. Compared to young adults,
older people are also worse at recognizing complex emotions (e.g., regretful, accusing,
reflective, preoccupied) in the eyes. Complex emotion recognition is frequently assessed by a
visual task called Reading the Mind in the Eyes (RME) Test (Baron-Cohen et al., 2001), in
which subjects are asked to judge emotional or mental state judgments about pictures of the
eye region. The results regarding older people‘s performance in the task are quite consistent.
Several studies have shown that older adults performed more poorly than younger adults on
the RME Test (Bailey and Henry, 2008; Phillips et al., 2002; Slessor et al., 2007). Moreover,
this decline in complex emotion recognition seems to occur from 55 years of age (Pardini and
Nichelli, 2009). However, judgments based on complex expressions from the whole face
were not tested, which may contain more useful signals such as nose and mouth movements.
Therefore the investigation of aging and recognition of complex emotions should be a
research area that future aging research should be stressed on.
222 Tao Yang and Michael J. Banissy

SUMMARY
This chapter summarized age-related changes on both affective and cognitive empathy
from a variety of self-report questionnaire, behavioral and neurological studies. Most
questionnaire studies indicate that late adulthood is associated with reduced capacity for
empathy. Behavioral evidences suggests that older adults may have deficits in both affective
and cognitive empathic components. Specifically, aging is associated with deficits on both
first- and second-order mentalizing across both verbal and visual modalities, which reflect a
specific age-related deficit in the ability to infer one‘s own and other people‘s thought,
emotional situation and mental states. In contrast, behavioural studies on affective empathy
and related processes like affect recognition are more mixed, with some studies suggesting
that affective empathy in older adults is similar to younger adults (Richter & Ute, 2011; Wand
& Su, 2013), but others demonstrating that older adults have higher empathic concern and
personal distress (Sze, Gyurak, Goodkind & Levenson, 2012). However, and again in
apparent contradiction, older adults also show declines in affect recognition, particularly for
negative facial expressions (Keightley et al., 2006; Macpherson et al., 2002; Williams et al.,
2006). It will be interesting to tease apart this confusing and somewhat conflicted pattern of
results with additional future studies, and additionally, to determine what neurocognitive
mechanisms might contribute to age-related changes in various cognitive and affective types
of empathy.
Basic caveats affecting these results may include our current difficulty in truly excluding
patients with early clinical stages of dementing disorders from what might appear to be
otherwise normative aging samples. In previous aging and empathy studies, some studies
have used Mini-Mental State Examination (MMSE) as a tool to rule out people potentially
have early signs of age-related Alzheimer‘s dementia. However, MMSE lacks sensitivity to
mild cognitive impairment and it fails to adequately discriminate patients with mild
Alzheimer‘s Disease from normal patients (Tombaugh & McIntyre, 1992). This suggests that
future studies may need to pay greater attention to the problem of unidentified members of an
aging cohort with prodromal stage dementing disorders, and to use emerging biomarkers and
other ways of excluding early clinical and even preclinical dementing disorders from these
normative aging groups.

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EMPATHY IN THE HELPING PROFESSIONS
In: Psychology and Neurobiology of Empathy ISBN: 978-1-63484-446-8
Editors: Douglas F. Watt and Jaak Panksepp © 2016 Nova Science Publishers, Inc.

Chapter 9

EMPATHY IN MEDICAL EDUCATION

Geon Ho Bahn1, MD, PhD, Teckyoung Kwon2, PhD,

and Minha Hong3, MD, PhD
1
Department of Psychiatry, Kyung Hee University School of Medicine,
Dongdaemun-Gu, Seoul, Korea
2
English Department, Kyung Hee University, Seoul, Korea
Dongdaemun-Gu, Seoul, Korea
3
Department of Psychiatry, Myong Ji Hospital, Goyang, Korea

ABSTRACT
Empathy is an important tool for interpersonal relationships and a better social life.
Especially for healthcare professionals, it is essential to establish a good doctor-patient
relationship in addition to possessing the requisite medical knowledge. According to
research on the empathy of medical students and doctors carried out in the US, the
duration of education and empathic capacity have a negative correlation, and females
have a better capacity of expressing empathy than men. It is ironic that the erosion of
empathy occurs during a time when the curriculum is shifting toward patient-care
activities, for which empathy is most essential. On the contrary, some reports applying
the same or similar empathy scales, conducted with respect to Asian medical students or
doctors, including Korea, Japan, or China, revealed that the education years and empathy
have a positive correlation. A few studies have shown that gender differences do not play
any role in those reports. Students from Okayama University Medical School, Japan,
showed a specific increase of the mean empathy score in each of the six successive years
of medical education. In addition to U.S.A. and Asian studies, research conducted in Iran
and New Zealand reported that medical students‘ capacity for empathy decreased with
each successive year. However, similar research in Ethiopian and Portuguese medical
schools showed an improvement of empathy as the years of medical education continued.
Interestingly, the empathy scores of beginning Asian medical students are lower than
those of U.S. students, as shown by in a study conducted at Jefferson Medical College.
Some of these differences may simply arise from cultural differences in defining and
interpreting the concept of empathy. When configuring programs to improve the capacity
for realizing empathy, medical professionals should reflect on those cultural
characteristics. Nonetheless, in light of the conflicting data about empathy in medical
230 Geon Ho Bahn, Teckyoung Kwon and Minha Hong

education, educators should consider developing programs to enhance and sustain

empathy. Indeed, better education in the humanities and narrative arts has been found to
raise awareness of empathy. Such interventions may improve physician skills by
promoting the capacity to express empathy among future medical practitioners.

INTRODUCTION
Empathy in Psychiatry and Psychoanalysis

The definition of empathy is multifaceted and complex. Because the psychological

phenomenon of emotion itself cannot be unambiguously defined, concepts of empathy often
vary depending on interpersonal perspectives embraced by practitioners in different scientific
specialties such as psychoanalysis, psychology, or scientific philosophy. Indeed, in the
present era empathy has become a popular issue in many medical disciplines, especially
psychiatry and psychoanalysis. Freud emphasized the importance of adopting an empathic
attitude as an essential component of analytic listening, and empathy was considered an
integral quality of the psychoanalytic attentional stance and a main ingredient in cementing
the therapeutic alliance from the very beginning of the era of psychoanalysis (Aragno, 2008).
Heinz Kohut (1959) especially greatly contributed to the revival of the theory of empathy; he
argued that not only does empathy play an important role in the therapy of the analyst, but
also in cultivating the unconscious sources of empathy. Kohut viewed empathy as a „vicarious
introspection‟ and defined it as a special tactic that can be used to observe and understand
another person‟s thoughts, wishes, emotions, and fantasies. Rogers (1975) also defined
empathy as entering into another person‘s inner world and being accustomed to it and being
more sensitive to emotional changes the person experiences, without adding any of the
observer‘s own negative emotions, such as anger, fear, and anxiety.
Others have made distinctions between true empathy and sympathy. According to
Eisenberg (1986), sympathy involves feelings of concern for the emotional state of another.
Nevertheless, it does not necessarily involve the vicarious experience of the other person‘s
ongoing emotional feelings, such as emotional contagion or matching. Thus, one may feel
concern for an angered individual without being necessarily angered oneself, which is
tantamount to a primary-process empathic reaction as defined by Watt (2007) and Panksepp
& Panksepp (2013). On the other hand, both Herbert Mead and Jean Piaget put an emphasis
on the cognitive aspects of empathy: Piaget (1962) envisioned empathy as the attitude of
„taking the perspective of others,‟ while Mead describes it as that of „taking the role of the
other‟ (Rothenberg, 1987). Furthermore, Harry Stack Sullivan viewed it as the concept of
sharing feelings through „emotional bonds‟ with others (see Migone, 1994). Regardless of
various definitions of empathy posited by individual analysts, as Greenson (1960)
emphasized, the importance of therapists feeling empathy with the patient when he or she first
goes to greet a patient: Namely, even before seeing the person with whom they will deal, it is
wise to approach them with an empathic attitude.
 Empathy in Medical Education 231

Empathy in Terms of the Moral Aspect

Some researchers have discussed the feeling of empathy in light of an ethical emotion
(Tangney, 1999). When associated with moral empathy, shame and guilt — which are distinct
social emotions--are indispensable to enhancing it. Shame presumably arises from the public
exposure, through which shortcomings or transgressions are recognized by others, which
often need to be repudiated. In contrast, guilt is a more private feeling, arising from self-
generated pangs of conscience. There appears to be a special link between guilt and empathy,
observed both in studies of affective styles or dispositions as well as in studies of emotional
state (Eisenberg, 1986). Indeed, numerous independent studies have examined the
relationship between shame and guilt, and their relationship to dispositional capacities for
interpersonal empathy, as studied in substantial samples of children, college students, and
adults (Tangney, 1996). The results are quite consistent: Guilt-prone individuals are generally
empathetic individuals. In other words, guilty feelings have generally been especially
effective in decreasing anger. In contrast, shame-proneness has been repeatedly associated
with an impaired capacity for other-oriented empathy as well as a propensity for self-oriented
personal distress responses (Tangey, 1999). Shame-prone individuals are more prone to anger
than their shame resistant peers. Once angered, shame-prone people are also more likely to
manage their anger in unconstructive ways. In a cross-sectional developmental study carried
out on a substantial sample of children, adolescents, college students, and adults, proneness to
shame was strongly related not only to the maladaptive and non-constructive responses to
anger, among individuals of all ages (Tangey, et al., 1996).
Some researchers have sought to clearly distinguish between the dynamics of other-
oriented empathy and self-oriented personal distress (Batson, Fultz & Schoedrade, 1987).
Other-oriented empathy typically embraces another person‘s perspective, as one vicariously
experiences similar feelings. These responses often involve not only feelings of sympathy but
deep cognitive concern for others, in the process of helping others. Significantly, the empathic
individual focuses on the experiences and needs of the other person, without focusing
explicitly on his or her own empathic responses. In contrast, self-oriented personal distress
often involves a primary focus on the feelings, needs, and experiences of the empathizer.
Empathic concern for others has been linked to altruistic helping behavior, whereas self-
oriented personal distress has comparatively little to do with empathy (Batson, et al., 1987),
and often actually becomes an obstacle to generation of pro-social behavior (Eisenberg et al.,
1993).

Empathy Resulting from the Integration of Affect and Cognition

Deutsch and Madle (1975) claim that empathy is not restricted solely to either cognition
or affect, because they are necessarily intertwined. In other words, approaching empathy from
just one of these perspectives is inadequate for understanding and fully utilizing empathy. For
instance, Feshbach (1975) defines empathy as a ―shared emotional response between an
observer and stimulus person‖ and suggests that empathic responsiveness requires three
interrelated skills or capacities: (a) the cognitive ability to take another person‘s perspective,
(b) the cognitive ability to accurately recognize and discriminate another person‘s affective
experiences, and (c) the affective ability to personally experience a range of emotions (since
232 Geon Ho Bahn, Teckyoung Kwon and Minha Hong

empathy involves sharing another person‘s emotional experience). In short, empathy is a

characteristic quality that overlaps with such concepts as compassion, attention, sympathy,
accepting of other viewpoints, imagination, geniality, loyalty, generosity, faithfulness, and
communication; this view supports an argument that presents empathy as having multi-
dimensional properties (Davis, 1983). Current conceptualizations of empathy emphasize the
integration of both affective and cognitive components (Panksepp & Panksepp, 2013).
Recently, researchers demonstrate the dynamic interaction of two components using fMRI
analysis: affective states via cingulo-insular circuitry and cognitive emotional components via
prefrontal-temporo-parietal circuit (Raz et al., 2013).

Empathy in Medicine

Generally, empathy in medicine has been described as an appropriate way of

understanding the patient (Pedersen, 2008). However, there is no general agreement
concerning how to define, teach, or study empathy (Pedersen, 2009). Some conceptual issues
that have been hotly debated include the issue of whether empathy is emotional or cognitive,
subjective or objective. The discussion even includes whether we think of the capacity of
communication and understanding generated by it, and acting appropriately based upon this
understanding. Some researchers (Evans, Stanley & Burrows, 1993; Linn, DiMatteo, Cope &
Robbins, 1987) have argued that empathy is a multidimensional construct and have used more
inclusive methods, while others (e.g., Branch, Pels & Hafler, 1998) have chosen to study
selected dimensions. Although empirical studies of empathy have been reviewed in various
publications, none of the previous reviews have a unified voice in terms of both qualitative
and quantitative methods, particularly when it is used to enhance empathy in medicine. To
doctors, empathy is an ability to stand in the patient‘s shoes and to look at the world from the
patient‘s perspective (Levinson, 1994). When one enters the medical school, students
commonly have a genuine love and desire to help others; as they progress through
professional medical education and become accustomed to diagnostic tools, they often grow
apart from their patients‘ perspectives and their capacity to empathize declines (Spiro, 1992).
However, in many countries, empathy has become a subject to be studied in medical
education. Yet it is still unclear how that can be optimally achieved and what exactly the
concept means and whether a greater focus on humanities as well as on development of social
skills is likely to enhance it. Indeed, it is not even clear whether such an enhancement would
be beneficial for physicians and/or patients (Williams & Lau, 2004). In this sense we can
argue that the study of empathy in the medical field is only beginning. Various investigations
are underway to define and illuminate the exact concept of empathy, which is a critical factor
to increase communion and quality of interactions between doctor and patient. To do this
properly, the empathetic capacity of both medical students and doctors need to be constantly
evaluated, as has been emphasized by Hong, Bahn & Lee (2011). Although the literature on
empathy development in medicine is already quite extensive, the authors of this chapter have
chosen to focus pointedly on the proper assessment of empathy and the methodologies that
may improve empathy among medical students.
 Empathy in Medical Education 233

EMPATHY IN MEDICAL PROFESSIONALS

Why Do Medical Students and Medical Professionals Need Empathy
Education?

Without understanding the patient‘s internal experience, it is not only difficult to properly
diagnose patients, but also hard to optimal treatments for them (Neuwirth, 1997). Therefore,
improved empathy within the doctor-patient relationship is likely to yield many benefits.
Given equal medical skills, empathic physicians — namely those who are sensitive to
patients‘ subjective emotional realities, will surely be able to provide better treatment care to
patients than those that focus just on concrete medical issues. Emotionally sensitive caring
attitudes are likely to facilitated treatment compliance and efficacy, for instance following
through with taking medication, following-up appointments, and hopefully making suggested
lifestyle changes (Bayne, Neukrug, Hays & Britton, 2013). Empathy and politeness may also
impact on pragmatically and financially significant issues (Smajdor, Stockl & Salter, 2011).
Even in medical litigations, which are constantly increasing in numbers, empathy plays an
important role. Without sufficient empathy, chances of miscommunication with patients
increase, and the likelihood of legal actions against doctors may increase (Beckman,
Markakis, Suchman & Frankel, 1994). Such problems loom even larger in circumstances
involving medical malpractice. Even though a treatment may have been appropriate
medically, patients or their families who did not feel sufficient empathy in practice, may not
as readily recognize or believe they have been well cared for. It is also well known that when
patients sue doctors or hospitals, the causes are often due to the mistakes that have emerged,
in part, through failures of courtesy (Smajdor, et al., 2011). To be an empathic physician,
students must be educated not only in the bio-medico-social aspects of medicine but also
relevant cultural and spiritual aspects. Indeed, the more that medical technology evolves, the
more attention should be paid to improved attention to empathic issues. In particular, to the
degree that high technology has promoted de-humanization in modern clinical practices, it is
important to promote restoration of empathic practices in dealing with patients (Suchman,
Markakis, Beckman & Frankel, 1997). Thus, the nurturing of empathic abilities remains a
crucial factor in the education of doctors (Fishbein, 1999).
How do current educational practices correspond to the ideal? Overall, it seems there is
inadequate attention paid to the cultivation of empathic skills: The undergraduate medical
curriculum is overwhelmed by biomedical sciences courses, where facts are emerging more
rapidly than synthetic understanding. For instance, rapid developments in cell and molecular
biologies tend to enforce their expansion in teaching curricula (Batistatou, Doulis, Tiniakos,
Anogiannaki & Charalabopoulos, 2010). Students are hard-pressed to master the facts and
theoretical perspectives and skills offered by most medical education curricula; the heavy
work-load might promote ―burnout‖ feelings (Thomas, 2004; Park, et al., 2016). The lack of
both encouragement and time for reflection engenders the adoption of a dogmatic approach to
medical practice. Thus, as emphasized by Spiro (1992), the more students get involved in the
massive facts and technicalities of modern medical education, the less time students have to
improve their empathic abilities. With the development of modern diagnostic tools, history-
taking can easily become perfunctory or even careless, with patients becoming ―objects‖ to be
cured or even envisioned as just ―interesting clinical cases, as opposed to full human beings.
234 Geon Ho Bahn, Teckyoung Kwon and Minha Hong

With the exclusion of humanities and an increased emphasis on molecular-biological

knowledge, doctors are, in effect, encouraged to focus on the ‗disease itself,‘ not the ‗patient,‘
often detracting from a future physicians‘ self-esteem. For instance, Beckman, Reed,
Shanafelt & West (2012) conclude that the well-being of the resident has little to do with their
medical knowledge but their competence as a human being. By using the Interpersonal
Reactivity Index (IRI), Davis (1983) found that low medical knowledge rarely serves as an
effective signal of impaired well-being or reduces empathic attitudes. This suggests that the
documented adverse effects of a resident‘s negative well-being on patient care are typically
not mediated by a lack of medical knowledge. The overall pattern suggests that quality
instruction in medical knowledge, should go hand-in-hand with empathic training, with some
courses set aside for that specific purpose.

Empathy toward an Evidence-Based Medicine

Empathy contributes to treatment efficiency and the accuracy of prognosis. A meta-

analysis of the effects of empathy on the outcome of treatment, based on 47 studies and 190
separate tests of the empathy-outcome association in 3026 clients, yielded a weighted effect
size of r = 0.32 (Bohart, Elliott, Greenberg & Watson, 2002). This is a medium effect but
which surpasses the effect sizes from studies of working alliances. Interestingly, empathy was
at least as, and maybe somewhat more, effective in cognitive-behavioral therapies than in
experiential, psychodynamic, and other therapies, providing some of the first evidence-based
scientific data on the medical effectiveness of empathy. The authors suggest, somewhat
paradoxically, that empathy may be more important in directive treatment, thus providing ‗an
effective ground for intervention.‘ Of course, it is possible that the other therapies already
simply have more intrinsic empathy than the more behavioristic cognitive-behavioral
approaches. In that sense, Hojat and colleague‘s (2011) verification of the relationship
between empathy and the clinical results of diabetic patients through psychometric measures
has also been a crucial piece research. These authors reported that patients of physicians with
high empathy scores were significantly more likely to have good control of hemoglobin A1C
than were patients of physicians with low empathy scores. Further, logistic regression
analyses indicated that physicians‘ empathy made a unique contribution to the prediction of
optimal clinical outcomes after controlling for physicians‘ and patients‘ demographic factors
and patients‘ health insurance.

Measurement of Empathy in Medical Education and Training

Despite the importance of empathy in a meaningful physician-patient interpersonal

relationship, there has been an absence of empirical investigation of the concept and its
implications for patient care. Perhaps one reason for this lack of empirical scrutiny of
empathy in medical education and medical care is that there is no conclusive definition of
empathy (Pederson, 2009). Another one may be the absence of a research instrument to
operationally measure the concept in medical settings, in order to empirically study its
development, and investigate its variation and correlates not only in different stages of
 Empathy in Medical Education 235

medical education but among different groups of medical students and physicians (Evans, et
al., 1993).
There are several instruments available to measure the level of empathy depending on the
subjects: the IRI (Davis, 1983), the Hogan Empathy Scale (Hogan, 1969), and the Emotional
Empathy Scale (Mehrabian & Epstein, 1972), which are also used to measure the level of
empathy of the general public; the Empathy Construct Rating Scale (La Monica, 1981), the
Empathic Understanding of Interpersonal Processes Scale (Carkhuff, 1969), and the Empathy
Test (Layton, 1979), which are used to measure that of nurses; and the Consultation and
Relational Empathy (CARE) measure, which is used for measuring patients‘ perception of
relational empathy in the consulting room (Mercer, Maxwell, Heaney, Watt, 2004). None of
these, however, are used to measure doctors‘ level of empathy. When Hemmerdinger,
Stoddart & Lilford (2007) searched previously published papers for empathy measuring
instruments used in the selecting process of medical students or medical related professionals
(since empathy is an important attribute in the medical field), no empathy measures were
found with sufficient evidence of predictive validity for use as a selection measure for
medical school. Pedersen (2009) also reviewed 206 publications about empirical research and
concluded that both important aspects and influences of empathy have been relatively
neglected. Another report of a systematic review for nursing research to assess empathy
studies between 1987 and 2007 concluded that there was no consistency in data (Yu & Kirk,
2008). However, this may be because the best tools have not been use. There are tools with a
sufficient evidential base to support their use as tools for investigating the role of empathy in
medical training and clinical care (Hemmerdinger, et al., 2007).
Considering the multidimensional characteristics of empathy, one of the problems of
empathy scales is that it is difficult to evaluate expressive factors. In terms of the internal
process of empathy, Carkhuff, Berenson & Tamagini (2014) emphasized the expressive
aspects of empathy as a communication skill of the helper. This communication means
―penetrating understanding‖ of other‘s experience - both verbally and nonverbally. Empathy
aids in easing one‘s pain and empathic behavior is presented in a verbal prosodic form that
conveys care. Henceforth, the development of measurements reflecting the various aspects of
empathy is needed. In other words, empathic ability and empathic responsiveness should not
be the identical. The nonverbal aspects of communicating empathy, timing and wording, are
highly important (Bohart, et al., 2002). In order to be effective, empathic understanding needs
to be accurate and sensitive in confirming the experiences and feelings of the patient. Perhaps
due to the multifaceted character of the construct, many different measures of empathy have
been developed (e.g., observer-, client-, and therapist-rated instruments), thereby providing
global measures as well as more dynamic measures that tap empathy on a moment-to-moment
basis.
Based on experience and an extensive review of the literature, a revised version of the
Jefferson Scale of Physician Empathy (JSPE) was developed (Hojat et al., 2001; Hojat et al.,
2002a). The JSPE was originally developed to measure the attitude of medical students
toward physician empathy in patient-care situations (the ―S‖ version), followed by pilot
studies with groups of practicing physicians, medical students, and residents. After several
iterations and refinements, The JSPE included 20 Likert-type items answered on a 7-point
scale. A revised version of the JSPE for physicians and health professionals (the ―HP‖
version) was also developed (Hojat, Gonella, Nasca, Mangione, Vergare & Magee, 2002b).
The JSPE-HP modified the wording of the ―S‖ version to make it more relevant to the
236 Geon Ho Bahn, Teckyoung Kwon and Minha Hong

caregiver‘s empathetic behavior rather than just to empathetic perception (attitudes): i.e., from
‗for physicians‘ to ‗for me.‘ These modifications were also intended to make the scale
applicable to other healthcare professionals (e.g., nurses, psychotherapists, pharmacists, etc),
as well as physicians. Nowadays, investigations of empathy using the JSPE have become
popular in many countries. The Center for Research in Medical Education & Health Care
(CRMEHC) of Jefferson Medical College of Thomas Jefferson University, where
Mohammadreza Hojat works, recently reported that the JSPE has been translated into 42
languages and is used in 60 countries. The target languages include Arabic, Chinese (China,
Taiwan), Croatian, Czech, Danish, Dutch (Belgium [Flemish], the Netherlands), Filipino,
Finnish, French (Belgium, Canada, France), German, Greek, Hebrew, Hindi, Hungarian,
Indonesian, Italian, Japanese, Korean, Lithuanian, Norwegian, Persian (Farsi), Polish,
Portuguese (Brazil, Portugal), Romanian, Russian, Serbian, Spanish (Catalan, Chile, Mexico,
Peru, Spain), Swedish, Thai, Turkish, and Urdu (Pakistan).

FACTORS AFFECTING EMPATHY IN MEDICAL EDUCATION

The significant number of research reports released in the U.S. suggest the following
facts: a decline of empathy during medical training in medical students and residents
(Shapiro, 2008; Hojat, et al., 2009; Chen, Lew, Hershman & Orlander, 2007), a higher
empathic capability in females than males (Hojat, et al., 2009; Chen, et al., 2007), and a
relationship between the students‘ choice of a future specialty preference and their empathy
level scores (Hojat, et al., 2009). The disturbing possibility is that medical education might be
injuring empathy instead of nurturing it (Magalhães, Salgueira, Costa & Costa. 2011). In the
U.S. data concerning medical students, it is ironic that the erosion of empathy occurs during a
time when the curriculum is shifting toward patient-care activities; this is when empathy is
most essential (Hojat, et al., 2009). Therefore, researchers in the U.S. determined that
measures to improve, or at least maintain, an acceptable level of empathy during the medical
education as well as the residency training are necessary, and that they practiced an
educational intervention on the preservation of empathy and reported the results (Hojat,
Axelrod, Spandorfer & Mangione, 2013).

Cultural Differences in Medical Education

As the JSPE came into wide use, researchers found interesting differences from varying
countries. One that stood out more was the difference of total scores on the JSPE. Subjects
from Korea (Roh, Hahm, Lee & Suh, 2010; Hong, et al., 2012), Japan (Kataoka, Koide, Ochi,
Hojat & Gonella, 2009; Kataoka, Koide, Hojat & Gonella, 2012), and China (Wen, Ma, Li &
Xian, 2013) had lower scores compared to those of American medical students/pharmacy
students/doctors/nursing students (Table 1). This can possibly explain the result of research
done at Jefferson Medical College that showed that Asian American students scored lower
than white American students on their empathy level (Berg, Majdan, Berg, Veloski & Hojat,
2011). The authors detected no significant difference between white and Asian American
students on their self-reported JSPE scores. However, the standardized patients‘ (SPs‘)
 Empathy in Medical Education 237

assessments on the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE)

and on the global rating of empathy (GRE) were significantly lower, indicating less empathy
on the part of Asian American students. There is another interesting study that should be
considered. When comparing the empathy levels between New Jersey School of Osteopathic
Medicine students and Jefferson allopathic medical students, the first- and second-year
osteopathic medical students had statistically significant lower levels of empathy compared to
Jefferson allopathic medical students in the same years of study (Kimmelman, Giacobbe,
Faden, Kumar, Pinckney & Steer, 2012). Of 405 respondents in the osteopathic medical
school, 124 (31%) were Asians. To determine whether the presence of Asian students in the
first and second years might explain the difference between two schools, the mean JSPE-S
scores of the 45 Asian and the 82 non-Asian first-year osteopathic students (103.5 ± 16.1 vs
111.4 ± 13.7, respectively) were compared. The difference of 7.9 points was statistically
significant. However, the comparison of second-year students did not result in any significant
differences. Kim, Kim & Chang (2004) explained such results for the following reason. The
terms ‗consider,‘ ‗understand,‘ and ‗think‘ are used to express cognitive qualities in English
speaking countries. However, in Korea, these terms are not so distinctively distinguished
from a more emotional term ‗feeling.‘ The scale used in Korea emphasized emotional
qualities, whereas the original scale assigned an equivalent amount of emphasis to both
cognitive and affective qualities. Total scores can result in lower levels, too. Suh, Hong, Lee,
Gonella & Hojat (2012) explained that Korean doctors‘ lower empathy scores, as compared to
American or Italian doctors‘ scores, were based on Confucian philosophy (Table 2). Korean
families are often patriarchal. Accordingly, the physician-patient relationship also can be
regarded as a vertical relationship. In other words, doctors may not feel much need to ask for
patient‘s opinions. Also, in Korean society, suppression of one‘s emotion has traditionally
been regarded as a virtue. This cultural peculiarity may partially explain why the mean of the
empathy scores of Korean physicians was lower than their counterparts in some western
societies, in which a horizontal pattern of physician-patient relationship is rather prevalent.
However, there has been another type of paternalism in western culture, too. Based on the
division of professional doctors from other healers, doctors have tended to come from the
powerful social classes (Smajdor, et al., 2011). Their elevated social status, in conjunction
with their scientific knowledge, created an exaggerated power imbalance in which
paternalism flourished. But recent trends in medical ethics and education are apt to accept
paternalism no longer. If such trends are still valid in English culture, as Smajdor (2011)
writes, then explaining the difference in empathy scores solely based on cultural differences
may not be sufficient.
The question of whether individuals are more accurate at recognizing the emotional
displays of members of their own culture versus those of other cultures has been an important
issue in emotion research for several decades (Soto & Levenson, 2009). In the realm of
emotion recognition, empathy accuracy is a good measure of what people can do. Soto and
Levenson (2009) compared four ethnic groups; African Americans, Chinese Americans,
European Americans, and Mexican Americans, all college students and born in the U.S.
Instead of static emotional stimuli (e.g., still photographs, vignettes, etc.) or one-time
emotional judgments (e.g., a photograph of a face is identified as ―angry‖), participants
watched videotaped conversations between dating couples and responded with an emotional
rating dial. During the experiment, seven physiological functions were measured; cardiac
inter-beat interval, pulse transmission time, finger pulse amplitude, ear pulse transmission
238 Geon Ho Bahn, Teckyoung Kwon and Minha Hong

time, skin conductance level, finger temperature, and general somatic activity. The results for
empathic accuracy supported the cultural equivalence model, with no evidence of greater
accuracy when raters viewed targets of their own ethnicity in the videotaped conversations.
The findings for physiologic linkage provided some support for the cultural advantage model,
with greater physiological linkage when Chinese Americans viewed and rated Chinese
American targets. Authors considered the well-documented collectivism in Chinese American
culture as a possible explanation. Taking the result of Soto and Levinson‘s study (2009) into
consideration, the different results of self-rated empathy scales depending on the race may not
be caused by differences from actual life experiences but instead caused by the confounding
factors of test questions. It is assumed that feelings and expressions of empathy vary from
cultures, policies, or environments. We need global collaboration to overcome those variances
and to investigate the concept of empathy as a fundamental human affect.

Changes during Training Years in Medical Education

According to a study on the empathy levels of medical school students in the U.S.,
conducted with the JSPE-S (Hojat et al., 2004), the students‘ empathy scores declined
significantly during their third year, which was their first full year of clinical experience. A
study at Boston University School of Medicine (Chen, et al., 2007) also found that empathy
scores of the U.S. medical school students on the JSPE-S went down during their clinical
years. Most interesting is the fact that the score increases as one goes through the first year,
decreases a little in the second year, and decreases significantly during the third year, when
students encounter a clinical clerkship in their first clinical year. A further study conducted at
Jefferson Medical College reported a similar finding; while empathy scores did not alter
significantly during the first two years (preclinical years), they decreased during the 3rd year
(first clinical year) and remained low until graduation (Hojat et al., 2009). Bellini and Shea
(2005) used the IRI to evaluate empathy in interns and internal medicine residents. For
empathic concern, the worsening in scores during internships remained lower throughout
residency. Chen, Kirschenbaum, Yan, Kirschenbaum & Aseltine (2012) examined the trend
of empathy longitudinally and reported similar findings as the previous data indicated (Chen,
et al., 2007). However, through another set of analyses, they revealed that empathy
trajectories significantly differed based on empathy levels at the beginning of the first year of
medical school. They divided students into three groups corresponding to high, medium, and
low levels of baseline empathy, which were then used to calculate product terms capturing
their interaction with time. Students entering medical school with high levels of empathy have
been found to better maintain their levels of empathy throughout their medical school careers.
In contrast to the subtle decline over time for those high in empathy at the baseline, the lower
two groups increase in empathy through year two, only to drop sharply between years two
and three. Researches done in the U.S. seem to produce consistent results. Joachim‘s paper
(Joachim, 2008) is one of the supporting the evidences. In fact, Joachim stresses the necessity
of forming a special educational system that will prevent a decrease of empathy as students
proceed in the medical education, especially during the third year when they begin their
clinical clerkship. Although there are not many data other than in the U.S. and Asia, the
studies from Iran (Shariat & Habibi, 2013), New Zealand (Lim, Moriarty, Huthwaite, Gray,
Pullon, Gallagher, 2013) and Portugal (Magalhães, et al., 2011) also reported that as medical
 Empathy in Medical Education 239

students pursued their education, empathic ability declined (Table 1). Another study produced
different results indicating that affective empathy declined in male students while cognitive
empathy was unchanged among medical students (Quince, Parker, Wood & Benson, 2011).
According to the research materials of the Jimma University in Ethiopia, authors used the
Balanced Emotional Empathy Scale (BEES) (Mehrabian, 2000) for the detection of ―heart-
reading,‖ i.e., emotional empathy and the revised version of The Reading the Mind in the
Eyes test (RME-R test) (Baron-Cohen, Wheelwright, Hill, Raste & Plumb, 2001) to evaluate
―mind reading,‖ i.e., cognitive empathy (Dehning, Girma, Gasperi, Meyer, Tesfaye &
Siebeck, 2012). First-year students scored higher than the final year (fifth-year) students in
the BEES measures of emotional empathy. However, this difference was not statistically
significant. Final year students had a significantly higher mean cognitive empathy score than
first-year students.
In the review of 11 relevant studies, Colliver, Conlee, Verhulst & Dorsey (2010) shows
that the evidence does not warrant the strong, disturbing conclusion that empathy declines
during the medical education. As shown in the studies of Colliver, Conlee, Verhulst & Dorsey
(2010), Hong, Bahn & Lee (2011) and Kataoka, et al., (2009), the researchers found no
negative effects brought about by clinical experiences on the levels of empathy (Table 2). The
studies in these Asian countries came to conclusion that both medical students and training
doctors disclosed the positive correlation with respect to empathy depending on the duration
of education. In the study carried out in Okayama University Medical School in Japan, the
researchers examined the whole six grades. The results indicated that, as the grade got higher,
the differences with respect to empathy were more significant (Kataoka, et al., 2009). In
another study, which sought to identify the correlation between communication skills for
emotional empathy and academic achievement on the clinical performance examination
(CPX), the fourth-year students had statistically more significant correlations than the third-
year students with regard to the rapport stage ‗active listening‘ and empathy stage ‗nonverbal
expression‘ (Jang, Seo, Cho, Hong & Woo, 2010). Hegazi and Wilson (2013) reported that
Australian medical students‘ mean empathy scores using the JSPE did increase from 108 to
111, but this increase was statistically insignificant. It is not clear whether this is an effect of
the medical education process or merely a natural maturation of age. Handford, Lemon,
Grimm & Vollmer-Conna (2013) reported that clinical practice, but not medical education,
has an impact on empathy development and maintaining empathic skills. The authors
compared five groups: three medical groups, consisting of medical students in their first two-
year phase, those in their last two-year phase of medical school, and medical practitioners,
versus two control groups, consisting of non-medical students and an older control group of
similar age and educational achievements. Participants answered questionnaires, performed a
modified version of the RME-R test, and monitored heart rate. The results obtained from the
questionnaires in this study differ from previous findings in the literature which state that self-
reported empathy declines throughout medical training (Bellini & Shea, 2005; Chen, et al.,
2007; Hojat et al., 2004). In contrast to previous findings, there was in fact no significant
change in self-reported empathy that could be attributed to medical training and practice. This
study also strongly supports the argument that changes in self-reported empathy are related to
a cognitive/emotional maturation rather than the effects of clinical training. Also, the data
from interoception sensitivity (physiological response) did not support a link between visceral
feedback and empathic processes. One of the limitations in this study was that all the
240 Geon Ho Bahn, Teckyoung Kwon and Minha Hong

participants were female (Handford, et al., 2013). One explanation for these different findings
is that empathy is increased as a result of differences in the medical education systems, but
there has been insufficient number of studies to be confident that such a causal relationship
exists (Hong, et al., 2012). In a brief report of medical students‘ empathy using Mehrabian‘s
BEES, meanwhile, there was no statistically significant difference among all four years
(Newton et al., 2000).

Gender Differences in Various Countries

In studies from the U.S., female medical students and doctors have tended to obtain
higher empathy scores than males (Hojat, et al., 2002b; Chen, et al., 2012). From studies of
measuring empathy in pharmacy students (Fjortoft, Van Winkle & Hojat, 2011) and in
nursing students (Fields, Mahan, Tillman, Harris, Maxwell & Hojat, 2011) in the U.S.,
women scored significantly higher than men. Males scored lower with respect to cognitive
and emotional empathy than females (Dehning, et al., 2012). In an Asian study targeting
Japanese medical students, female students gained higher marks than male students as they
advanced through school (Kataoka, et al., 2009). In an Australian study (Hegazi & Wilson,
2013), female medical students, all first year to fifth year, achieved higher scores than male
students; this fact can be due to differences in the affective component of empathy. On the
other hand, items which showed no significant differences between genders were
predominantly cognitive in nature, that is, items which measured the cognitive component of
empathy. Hojat (2002b) presented women as possessing a better capacity for catching and
understanding emotional signals and therefore forming a superior empathic relationship as a
reason for the differing results based on gender. The evolutionary theory of parental
investment hypothesizes that this reality is due to women who are to develop more caregiving
attitudes toward their offspring than men (Trivers, 1972). Recent research has shown a
correlation between right hemisphere activation on the face task and empathy in women only,
suggesting a possible neural basis for gender differences in empathy (Rueckert & Naybar,
2008). An empathy study with adolescents, females were generally more sensitive and
empathic than males of the same age, and the differences grew with age (Mestre, Samper,
Frias & Tur, 2009).
There is a hypothesis about the difference between the male and female brain that should
be considered (Baron-Cohen, 2003). The male brain is hard-wired for systematizing: the drive
to analyze and explore a system, to extract underlying rules that govern the behavior of the
system, and to construct a system. On the other hand, the female brain is hard-wired for
empathizing. This difference might have influence with regard to male- and female-
dominated occupations and physicians‘ specialty preferences. However, it is noteworthy that
gender does not determine one‘s brain type. It means that a female physician can have a male-
type brain. The role of culture and socialization as contributing factors in determining a male
brain versus a female brain has also to be considered (Baron-Cohen, 2003).
 Table 1. Empathy of medical students using Jefferson Scale of Physician Empathy-Student version (JSPE-S)

Size Total Gender Grade

JSPE-S Female Male Orienta- 1st year 2nd year 3rd year 4th year 5th year 6th year
Mean ± tion
SD
US 456 115.1 ± 115.6 ± 115.1 ± 109.1 ± 11.8 109.1 ± 14.1 longitudinal
(Hojat, et al. 10.0 11.1 11.0 (339) (356)
2009) (456) (399) (375)
(Berg, et al. 176 108.4 ±
2011) 12.7
(Hojat, et al. 371 122 ± 119 ± p < 0.01
2002a) 10 (173) 11 (198)
USA 658 116.5 112.1 p < 0.001 115.5a 118.5b [1.8] 118.2b [1.8] 112.7a,c [1.9] 106.6c [2.3] Groups that share the cross-
(Chen, et al. [1.8] (138) (142) (115) (91) same superscript are not sectional,
2007) (172) significantly different
from one another. [ ]: standard
All differences in JSE-S error
scores are significant at
the P < 0.05 level.
Korea 292 108.14 ± 109.2 ± 106.8 ± t = -1.809; 104.7 ± 108.6 ± 109.6 ± 9.9 t/F = 5.727;
(Lee, et al. 10.83 11.0 11.6 P = 0.072 12.3 (87) 11.6 (98) (105) p = 0.004;
2009) (124) (168) Post hoc 1st < 3rd
*
(Hong, et al. 233 110.09 ± 111.14 ± 109.24 ± p = 0.203 108.3 ± 109.31 ± 111.34 ± Medical
2012) 11.25 10.55 11.74 13.29* (31) 9.96* 10.47* college
†
(103) (130) 109.58 ± (38) (44) Medical
10.93† 110.17 ± 111.24 ± school
(43) 13.06† 10.27†
(40) (37)
Japan 378 104.3 ± 107.0 ± 103.7 ± t(376) = 2.2; P 98.5 ± 15.4 103.8 ± 105.0 ± 10.8 102.8 ± 14.4 105.4 ± 107.8 ± F(5,394) = 3.6;
(Kataoka, 13.1 11.1 13.2 = 0.02 (50) 15.4 (96) (65) 13.6 12.1 P = 0.003;
et al. 2009) (103) (275) (56) (47) (86) Post hoc
1st < 2,3,5,6th
Iran 1187 101.4 ± 102.75 ± 98.94 ± t(1160) = 4.3; 1-3 rd year 4-61/2 th year 61/2-7th year F(2,1098) = 32; preclinical/
(Shariat, 14.5 13.94 15.23 p < 0.001 105.5 ± 96.8 ± 15.1 100.3 ± p < 0.001 clinical/
Habibi 2013) (759) (403) 13.2 (423) (471) 16.2 (207) interns
Kuwait 264 104.6 ± 107.1 ± 100.6 ± p = 0.003 100.8 ± 104.3 ± 15.8 110.9 ± 13.1 105.1 ± 103.4 ± p = 0.037
(Hasan, 16.3 14.1 18.5 14.9 (56) (44) 17.8 17.8
et al. 2013) (167) (96) (61) (58) (45)
 Table 1. (Continued)

Size Total Gender Grade

JSPE-S Female Male Orienta- 1st year 2nd year 3rd year 4th year 5th year 6th year
Mean tion
± SD
Brazil 296 114.95 ± 116.47 ± 113.84 ± t = -1.26; p = 5,6th grade
(Paro, et al. 12.41 12.81 12.68 0.21 only
2012) (57) (92)
Portugal 476 112.86 ± 110.32 ± F (1,387) = 118.21 ± 110.31 ± F(1,387) = 19.33;
(Magalhaes, et 10.81 10.69 8.82; 9.10(356) 10.63 p < 0.001;
al. 2011) (321) (155) p < .01; (120) ɳ 2p = 0.48;
ɳ 2p = 0.23; π = 0.99
π = 0.84 1st > 6th
Poland 150 112.48 ± 112.59 ± 110.90 ± * including
(Kliszcz, 10.88 12.51* 12.16* physicians,
et al. 2006) nurses,
midwives
students, and
nursing
students
Spain 128* 125.1 ± 127.0 ± 120.5 ± 124.5 ± *experimental
(Fernández- 9.3*,‡ 9.3*,‡ 10.1*,‡ 7.58* group,
Olano, et al. 75† (82) †control group
(42) (86)
2008) ‡ including
119. ±
119.9 ± 3.7† both medical
3.6†,‡ 120.2 ± 118.3 ±
students and
†,‡ †,‡ (55)
3.7 3.7 medical
(35) (40) residents
*
Australia 404 109.07 ± 111.30 106.15 p < 0.001 107.71 ± 108.87 ± 108.00 ± 111.22 ± obtaining data
(Hegazi, 14.94 (229) (175) 13.09* 13.18* 109.23 ± 17.84* 17.15* from the
Wilson 2013) (90) (101) 15.48* (32) (74) author on
(107) request

New Zealand 72 beginning end Y5 Y6 F(2,213) = 249.73; longitudinal

(Lim, et al. Y5 113.55 ± 82.52 ± p < 0.001;
2013) 114.21 ± 10.50 17.87 Post hoc beginning
9.46 & end of
Y5 > Y6
 Table 2. Empathy of physicians using Jefferson Scale of Physician Empathy-Health Provider version (JSPE-HP)

Total Gender
Size JSE-HP Specialty
Mean ± SD Female Male
US 120.9 ± 119.1 ± t = 1.71; df F = 1.99;
120.0 ± PSY > FM, GS, OBGY, CS,
(Hojat, et al. 704 12.2 11.8 = 684; p = df = 11,493;
12.0 RAD, NS, OS, ANE
2002b) (179) (507) 0.08 p < 0.05
Korea 100.3 ± 96.5 ± t(227) = DER = IM = REB = F(7,221) = * specialties with few
98.2 ±
(Suh, et al. 229 11.7 12.0 2.35; Internship > GP = RAD = 3.84; p < physicians were grouped
12.0
2012) (103) (126) p < 0.05 Other* 0.01 into ―Other‖ category
F = 4.026;
1st 100.7 ± 11.6;
p = 0.008;
(Hong, et al. 2nd 101.2 ± 11.1; † psychiatric residents
316† Post hoc 1st <
2011) 3rd 105.2 ± 9.3; only
2nd, 3rd,4th;
4th 106.0 ± 13.8
2nd < 4th
*
female physicians only.
a a
People-oriented IM, PED, PSY;
Japan 110 ± F(2,282) = b
110 ± (112.9 ± 11.7) > ANE, surgery and
(Kataoka, et al. 285 11.9* 8.4; p <
11.9 Technology-orientedb surgical specialties,
2012) (285) 0.001
(106.9 ± 11.2) PATH, OPH, OS, OBGY,
URO
China IM, OBGY, *
109.5 ± t = 2.71; PATH, RAD, ANE,
(Wen, et al. 933 F>M Surgery > PED,
11.9 p = 0.01 * radiation oncology
2013) Medical subspecialties
Italia 117.5 ± t(287) =
115.1 ± 114.5 ± 15.6 Medical (117.5 ± 15.0), t(286) = 1.49;
(Di Lillo, et al. 289 14.6 1.33;
15.55 (229) Surgical (114.2 ± 15.6) P = 0.13
2009) (60) P = 0.17
France
111.8 ±
(Lelorain, et al. 295
10.6
2013)
PSY = Psychiatry; FM = Family Medicine; GS = General Surgery; OBGY = Obstetrics/gynecology; CS = Cardiovascular Surgery; RAD = Radiology; NS = Neurosurgery; OS =
Orthopedic surgery; ANE = Anesthesiology; DER = Dermatology; IM = Internal Medicine; REB = Rehabilitation Medicine; GP = General Practice; PED = General
Pediatrics; PATH = Pathology; OPH = Ophthalmology; URO = Urology.
244 Geon Ho Bahn, Teckyoung Kwon and Minha Hong

Nevertheless, in Korea, researches targeting medical students (Lee, Bahn, Lee, Park,
Yoon & Baek, 2009; Hong, et al., 2012) (Table 1) and psychiatric residents (Hong, et al.,
2011) (Table 2) revealed a contrasting result: gender did not influence one‘s empathic ability.
From the analysis of empathy scores of psychiatric residents, there was no gender difference,
but the average score of married residents was significantly higher than that of unmarried
residents (Hong, et al., 2011). One research comparing female and male doctors‘ empathy
scores showed a higher score for female doctors, but the degree of difference was
insignificant (Kang, Kim & Chang, 2006). A recent empathy study from Italian doctors did
not show much difference either (Di Lillo, Cicchetti, Lo Scalzo, Taroni & Hojat, 2009) (Table
2). On the validation of the Polish version of the JSPE, there were no statistically significant
differences on empathy scores between genders among five groups of respondents:
physicians, nurses, medical students, midwifery students, and nursing students (Kliszcz,
Nowicka-Sauer, Trzeciak, Nowak & Sadowska, 2006).
A recent study (Ohm, Vogel, Sehner, Wijnen-Meijer & Harendza, 2013) assessed the
clinical competency, including history taking and empathetic communication skills, of thirty
near-graduates from Hamburg Medical School. Female participants were rated as being more
empathetic across all cases with significant differences versus male participants. When data
from all female standardized patients (SPs) were combined, female participants were rated to
be significantly more empathetic than male participants, whereas for combined ratings from
male SPs no significant difference was found between female and male participants. There
are similar studies presenting higher empathetic ratings among female medical students or
physicians by female SPs (Schmid Mast, Hall & Roter, 2007; Carlson, Peets, Grant &
McLaughlin, 2010). For medical educators, the followings are left to be investigated: do these
findings reflect more patient-centered interactions and communication patterns of female
students, or do they represent simply different perceptions of empathy by female SPs or by
the female patient?

Different Degrees of Empathy to the Specialty Preference

In the evaluation of empathy capability that was carried out in the Jefferson Health
System, with 704 doctors from 12 different specialties, psychiatrists appeared to be the most
empathic group (mean score 127.0 from JSPE-HP) followed by specialists in internal
medicine (121.7) and in pediatrics (121.5), while orthopedics (116.5) and anesthetics (116.1)
were the lowest two specialties (Hojat, et al., 2002b) (Table 2). According to Chen (2007,
2012)‘s investigations, the empathic ability of medical students were divided into two groups:
the people-oriented specialty preferences (internal medicine, family medicine, pediatrics,
neurology, rehabilitation medicine, psychiatry, emergency medicine, obstetrics &
gynecology, ophthalmology, dermatology) and the technology-oriented specialty preferences
(anesthesiology, pathology, radiology, radiation oncology, surgery). The people-oriented
specialty preference group obtained higher empathy scores than the technology-oriented
specialty group. Another interpretation, however, has to be taken into consideration. Although
Chen (2007) categorized medical students as preferring either people-oriented or technology-
oriented specialties, the vast majority of incoming and first- through third-year medical
students, except fourth-year students, had small mean differences ranging from 0.46 to 0.62
when comparing their average Likert score for the people-oriented as well as the technology-
 Empathy in Medical Education 245

oriented specialty groups. In some studies (Di Lillo, et al., 2009; Kimmelman, et al., 2012;
Lee, et al., 2009), there was no difference between the two groups. The desired specialties
among Kuwait medical students were not significantly associated with levels of empathy
(Hasan et al., 2013). If there could be a difference in choosing specialties depending on the
empathic ability of the individuals, it would be better to select students with higher empathy
abilities in the first place. As a result, there has been a discussion about applying the
―empathy quotient‖ in the medical admission process in order to draft people with good
empathic abilities (Bouma, 2008). However, in a practical sense, this sounds hardly a feasible
task. On the other hand, relatively unempathic or less empathic individuals could choose a
non-core specialty like that of cardiovascular surgeons, radiologists, neurosurgeons,
orthopedic surgeons, anesthesiologists, and pathologists to compensate for their low empathic
function (Newton et al., 2000).
Although there have been many psychosocial researches on the differences of empathic
abilities between genders, specialty preferences, and personalities, it is hard to find evidence
for the causes of these differences. In order to explain the differences, we could attempt to
correlate the differences with the recently developing field, neurobiological research, into
empathy. Neurobiological research has yielded insight into the functional mechanisms that
may partially explain the observed individual differences in the capacity of empathy
(Shamay-Tsoory, 2011). Recent studies suggest a model of two separate components of
empathy: emotional versus cognitive (Watt, 2007). The distinctions between the emotional
and cognitive empathy components may relate to different neurochemical systems: the
oxytocinergic system, which is associated with increased emotional empathy (Panksepp,
2009; Hurlemann et al., 2010), and the dopaminergic functioning associated with the
cognitive aspects of empathy (Lackner, Bowman & Sabbagh, 2010). These two empathic
components might also have two different neuroanatomical pathways. Firstly, we can find
evidence, especially from the mirror neuron system (MNS), related with emotional empathy.
Simulation theories were greatly reinforced by the discovery of the mirror neurons, a set of
neurons that fire both when a monkey acts and when it observes the same action performed
by another monkey (Rizzolatti, Fabbri-Destro & Cattaneo, 2009). Given its observation-
execution properties, it was suggested that the MNS is particularly well suited to provide the
appropriate mechanism for motor empathy, imitation, and emotional contagion (Shamay-
Tsoory, 2011). In the inferior frontal gyrus (IFG) and inferior parietal lobule, MNS has been
identified (Rizzolatti, et al., 2009). Whereas emotion recognition and emotional contagion
appear to involve the IFG, shared pain appears to involve regions related to the first-hand
experience of pain, such as parts of the pain matrix. Specifically, a network, including the
anterior cingulate cortex and the insula, was reported to respond to both felt and observed
pain (Decety, Dchols & Correll, 2010). The second component, cognitive empathy
(understanding another‘s perspective), involves theory of mind (ToM) (Baron-Cohen, 2009)
and mentalization (Amodio & Frith, 2006), involving a set of brain regions including the
medial prefrontal cortex, the superior temporal sulcus, the temporoparietal junction, and the
temporal poles (Frith & Singer, 2008; Van Overwalle & Baetens, 2009). Such neurochemical
and neuroanatomical differences in the two aspects of empathy could work as important
factors in choosing specialties for doctors. This principle can also be applied when patients
choose doctors: i.e., from the perspective of the patient, not all patients wish to be the object
of empathy and caring (Bouma, 2008).
246 Geon Ho Bahn, Teckyoung Kwon and Minha Hong

Personality and Empathy

There have been numerous studies on the relevance that may exist between empathy and
prosocial behavior, altruistic behavior, and aggression control (Feshbach, 1975). Empathy can
be understood as incompatible with impulsiveness or aggression because impulsive people
tend to misunderstand others due to their incapacity to understand others‘ points of view. In
the correlation analysis between empathy and personality factors, using the Eysenck
Personality Inventory (Eysenck & Eysenck, 1975), there was not much difference between
the amount of empathy and extraversion-introversion or neurotic tendency. However, there
was more significance in the impulsiveness category, meaning that, if one is less impulsive,
he or she has more capacity for empathy (Kang, et al., 2006). Impulsivity as a personality
characteristic has a positive correlation with variable and inefficient performance and fast
cognitive speed in broad awareness-movement tasks. Therefore, the characteristics of an
impulsive person can be described as ―actions without second thoughts,‖ ―fast reactions rather
than a controlled one‖ and ―adventurousness‖ (Hilakivi, Veilahti, Asplund, Sinivuo, Laitinen
& Koskenvuo, 1989).
In the study by Lee (2009), the personality dimensions of the Temperament and
Character Inventory (TCI) (Cloninger, 1987), which had a significant correlation with
empathic measures, included reward dependence, cooperativeness and self-directedness plus
cooperativeness. These dimensions reflect the ability to change one‘s emotional response or
behavior depending on another‘s positive or negative feedback. The supportive help may
include enhancing cooperative and harmonious personal relationships with another‘s desires
and emotions, not to mention, a tendency to voluntarily direct one‘s behavior and act with
responsibility. Aspects composing the personality, excluding temperament, including such
characteristics as cooperativeness and self-directedness, could be gained and developed by
interactions with the environment. Among psychiatric residents, subscales, such as the
persistence and cooperativeness dimensions of the TCI, showed a significant correlation with
empathic score (Hong, et al., 2011). The patience subscale is related with diligence and
sincerity, whereas the solidarity subscale is related with accepting others and a tendency to
achieve harmony and balance (Cloninger, 1987). Based on the conceptual relevance and
currently available empirical evidence, Hojat, Erdmann & Gonella (2013) proposed that
measures of two personality attributes, ―conscientiousness‖ and ―empathy,‖ be considered in
predicting educational and clinical outcomes, in career counseling, and in assessments of
educational outcomes. In addition to these, the potential ―tie-breakers‖ for admission
decisions among candidates with similar academic qualifications would be also accounted.
Medical educators should consider these personality traits when establishing the curriculum
for medical students and resident training (Lee, et al., 2009).

HOW TO ENHANCE AND MAINTAIN EMPATHY

Obstacles to the Development of Empathy in Medical Education

To teach empathetic attitudes and skills for medical students, we have to consider the
following question. Is it true that the more empathetic physicians are, the better they are at
 Empathy in Medical Education 247

gathering medical information from patients‘ history? It seems that gathering sufficient
information from a patient‘s history and empathic communication are two completely
separate sides of the coin of history taking (Ohm, et al., 2013). We have a similar dilemma.
Whereas the most doctors accept the value of empathy in the medical field, the patients,
apparently, do not feel those doctors‘ empathetic behavior. Why does this reaction occur?
Why is it so difficult then to promote the concept of empathy during medical education? Two
logical reasons can be cited: (a) medical students and residents have complex and mostly
unresolved emotional responses to the universal human vulnerability to illness, disability,
decay, and ultimately death, all of which they must confront in the process of rendering
patient care; (b) modernist assumptions about the capacity to protect, control, and restore run
deep in institutional cultures of mainstream biomedicine, while creating barriers to empathic
relationships (Shapiro, 2008).

Brief or Optional Programs

At most medical schools, communication skills are taught and assessed through SPs‘
interactions (Deladisma et al., 2007). Despite having advantages over real patients, SP
training has some limitations such as substantial effort and expense to train SPs, as well as
difficulty for repetitive practice. In light of those limitations, it can be suggested that virtual
patients (VPs) can be a substitute for SP in medical education. VPs are interactive computer
programs that simulate real-life clinical scenarios in which the learner acts as a healthcare
professional, in order to obtain a history and physical examination for the diagnostic and
therapeutic decisions. VPs offer several potential advantages over SPs, such as limiting the
effort and expense associated with SP training, creating diverse virtual clinical scenarios, and
providing a controllable, secure, and safe learning environment with the opportunity for
extensive repetitive practice. VP scenarios have the potential to accelerate student learning
and enhance traditional SP teaching and testing programs. What difference would these two
programs have in terms of empathy education? Deladisma et al., (2007) designed an
experiment to determine whether more complex communication skills, such as nonverbal
behaviors and empathy, were similar when medical students interacted with a VP versus a SP.
Medical students were randomly assigned to undergo a video-taped abdominal pain scenario
with either an SP or a VP with identical scripted responses. Students‘ interactions were
videotaped. Clinicians rated videotaped student interaction with respect to nonverbal skills
(eye gaze, head nod, and body lean toward patient), empathic behaviors, levels of immersion,
anxiety, attitude, and overall rating for the social interaction using a Likert-type scale with
descriptions. The students in the SP group were rated higher with respect to nonverbal
communication skills, empathy rating, and overall rating than the VP group. Empathy was
positively correlated with observed nonverbal communication behaviors. Eye contact was the
most strongly correlated factor with empathy, followed by the head nod, and body lean.
Many researchers have sought to prove the effectiveness of a short-term workshop in
increasing or sustaining one‘s level of empathy. Van Winkle, Fjortoft & Hojat (2012) studied
the impact of a short-term workshop about aging on the empathy scores of pharmacy and
medical students by comparing two groups. The results indicated that the workshop promoted
a temporary increase in empathy, but they returned to their original scores when measured
again after 26 days. Although the content was not specifically related to medical practice,
248 Geon Ho Bahn, Teckyoung Kwon and Minha Hong

Fernández-Olano, Montoya-Fernández & Salinas-Sánchez, (2008) assessed the impact of a

communication skills workshop on the empathy level of medical students and medical
residents in Spain. The experimental group participated in an activity consisting of a 25-hour
theoretical/practical workshop on communication and empathy. Post-workshop empathy
scores increased significantly in the experimental group, improving in 68.9% of the
participants. No significant increase in empathy scores after the second assessment was
observed in the controls. A communication skills workshop thus yields a slight improvement
of crucial practice in subjects‘ empathy.

Effects of Continuous, Long-Term Activities

From a one-year follow-up study of medical students (Hong, et al., 2012), empathy
improved significantly after one year of medical education, regardless of the year of study
and the medical education system. After a thorough examination, it was suggested that a class
entitled ‗Physicians in Society,‘ taken for three years by students, might have a positive
correlation with empathy development. This class is worth one credit and is a required subject
for one hour per week. The class deals with medical ethics, doctor-patient relationships, and
communication; the course contents are thought to improve the students‘ attitudes towards
patients, their understanding of ethics, and their capacity for empathy. Another longitudinal
and mandatory intervention program, ‗Humanism and Professionalism,‘ was found to be
effective in preserving empathy in third year students at the Robert Wood Johnson Medical
School (Rosenthal et al., 2011). The ‗Humanism and Professionalism‘ program included
blogging about clerkship experience, debriefing after significant events, and discussing
journal articles, fictions, and films. After the completion of the third year clerkship, in which
gradual empathy erosion may happen in U.S. medical schools (Hojat et al., 2009), students
did not decline in empathy. Although the authors cannot be certain that the ‗Humanism and
Professionalism‘ interventions were responsible for the lack of decline in empathy, student
feedback indicated that the sessions helped them prevent burnout and to better recognize
positive and negative role models. The exact mechanism as to how the classes such as
‗Physicians in Society‘ and ‗Humanism and Professionalism,‖ can have an effect on empathy
should be determined in future studies according to whether groups took the class or not.
During lectures in classrooms and clinical clerkships, faculty might implicitly encourage
students to value empathy (Bouma, 2008). Instead of explicitly training students to behave
empathetically, students would be given the opportunity to observe faculty members‘
empathic behavior and generate an internal motivation to emulate them. This could be an
effective means for encouraging empathy in medical practice.

Arts and Humanities in Medical Education

In treating disease, the ‗scientific aspect of medicine‘ and the ‗artistic aspect of medicine‘
have a complementary effect (Peabody, 1984). Spiro has been highly influential in
introducing empathy into the medical curriculum in the U.S., largely through a focus on
literature and humanities (Smajdor, et al., 2011). Hunter, Charon & Coulehan (1995) also
emphasized the use of literature for medical education. They insisted that five broad goals can
 Empathy in Medical Education 249

be met by including the study of literature in medical education: (a) Literary accounts of
illness can teach physicians concrete and powerful lessons about the lives of sick people; (b)
great works of fiction about medicine enable physicians to recognize the power and
implications of what they do; (c) through the study of narrative, physicians may better
understand patients‘ stories of sickness and thus solidify their personal stake in medical
practice; (d) literary study contributes to physicians‘ expertise in narrative ethics; and (e)
literary theory also offers new perspectives on the work and the genres of medicine (for
details, see Charon, 2012). All sciences included in medical humanities are important for the
high quality education of future doctors. Introduction into the world of arts and literature
induces the development of observational skills, analytical reasoning, empathy and self-
reflection (Batistatou, et al., 2010). Medical humanities provide insight into human
conditions, illness and suffering, perception of oneself, as well as into professionalism and
responsibilities to self and others, including colleagues and patients. Art and humanities
courses, which include poetry, prose, writing and reading of literature, can stimulate empathic
development in medical students (Wolters & Wijnen-Meijer, 2012). Batt-Rawden, Chisolm,
Anton & Flickinger (2013) conducted an updated, systematic review of the literature on
empathy-enhancing educational interventions in undergraduate medical education. They
found that several types of interventions were successful in maintaining and enhancing
empathy in medical students, namely, patient narrative and creative arts interventions, writing
interventions, drama interventions, communication skills training interventions, problem-
based learning interventions, interpersonal skills training, patient interview interventions,
experiential learning interventions, and empathy interventions. Recently, medicine practiced
with narrative competence (the ability to acknowledge, absorb, interpret, and act on the
stories and plight of others), has been proposed as a model for humane and effective medical
practice (Charon, 2001).
How do we develop and enhance empathy as a result of reading and writing?
Historically, the form of narrative has been transformed according to the changes of the
society as well as to the new ethics we need in it. On the Greek stage, the chorus is the voice
of the author to help the audience‘s understanding (Nietzsche, 1886). In the 19th century
novel, the authorial voice of a narrator expressed that usually in first person terms or the
omniscient third person stance (Stanzel, 1984). As the reading population increased, however,
that role disappeared and the fictional devices used became complicated: thereby the central
or reflective character became transformed as seen in Henry James‘s fictions. Henceforth, the
third person narrators do not inform readers directly but rather often focus upon and follow
the actions and the minds of main characters so as to enhance the reader‘s empathy (Cohn,
1978). Thereby, we can identify with main characters, which enable us to make critical
judgments about them as, for example, in ―The Beast in the Jungle‖ (James, 1903). The way
Henry James attracts readers toward the appreciation of the dynamic interconnection between
affect and cognition, the two brain functions that critically interact to enhance empathic
attitudes, is to construct a third person narration that focuses on the protagonist‘s
consciousness, a stance that can be echoed in scientists‘ experiments. For instance, Omer
proposes that narrative empathy can be a useful medium to enhance the communion between
doctor and patient by reintegrating and modifying the external narrative with the internal one
— yielding a harmony of two oppositions (Omer, 1997). Through the balance between
emotion and cognition, literature is able to re-enliven repressed affections within us and to
restore more prosocial, normal ways of feeling and thinking, skills that may diminish in
250 Geon Ho Bahn, Teckyoung Kwon and Minha Hong

modern emotionally-alienating societies. With respect to the development of curricula and

effective interdisciplinary teaching methods, medical humanities have, in fact, contributed
substantially to medical education in recent years (Avrahami, 2011). However, there is not
enough evidence yet, to provide adequate outcome evidence for the impact of such curricula
for doctors‘ attitudes and their ongoing work with patients (Ousager & Johannenssen, 2010).

Empathy Education in the Future

Long-term follow-up research would be needed to confirm the beneficial effects of

empathy strengthening programs if they were used in the curriculum as regular mandatory
courses instead of optional ones. Global incorporation of relevant literary works into medical
education may be facilitated by well-designed international comparative studies, using
standards such as empathy rating scales. As seen in various empathy research papers,
although medical educators and researchers see an educational focus on medical empathy as
necessary part of the curriculum, and many assume that it will be effective, it is true that there
is still no set standardized evidence-based educational model yet. Obviously, to construct a
satisfactory model is hardly an easy job, especially if the goal is for elevated levels of genuine
empathy to emerge (Bayne, et al., 2013). Also, genuine empathy may be difficult for some
individuals to achieve, considering the different personalities and situational barriers, and
mere instrumental empathy may be counterproductive if it is not deemed to be sufficiently
sincere. Still, we anticipate that evidence-based empathy training could beneficially impact
medical services and both patient and physician satisfaction. Therefore, it may be wise to
implement feasible training programs so as to help assure the likelihood students will be
optimally empathetic when they begin to practice.

CONCLUSION
Although probably everyone accepts the significance of empathy in medical education
and clinical practice, it is hard to specify how that can be measured or achieved. Since the
development of the Jefferson Scale of Physician Empathy, numerous medical fields and
countries have studied physicians‘ and medical students‘ empathy levels focusing on gender,
specialty, and training period. This work has yielded diverse results, yet not completely
consistent across studies. From such ongoing work, we hopefully will eventually reveal the
best way to proceed. For the enhancement of a medical personnel‘s capacity for empathy as
well as for a positive effect on patients‘ treatments, we still need to design and implement
evidence-based programs to develop, enhance and sustain empathy. The program will need to
be suitable for a medical educational curriculum, where time-demands are extreme. Through
theoretical and practical experiences, educators of medical professionals should recommend
continuous and mandatory education, including art and humanities, not to mention, literature.
Those curricula should not be brief or optional programs, but in-depth and sustainable ones.
After all, elevated empathy is not just a key goal of medical education, but for all human
interactions, including how we treat nonhuman beings.
 Empathy in Medical Education 251

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Yu, J. & Kirk, M. (2008). Measurement of empathy in nursing research: systematic review.
Journal of Advanced Nursing, 64(5), 440-454.
In: Psychology and Neurobiology of Empathy ISBN: 978-1-63484-446-8
Editors: Douglas F. Watt and Jaak Panksepp © 2016 Nova Science Publishers, Inc.

Chapter 10

EMPATHY: ANGEL OR DEVIL?

HOW SHARED EMOTIONS CAN HELP OR HINDER
NURSES IN THEIR RELATIONSHIPS WITH PATIENTS

Anna Maria Meneghini, Laura Cunico

and Riccardo Sartori
Department of Philosophy, Education and Psychology,
University of Verona, Italy

From the standpoint of the discipline of psychology, empathy is a construct, that is to say
a concept used to describe a specific psychological activity or a pattern of activity that is
believed to occur or exist but cannot be directly observed or measured (Sartori & Pasini,
2007). One popular and widely referenced definition might be: ―We empathize with others
when we have (a) an affective state that (b) is isomorphic to another person‘s affective state
and (c) was elicited by observing or imagining another person‘s affective state, and (d) when
we know that the other person‘s affective state is the source of our own affective state‖ (Hein
& Singer, 2010, p. 111). This is a working or basic definition shared by such scholars as
Eisenberg et al. (1994), de Vignemont and Singer (2006), Gallese (2007) and Decety et al.
(2012) among others (but see discussion of empathy definitions in first chapter by Watt and
Panksepp in this volume). It implies that empathy involves sharing the same emotional state
as someone else and does not refer to a situation in which the observer feels different or
fundamentally incongruent emotions. Regarding studies that have attempted to clarify the
mechanisms underlying empathic processes, Decety et al. (2012, p. 44) have recently argued
that the ―development of human empathy has been elaborated through the integration of other
abstract and domain-general high-level cognitive abilities such as executive functions,
language, and theory of mind, underpinned by the prefrontal cortex, which expand the range
of situations that can elicit empathy and the range of behaviors that can be driven by
empathy.‖ Therefore, in this review, we will assume that empathy is mainly an emotional
phenomenon (―suffering with another person‖ as suggested by the basic etymology of the
word; see Watt, 2005, 2007) and that certain cognitive aspects (e.g., perspective taking and
theory of mind) are probably closely related (typically conjoined with more affective
260 Anna Maria Meneghini, Laura Cunico and Riccardo Sartori

responses including contagion/affective resonance) in empathizers, but these cognitive

aspects are probably not fundamental to more affective empathy. However, the typically
highly conjoined nature of affective empathy/contagion and theory of mind/perspective taking
operations has led many authors to talk about empathy as having both more cognitive as well
as more affective dimensions (Blair, 2005). Thus, we refer to emotional empathy as the
vicarious experience of the emotional states of other people, i.e., feeling and sharing how
another person feels (Mehrabian, 1996). As emphasized by Watt (2007) and discussed in the
chapter by Watt and Panksepp in this volume, most empathy concepts probably sit on the
emotion/cognition border, a location that no doubt contributes to the significant
terminological confusion that surrounds empathy concepts.

EMOTIONAL EMPATHY, COGNITIVE EMPATHY

AND DEVELOPMENTAL PERSPECTIVE

As emphasized in the fourth element of the definition of empathy proposed above (i.e.,
when we know that the other person‘s affective state is the source of our own affective state),
the importance of being able to identify one‘s own emotional state and that of the other
person is presumably fundamental to more complex human empathy. When one studies the
developmental phases of empathy, it is clear that progressive cognitive mediation is used by
children in empathic processes in order to allow them to be conscious of being in tune with
another person‘s emotional state and also to be aware that their current feeling is elicited by
the feeling of the other person (Bonino et al., 1998; Eisenberg, 2000).
According to the developmental model of Eisenberg (2000), the first stage in the
developmental process of empathy is characterized by basic emotional contagion; that is, the
intense emotional sharing beyond cognitive control which is typical of infants and very young
children. This primitive and automatic process is probably gradually inhibited due to an
increase in the affective modulation/inhibition skills that are developing, but however persists
even in adults (Barsade, 2002; Bonino, 2006; Watt, 2007). The second stage is parallel
sharing empathy, where cognitive mediation still does not reach an adequate level of
differentiation between the empathizer and the subject possibly resulting in the attribution of
the former‘s own emotions and feelings to the latter. The last stage, appropriately named
empathy, involves conscious awareness of the use of cognitive mediation, on one hand, and
the sharing of elements of the emotional state on the other (Eisenberg 2000). This proposed
developmental model shows how cognitive mediation in empathic processes becomes more
and more sophisticated until the person is able to feel what the other is feeling with the
awareness that what they are experiencing is a resonance with the other‘s feeling. The
development of empathy during these phases is affected by personal experiences especially
experiences of successful non-traumatic attachment, which may be one of or the most
important developmental foundations in terms of developing empathic skills (Watt, 2005).
This hypothesis is supported by converging evidence that there is a large overlap among the
brain structures and neural networks involved in empathy and attachment processes (e.g., see
Lorderbaum et al., 2004; Panksepp, 1998; Watt, 2007). Most people presumably achieve this
last phase (empathy) during their lifetime (Bonino, 2006). This means that an adult has more
than one cognitive mediation process available for different situations because neither the first
 Empathy: Angel or Devil? 261

nor the second stage is strictly linked to a particular age, suggesting that an adult can
sometimes regress to parallel sharing empathy or to simple emotional contagion. For
example, in situations involving intense, distressing emotions, the person may be over-
aroused by unpleasant feelings (emotional contagion) and the witness might be induced to
avoid and/or refuse the relationship. Similarly, an adult can regress to parallel sharing
empathy and feel what he/she feels in a comparable situation and thus does not conceive what
the other is actually feeling.
According to some points of view (Sagi & Hoffman, 1976; Bonino, 2006; Watt, 2005,
2007), even though emotional contagion cannot be considered equivalent to a full empathic
response per se (due to the lack of recognition that the other person‘s emotion is the trigger of
one‘s own affective state and the lack of stable concern for the other), it is a clear
developmental precursor to the development of the capacity to empathize, and provides a core
and essential mechanism for emotion induction in empathy processes. Moreover, if we agree
with the idea that empathy is characterized by a relatively automatic early process stage in
terms of neural responses, emotional contagion might be thought of as a developmental
precursor of other more sophisticated types of empathy. Highly sophisticated types of
empathy are then modulated by an individual‘s ability to take on another person‘s perspective
(perspective taking, Davis, 1983) and to regulate emotions (Eisenberg & Fabes, 1992). Thus,
when we analyse empathic processes in adults from a phenomenological point of view, it is
useful to take into account both components of empathy: emotional empathy (vicarious
feelings experience: Mehrabian, 1996) and the ability to share the perspective of others
(perspective taking: Davis, 1983; Decety & Jackson, 2006). At present, some evidence from
studies involving patients with marked social deficits (such as autism or psychopathy) has
suggested that the two components refer to distinct processes which rely on different neural
circuitries (Blair, 2005; Singer, 2006; Decety & Jackson, 2006). In addition, some evidence
has been collected in non-clinical subjects. For example, Besel and Yuille (2010) recently
evaluated the timing of reactivity of participants in terms of the expression of fear taking into
account these two separate components of empathy. The results of their study showed that
high scores in emotional empathy were associated with high accuracy in the identification of
emotion expressed when the stimuli exposures were brief (50 ms), but the advantage gained
by the empathetic group at this automatic level disappeared (no significant differences
between the participants high and low in emotional empathy) when the exposures were longer
(200 ms). On the contrary, the levels of cognitive empathy assessed seemed to be unrelated to
the participants‘ performances in emotion recognition tasks. According to the authors, this
implies that when the situation did not require fast recognition, as in the case of a longer
duration, a cognitive interpretation may compensate for inadequate automatic processing. In
any case, there still remains the matter of the interaction between the cognitive and emotional
elements of the process in empathic behaviour.
In conclusion, it might be hypothesised that a large part of human social life is
fundamentally facilitated and stabilized by empathy. Many scholars agree that besides
evidence that empathy originally developed as a function of parental care, it has now become
a means to promote prosocial behaviours and the formation and maintenance of strong social
bonds even between unrelated individuals (Decety et al., 2012). But is each human being
equal in terms of empathic trait/tendency and are his/her empathic responses the same in
every situation? Watt (2005, 2007) hypothesized that many complex factors account for
enormous variability in both the capacity for empathy as well as the intensity of empathic
262 Anna Maria Meneghini, Laura Cunico and Riccardo Sartori

responses in any given situation, and suggested that these variables are classifiable into four
classes of modulating factors:

 a genotypical group that refers to predisposing genomic variables promoting ‗native

empathic ability‘ consistent with evidence that contagion is inheritable,
 a phenotypical group that refers to the degree of proximity or attachment to or the
familiarity with the target involved in the empathic process, as well as how particular
social developmental trajectories may have maximized or inhibited the envelope of
genetically modulated empathic capacities,
 the characteristics of the target as perceived by the empathizer (e.g., the target‘s
vulnerability, ‗cuteness‘ or helplessness which is a significant modulator of empathy
gradients in which underscores the intrinsic connection of empathy to Panksepp‘s
prototype of mammalian nurturance and maternal care),
 a group of state-dependent variables such as the current affective state of the
empathizer, and where anger for example is a potent inhibitor of empathy cascades.

The first two classes might be considered dispositional/developmental variables that

affect the empathic activation, the last two classes take into account how the more immediate
affective situation is structured and are therefore situation-dependent variables. According to
Watt‘s Gated Resonance Induction Model (2005, 2007), all these variables work and
presumably interact, in terms of determining a ―global gate‖ which modulates the activation
of the empathic response: when the variables working on the ―global gate‖ level are
maximized, the resonance elicited by the other‘s emotional state is intense, as is the
corresponding motivation to reduce suffering. According to Watt, it is still unclear how this
notion of global gating might work at a neurological level, but he suspects that it is clearly
related to attachment processes which amplify resonance induction. ‗Gating‘ or modulating of
empathic responses also clearly follows the fundamental operating logic of prototype emotion
as outlined by Panksepp (1998) and many others – in which positive states facilitate other
positives while negative states do the reverse and facilitate negative states instead. In other
words, being fundamentally angry at the suffering party is a potent inhibitor of empathy
response, consistent with empathy representing a more positive prosocial emotional process
towards the suffering party. On the other hand, attachment to the suffering party, the relative
vulnerability of the suffering party, and the positive affective state of the observer all
presumably amplify empathy cascades (Watt, 2007).
In order to better understand what often widely differential results are obtained by
different studies on empathy processes, it is necessary to examine that both theoretical
assumptions and research methods, as well as how studies might operationalize different
variables of the empathy process. In some cases, studies focus on an individual‘s capability to
infer the content of another person‘s thoughts and feelings (empathic accuracy: Ickes, 2001 –
a variable that may relate to good theory of mind operations); otherwise, individual levels of
attitude and tendencies to share other‘s thoughts and feelings are analysed focusing on the
dispositional aspects of the empathy (trait empathy) (Davis, 1983; Mehrabian, 1996); thirdly,
empathy has been conceptualized as an observer‘s affective or behavioural response which
can be influenced by various elements in the situation (state empathy). Before analysing
human differences in empathic tendency, it is useful to recall here that several instruments
 Empathy: Angel or Devil? 263

(mainly various psychological tests, but also many inventories and questionnaires) have been
constructed in order to measure the various different aspects of empathy. Indeed, literature on
empathy suggests many potential definitions and emphases, and any case suggests that
empathy remains a multifactorial and multicomponent construct composed of diverse
cognitive, emotional and behavioural aspects. In literature reviews looking at the
measurement of empathy (for example those by Yu & Kirk, 2008, 2009), empathy
instruments are classified on the basis of the theoretical model of empathy they refer to, that
is, their focus on cognitive, emotional, behavioural dimensions or some/all of these. From this
point of view, it is possible to refer to the Hogan Empathy Scale (Hogan, 1969) for cognitive
aspects; the Interpersonal Reactivity Index (Davis, 1980) for both cognitive and emotional
aspects; the Jefferson Scale of Physician Empathy (Hojat et al., 2001) for behavioural aspects;
and the Balanced Emotional Empathy Scale (BEES) (Mehrabian, 1996, unpublished data) for
emotional aspects. Other instruments for empathy measurement are the Empathy Construct
Rating Scale (La Monica, 1981), the Layton Empathy Test (Layton, 1979), the Reynolds
Empathy Scale (Reynolds, 2000), the Perception of Empathy Inventory (Wheller, 1995) and
the Barret-Lennard Relationship Inventory (Barret-Lennard, 1978). Such diversity of
instruments and approaches/methods suggests a large potential for divergent findings across
studies; as Watt (2007) notes, empathy research often times resembles the proverbial three
blind men inspecting the elephant.

DIFFERENCES IN EMPATHIC TENDENCY

What are the dispositional factors that are related to variability in empathic tendency?
Differences in empathic trait were observed according to the gender of the empathizer. Many
studies have reported that female adults are generally more empathic (e.g., Lennon &
Eisenberg, 1987; Batson et al., 1996; Schieman & Van Gundy, 2000; Toussaint & Webb,
2005; Besel & Yuille, 2010; Smith et al., 2010) and more able to recognise emotions
(Graham & Ickes, 1997) than males. Research conducted by our group (Meneghini & Sartori,
2004) revealed differences between genders and showed that these differences are correlated
to the frequencies of feelings in a person‘s everyday life. The study involved a sample of 753
participants (about 50% females and 50% males, all Italian) and showed that women have
higher scores than men in terms of emotional empathic tendency (as assessed by the Italian
version of the Balanced Emotional Empathy Scale by Meneghini et al., 2012). The
participants in the study were divided into two groups labelled ―High Empathic Tendency‖
and ―Low Empathic Tendency‖ by virtue of their scores on the Balanced Emotional Empathy
Scale. Of all the participants belonging to the first group, 73.3% were females. These
participants also showed higher emotional frequencies than the other group (Low Empathic
Tendency) for sadness, surprise, fear and shame. Moreover, participants who reported high
empathic tendency, regardless of the gender, showed higher everyday frequencies in positive
emotions (joy and interest). This suggests, not surprisingly, that empathy may have an
intrinsic association with social and relationship success.
These results bring up another potential issue regarding differences related to empathic
tendency: those who are more easily aroused by emotional stimuli (people whose affective
response threshold is low, Eisenberg & Fabes, 1992) and experience more frequent and more
264 Anna Maria Meneghini, Laura Cunico and Riccardo Sartori

intense emotions can be better at expressing emotions than others. Notarius and Levenson
(1979) preselected the participants of their study and then categorized them on the basis of the
subjects‘ facial expressiveness while they were viewing a film: each change of facial
expression (from neutral to non-neutral and vice versa) was counted as one occurrence. The
participants who scored high in the changes of facial expressions of emotions were classified
as ‗natural expressers,‘ who scored low ‗natural inhibitors.‘ The authors reported that who
were natural expressers of emotions, showed significantly higher empathic tendency levels in
comparison with ‗natural inhibitors.‘ Also according to Sonnby-Borgström (2002), intense
automatic facial mimicry is related to high levels of empathy – consistent with many models
suggesting that contagion forms basic foundations for more complex human empathy.
Comparing facial mimicry reactions to the stimuli (faces expressing various emotions) with
the self-reported intensity of feelings of a group of participants, she found positive
correlations between the individual level of empathy and the intensity of the mimicry. These
correlations were stronger than those between mimicry and the conscious interpretation of the
situation.
A basic finding of much empathy research is that women are – on average at least –
consistently more empathic than men (e.g., Lennon & Eisenberg, 1987; Batson et al., 1996;
Schieman & Van Gundy, 2000; Toussaint & Webb, 2005; Besel & Yuille, 2010; Smith et al.,
2010). However the basis for this tendency is not clearly established. One question might be
whether a higher empathic tendency in women might be due to their greater emotional
expressiveness or their more social orientation. Is any advantage in emotional expressiveness
innate/genetic, or due to social learning and acculturation during their early years of life? In a
study by Sonnby-Borgström et al. (2008), where subliminal exposure was used, male and
female participants did not show differences in congruent mimicry responsiveness
(contagion). Only when the stimuli exposures were ―over threshold,‖ did the performances of
women and men diverge: in some emotions (e.g., happiness and anger) the female
participants showed more congruent and intense mimicry responsiveness and, in addition,
more intense feelings (self-reported). Panksepp (1998) has suggested that this gender
difference may emerge from the intrinsically greater role mammalian females have in the
nurturance and care of the young.
Further evidence around a gender difference in relationship to basic empathic capacity is
available from data collected from children. Feshbach and Roe (1968), for example, observed
that boys of 6/7 years performed as well as girls of the same age in a discriminatory task
related to emotions. What seemed to distinguish the genders was the propensity to express
specific emotions: male participants tended to avoid showing fear which is less culturally
accepted in men than in women (Strayer, 1987). In a longitudinal study (participants‘ levels
of emotional and cognitive empathy was assessed three times in three years) Mestre and
colleagues (Mestre et al., 2009) tested differences in empathy in a group of male and female
adolescents and found that sex differences increased considerable with age: ―Same age girl
are therefore more empathic than boys and sex differences are greater (large effect size) as
they move on to the following developmental stage‖ (Mestre et al., 2009, p. 81). All this
seems to bolster the idea that empathy and interpersonal skills are generally viewed as more
important to the concept of self by women than men. Klein and Hodges (2001), in their study
with female and male adults, manipulated the instructions in order to evaluate, within each
gender, the participants‘ abilities to infer the thoughts and feelings of a target person. Data
revealed a significant main effect for gender: in the ―empathy condition‖ women performed
 Empathy: Angel or Devil? 265

better in empathic accuracy. In the ―cognitive condition‖ women and men did not differ in
their performances. Finally, the authors stated: ―it is not a difference in ability that leads
women to be more empathic in some circumstances but a difference in motivation. Certain
factors in the situation seem to cue women that the skill that is being measured is relevant to
their female gender role, which in turn motivates them to try harder to understand what the
other person is thinking or feeling‖ (Klein & Hodges, 2001 p. 727). So, might it be concluded
that women‘s advantage in empathic ability might be due to social expectations? At the
moment, whether and to what extent the differences between genders can be explained in
terms of biological variations or nurture variables is still not totally clear (Lamm et al., 2011).
However it is certainly possible if not probable that culture amplifies what may be relatively
small differences in genetic endowment to create larger differences in an emerging
phenotype.
Further factors are considered as potentially associated to inter-individual differences in
empathic tendency. Eisenberg and Fabes (1992) proposed that individual levels of empathic
tendency could be related to the intensity and threshold of responding to emotional stimuli
(Derryberry & Rothbart, 1988; Larsen & Diener, 1987; Mehrabian et al., 1988), and to
people‘s abilities to modulate their emotional reaction (Derryberry & Rothbart, 1988), i.e.,
how people deal with emotional arousal. The authors posited that several types of regulation
might be involved in the process of sharing others‘ emotions: attentional control (i.e.,
personal ability to manage one‘s own attention focusing and shifting), activation control (i.e.,
the ability to initiate and maintain behaviours that are not pleasurable) and inhibitory control
(i.e., the individual ability to suppress toned impulses positively and thereby resist the
execution of inappropriate approach tendencies). Therefore, those who usually successfully
regulate their emotional arousal are also able to modulate their vicariously induced emotions
and are therefore more prone to sharing other‘s emotion, even if it is a distressing emotion, as
compared with those who are relatively weak in attentional and activation control (Eisenberg
& Fabes, 1992).
Another individual characteristic which has been long suspected as intrinsically related to
empathic personality traits is a more prosocial personality orientation (Penner et al., 1995;
Penner, 2002). Batson (1991), for example, highlighted how empathic individuals also help in
circumstances in which there is danger to themselves. According to Penner and colleagues,
empathy is one of the components of the prosocial personality and therefore, when this is at a
high level, the prosocial behaviour is equally high. Some scholars (Cozolino, 2006;
Eisenberg, 1986; Batson, 1991; Castiello et al., 2010) have stated that human beings come
into the world wired to socially interact. Individual interactive experiences, especially during
the early years, modulate congenital propensity for sociality. Watt (2007), for example,
hypothesized that empathic abilities may be reinforced or impaired by differential early
attachment experiences in childhood (see also: Mikulincer et al., 2001). It was found that
highly empathic people are more prone to feeling empathy for a person in need and, as a
consequence, he/she often engages in helping behaviours (Batson, 1991). As Batson et al.
(2005) assert, in many cases the similarity between a person and the individual in need seems
to increase the likelihood of empathic concern. Otherwise, similarity is neither a necessary
nor a sufficient condition.
We assessed empathic tendencies by means of the Balanced Emotional Empathy Scale
(Meneghini et al., 2012) in a large group of volunteers working in non-profit organizations.
Data showed that the volunteers (N = 483), as compared to the participants who were not
266 Anna Maria Meneghini, Laura Cunico and Riccardo Sartori

engaged in voluntary service (N = 443), showed a higher propensity to share emotions with
people who did not belong to their in-group (Meneghini & Sartori, 2011). Results showed
that both groups performed equally in terms of propensity to share emotions with family
members and friends (ingroup), but volunteers scored higher than participants not involved in
voluntary service in those items which referred to the tendency to be empathic towards
strangers (outgroup). This suggests the interesting conclusion that less empathic individuals
are more likely to follow ingroup/outgroup distinctions, which in some instances can promote
harsh and even cruel responses to others identified as different (see discussion of this as a
potent empathy gating variable in chapter by Watt and Panksepp in this volume).
Recently a study conducted by Banissy et al. (2012) aimed to explore whether individual
differences in trait empathy dimensions were related to morphological differences in human
brain structure (i.e., grey matter) of the regions that previous study found implicated in the
affective facets of empathy (e.g., Chakrabarti et al., 2006; Jabbi et al., 2007; Lamm et al.,
2011; Singer et al., 2004; Decety, 2010; Singer & Lamm, 2009). Using the voxel-based
morphometry assessment technique, the authors showed that the grey matter structure is
associated to differences in the various components of trait empathy: for example, less grey
matter volume in the anterior cingulate may facilitate affective empathy. Nevertheless, the
authors stressed that the mechanisms driving these variations are unknown and that is:
―important to consider the extent to which inter-individual differences in empathy are a
consequence of, or contribute to, the structural differences that we observe‖ (Banissy et al.,
2012, p. 2038). In other words, the relative contributions of environmental and biological
factors in the development of empathic abilities have to be further clarified.
To conclude, individual levels of empathic tendency appear to vary according to some
individual characteristics such as sex, age, facial emotion expressiveness, prosocial
orientation, but it is not yet known to what extent these characteristics contribute to the inter-
individual variations in empathic tendency and, moreover, whether and how they interact.
Further research is needed to address this question of the developmental epigenesis of
empathy and untangle what are likely to be complex interactions between multiple variables.

DIFFERENCES IN EMPATHIC RESPONSIVENESS

DUE TO SITUATIONAL FACTORS
If we acknowledge that variability in depth of empathic tendencies (core empathic traits)
exists, empirical evidence has shown that there are some situational factors that favour or
conversely may impair empathic processes: 1) characteristics of the target (gender, whether
and how he/she is affectively linked with the empathizer, and even whether he/she might look
like the empathizer), 2) the current emotional state of the empathizer and the type of emotion
the empathizer is called to share.

The Various Characteristics of the Target

Feshbach and Roe (1968) showed that levels of empathy in children vary systematically
according to the gender of the target. They also assessed whether this relationship held for
 Empathy: Angel or Devil? 267

each target primary emotion (e.g., joy, sadness, fear, anger). The participants of their study
stated that they experienced a higher intensity of sharing (self-reported) when the target‘s
gender was the same as the empathizer than when it was not. This suggests that male and
female individuals might perceive targets of the same gender as being more similar to
themselves and, as mentioned above, similarity seems to increase empathy (Lamm et al.,
2010) and helping and other prosocial responses (Batson et al., 2005). The degree of
similarity will be discussed hereafter with reference to some recent interesting results
observed in research where the race of the participants involved is taken into account.
As regarding the effect of any potential affective link between people involved in a
empathic paradigm, a study by Singer et al. (2006) showed that brain empathic responses vary
according to the modulation of the affective link between individuals, consistent with notions
of attachment as a ‗gating‘ variable (Watt, 2007). In order to evaluate how the fairness of the
target influences the empathizer‘s responsiveness, Singer et al. (2006) collected data using
male and female participants engaged in an economic game. Two players (who had
previously made an agreement with the researchers regarding their behavior) played fairly or
unfairly with each participant and the researchers measured the participant‘s brain activity (by
means of functional magnetic resonance imaging) while they were observing the other players
receiving punishment eliciting pain. The results showed that pain-related brain areas
(presumably indexing empathy-related responses) were activated in all participants (men and
women) while they were observing fair players, but the empathy-related responses
significantly decreased in men while they were observing the unfair confederates receiving
painful punishment. Singer et al. (2006, p. 466) suggested ―that in men (at least) empathic
responses are shaped by valuation of other people‘s social behavior, such that they empathize
with fair opponents while favoring the physical punishment of unfair opponents.‖
Recently some studies have observed various reactions of people when they are called to
empathize with other-race individuals (outgroup) in pain (Azevedo et al., 2012; Avenanti et
al., 2010). The researchers, in these cases, observed diminished autonomic responses and
decreased activity in the bilateral anterior insula (presumably indexing lowered emotional
empathy) if the target is an other-race person, compared to cases of own-race targets
(ingroup). This means that when the target is a member of the same race, the observer shows
stronger emotional empathy than in cases where the people suffering belong to a different
race. According to the authors, these observations seem to suggest, on one hand, the relative
influence of culturally acquired implicit attitudes and on the other hand, ―the relative effect of
perceived familiarity/similarity in shaping empathy-related responses to the pain of out-group
individuals in the absence of previous racial associations‖ (Azevedo et al., 2012, p. 11) (See
also discussion of this issue in chapter by Watt and Panksepp).

The Current Feelings of the Empathiser and the Emotion Expressed by

the Target

On a general level, Duan (2000) showed that not all emotions elicit the empathic process
with the same intensity: people are more inclined to share positive emotional states (e.g., joy,
happiness) than negative ones (e.g., sadness) and when unpleasant emotions are involved, it
seems that it is easier to empathize with a person when he/she is sad than when he/she is
angry or ashamed, suggesting the possibility of differential thresholds for contagion
268 Anna Maria Meneghini, Laura Cunico and Riccardo Sartori

mechanisms across various types of emotion – a possibility that has been minimally
researched. Note that in Duan‘s study the participants had during a pre-test step evaluated
sadness as a less unpleasant and more familiar emotion than anger or shame. It might be
worth noting as consistent with these considerations, as Watt (2007) hypothesized, that the
sharing of different emotions might recruit somewhat different networks, according to the
mechanism involved in the eliciting of the contagion process across different emotions.
A study reported by Bonino et al. (1998) involved two groups of adults who differed
regarding empathic proneness. Individual levels of empathy were assessed by means of a
revised form of the questionnaire by Feshbach et al. (1991). After the assessment two groups
were created by the researchers on the bases of the participants‘ scores: highly empathic
group and less empathic group. The study task was to recognize the emotion expressed by a
target (positive, neutral or negative). Before of it each participant were asked to evaluate
his/her emotional state as positive, neutral or negative. Data showed that the less empathic
participant performed significantly worse than the other group when they were in a positive or
negative emotional state, independently from the emotion expressed by the target (no
differences between the two groups emerged for the participants in neutral state). More
interestingly, among the less empathic participants, those who were experiencing unpleasant
emotional arousal were significantly less accurate than participants of the same group who
were experiencing pleasant feelings both in the case of positive and negative emotion
expressed by the target. In contrast, when the observer (belonging to the low empathic group)
is experiencing a positive affective state the target‘s emotion recognition is accurate if it is
positive but frequently inaccurate when it is negative. The authors speculated that, when
participants experienced unpleasant arousal and their empathic level is low, the identification
of the target‘s emotion may have been impeded by a global tendency to project their current
feelings onto the target, especially when the observed emotion is unpleasant. In other words,
in the less empathic group, there may be a kind of defensive coping strategy to inhibit
contagion in the face of the other person‘s unpleasant feeling in order to avoid feeling
negative affect.
Taking all this into account, it can be concluded that there are two groups of elements
playing important roles which contribute to the modulation of the effective initiation of the
empathic process: 1) the individual‘s empathic tendencies (dispositional variables); and 2)
multiple contextual characteristics which may undermine a person‘s openness to empathic
responsiveness. Confirmation of this has been provided by research on the intensity of the
activations of the brain structures underpinning empathic processes (e.g., Singer et al., 2006;
Decety et al., 2009; Cheng et al., 2012). It has been demonstrated that these neural activations
may be impeded, decreased or favoured by some individual characteristics and/or the results
of appraisal processes. An important issue is how these elements interact in real situations,
especially if we consider circumstances in which a person is called on to share another‘s pain.

WHEN IT PAYS TO SHARE: EMPATHY FOR PHYSICAL PAIN

During the last two decades, social neuroscience (Adolph, 2003; Blakmore et al., 2004)
has focused on the investigation of the relationship between basic social abilities and
empathic intensity and/or the responsiveness of the empathizer. Certain neural correlates have
 Empathy: Angel or Devil? 269

been identified related to attending to, recognizing, and remembering socially relevant stimuli
such as facial expressions of fear (Hart et al., 2000; Morris et al., 1996), attractive faces
(O‘Doherty et al., 2003), indicators of trustworthiness (Winston et al., 2002), the faces of fair
and unfair players in a game (Singer et al, 2006) and race and intergroup processing
(Avenanti et al., 2010; Azevedo et al., 2012). Besides the natural tendency of human beings to
attempt to connect socially (Cozolino, 2006) and to empathize with others (Bonino, 2006;
Watt, 2007) in order to maintain positive social relationships, there are some situation-
dependent factors that may conflict with this tendency. This is what happens, for example, in
situations when others are suffering. As a general finding but not an absolutely invariant one,
circumstances involving other people who are suffering frequently reduce empathic responses
since the communication of pain may promote automatic self-protective responses (Bonino et
al., 1998, Bonino & Giordanengo, 1993; Watt, 2005; Issner et al., 2012).
In order to better understand how, at phenomenological level, various factors may
interact to promote or impede the sharing of another person‘s physical pain, it is useful to
consider how first-person and vicarious experiences of pain might operate at a neural systems
level. A first-person experience of pain has been often described by referring to two main
phenomenological dimensions: the sensory and affective components of pain. The sensory
dimension involves spatial and temporal aspects and those aspects that are related to the
intensity of the pain, the other dimension (affective) refers to the unpleasantness or
aversiveness of the nociceptive stimulus. On a neural level, the two dimensions relate to
separate nodes of a complex neural network, the so-called pain matrix (see Derbyshire, 2000;
Avenanti & Aglioti, 2006), with the sensory aspects predictably loading on sensory
association cortices, while aversive aspects load on limbic and paralimbic systems.
Neuroscientific studies (for reviews see: Lamm et al, 2011; Fan et al., 2011) have shown
increases in activities in these pain-related brain regions when an observing subject witnesses
a potentially painful stimulus being applied to another person.

Sharing of Other People‟s Pain: Neural Correlations

In a study carried out by Singer et al. (2004), a number of couples were recruited. The
study aimed to show whether the affective dimension of pain is involved in the empathy of
pain. The researchers measured empathy in vivo by assessing the female partner‘s brain
activity while painful stimulation was applied either to her or to her partner. The data,
collected by means of functional magnetic resonance imaging, showed that the anterior
insula and the anterior cingulate cortex (i.e., areas involved in the affective/aversive
component of pain) were active in both cases. In contrast, researchers observed that areas
related to the more sensory dimension of pain were active only in the case of a first-person
experience of pain. Some further studies produced similar results reporting activation in
affective networks even when participants were observing an unknown but likeable person
suffering pain (Singer et al., 2006) or watched videos showing body parts in potentially
painful situations (Jackson et al., 2005, 2006) such as painful facial expressions (Lamm et al.,
2007) or a hand being pricked by needles (Morrison et al., 2004).
In contrast to these findings, but using different methods (transcranial magnetic
stimulation and somatosensory-evoked potentials), Avenanti et al. (2005), Avenanti et al.
(2006) and Bufalari et al. (2007) tested the hypothesis that, in some painful situations, neural
270 Anna Maria Meneghini, Laura Cunico and Riccardo Sartori

activity in the somatosensory system is activated as well. The researchers compared situations
involving onlooker observation of pain inflicted on a research subject (pain stimulus), as well
as situations in which the onlooker observed a simple touch stimulus (touch stimulus). The
results showed that during viewing of the video clips showing pain and tactile stimuli, neural
activity in the primary somatosensory cortex respectively increased and decreased in
amplitude. These modulations correlated with the intensity but not with the unpleasantness
(attributed to the affective components of the pain matrix) of the sensations of pain and touch
that each participant had previously attributed to the model. Moreover, the abovementioned
modulations did not relate to the self-reported level of aversion induced by the video clips in
the onlooker. Thus, according to authors‘ point of view, these results suggest that the sensory
components of the pain matrix are involved when a person witnesses the pain of others.
However, as is frequently the case, different methods in these studies (transcranial magnetic
stimulation and somatosensory-evoked potentials) compared to previous functional imaging
studies make cross study comparisons difficult.
Consistent with these considerations, Lamm et al. (2011) conducted a meta-analysis
regarding discrepancies in pain matrix activation across studies. The authors analyzed 32
separate studies investigating empathy for physical pain in terms of neural correlates, and
came to the conclusion that the discrepancies observed in the activation of certain brain
regions (affective versus sensory nodes activation in the pain matrix) can be explained by the
type of experimental paradigm used by the researcher. In the studies investigating the neural
correlates of empathy for pain two different types of paradigms were widely utilized. One
type (using a picture-based paradigm) is based on the viewing of body parts of a model in
painful situations (e.g., needle injections into a target‘s hand or feet), the other type (using a
cue-based paradigm) implies that the target and the empathizer (the participant) are spatially
close - the participant sees abstract visual symbols (cues) which indicate whether the target is
receiving painful or non painful electrical stimulation. In this case the experimental
conditions aim ―to create ongoing interaction and optimize ecological validity‖ (Lamm et al.,
2011, p. 2493). While viewing pictures depicting suffering limbs (a picture-based paradigm)
appears to recruit areas underpinning action understanding to a stronger extent, eliciting
empathy by means of abstract visual information about another person‘s affective state (a
cue-based paradigm) appears to more engage areas associated with inferring and representing
the mental states of the self and others. We are not specifically referring to theory of mind
regions, here, but to cognitive processes (clearly involving cortical areas) that are involved in
imagination. In other words, according to the authors‘ suggestion, when the paradigm uses
visual stimuli, the sensory dimension of pain is heavily engaged in order to give the onlooker
a better understanding of what the target is feeling; when the other person‘s pain is imagined
to be a consequence of experimental conditions/instructions, the neural correlates of the
affective dimension of pain of the observer are more active. Summarizing, Lamm et al. (2011,
p. 2500) stated that their findings ―demonstrate that this core network [i.e., the pain matrix]
can be recruited by two different pathways, one underlying the understanding of actions and
the other the understanding of mental states. Which pathway will be predominantly recruited
to elicit empathy depends on the type of information available for the elicitation of empathy
(concrete vs. abstract), and how ‗social‘ the situation is in which the subjects are placed.‖ As
the sensory components seem to be activated in the case in which empathy is triggered by
strong visual stimuli (parts of the body), they suggest that ―this speaks against a specific
somato-sensory matching of the somatosensory and nociceptive components of both the
 Empathy: Angel or Devil? 271

painful and non-painful experiences […] we propose that somatosensory activation during
empathy for pain paradigms reflects rather unspecific co-activation elicited by the display of
body parts being touched rather than a specific matching of the other‘s somatosensory and
nociceptive state‖ (Lamm et al., 2011, p. 2499). Somatosensory components are therefore
involved in the general sharing of another person‘s emotions (i.e., empathy), but affective
components seem to be specific to pain sharing situations. In any case, it might be asserted
that, when people witness another persons‘ pain, the pain matrix is heavily involved mapping
the first-hand experience of pain (Singer et al., 2006; Hutchinson et al., 1999; Cheng et al.,
2007; Lamm et al., 2007; Benuzzi et al., 2008; Cheng et al., 2008; Bufalari et al., 2007;
Valeriani et al., 2008; Keysers et al., 2010).
Intriguingly from our point of view, it seems that in vicarious experiences of pain,
dispositional and situational factors influence the firing of the components of the neural
network (the ‗pain matrix,‘ i.e., those areas that are activated during a personal experience of
pain). Singer et al. (2004) and Singer et al. (2006) observed that participants‘ scores in
questionnaires assessing the empathic trait (i.e., scores referring to both the Empathic
Concern of Interpersonal Reactivity Index and the Balanced Emotional Empathy Scale)
covary with participants‘ brain responses in pain-sensitive areas. Similar correlations were
reported by Jabbi et al. (2007). Avenanti et al. (2009) showed that neural activity in
somatomotor mirror responses varies according both to state- and trait differences in
empathy: the corticospinal excitability (mapping from the specific muscle that is penetrated in
the case of video clips) correlates with sensory qualities of the pain that the onlooker has
ascribed to the model. Moreover, somatomotor responses of the onlooker were related to
his/her empathic trait as assessed by the Interpersonal Reactivity Index (Davis, 1983).
Neural empathy responses were shown to be related to further situation-dependent
factors: e.g., participants‘ affect appraisal (whether the other person‘s suffering is thought
‗justified‘: Lamm et al., 2007), previous experiences with this type of situation (Cheng et al.,
2007; 2008) and the intensity of the pain inflicted (Avenanti et al., 2006). In addition, the
current emotional state of the witness of the suffering other seems to directly impact the
empathic process, especially if the onlooker is feeling pain. A study by Valeriani et al. (2008)
indicates that in such circumstances, the onlooker evaluates the intensity of a stranger‘s pain
as being less intense if the onlooker is not in pain versus being in pain. This affective variable
in the witness may therefore modulate the resulting response, consistent with the basic model
of empathy by Watt (2007). According to the various conditions of the experiment, even if
the pain was inflicted in the same manner and involved the same body part, a specific
reduction in the activation of the somatic nodes of the pain matrix in those participants
(onlookers) who were experiencing pain themselves while they were watching the film clips
was observed. Conversely, the same modulation was not observed in the components
supposedly associated with affective/aversive quality of pain experience. The authors‘
summary elucidates variables of interest: ―we have demonstrated that viewing ‗flesh and
bone‘ painful stimuli delivered to a stranger model modulates the pain system of onlookers
suffering from acute pain induced by the laser stimuli [...] we demonstrate that suffering
individuals map the observed pain according to their feelings rather than to the feelings
attributed to a stranger model. This may suggest that the personal experience of pain
influences social interactions by inducing the sufferer to evaluate the others according to an
egocentric stance. This result paves the way to future studies aimed at clarifying the extent to
272 Anna Maria Meneghini, Laura Cunico and Riccardo Sartori

which this default tendency to self-centered empathy in individuals who are in pain may be
amended by different types of social bonds‖ (Valeriani et al., 2008, p. 1427).
Consistent with these notions, a study conducted by Mailhot et al. (2012) reported that
viewing expressions of pain increases own shock-pain unpleasantness ratings. A series of
video clips displaying neutral facial expressions and expressions of pain were presented to the
participants, followed by electrical stimulation varying in intensity (high and low). The
physical pain induced by the electric stimulation was rated from each participant (by means of
visual analog scales) about two dimensions: the intensity and the unpleasantness of the
sensation. At the end of the experiment the participants completed the Empathy Quotient
(Baron-Cohen & Wheelwright, 2004) in order to assess their level of empathic trait. Results
showed that the participants assessed their own pain higher when they were paying attention
to someone else in pain (after the video clips displaying facial expressions of pain) than when
they did not (after the video clips displaying neutral facial expressions). Interestingly, this
effect was modulated by the individual‘s level of empathic trait: intensity and unpleasantness
related to self-pain increased less or even decreased in participants scoring high in the
empathy trait. These results, together with those reported above suggest that people‘s ratings
of self and others‘ intensity and unpleasantness of pain influence each other and that the
empathic trait might modulate this relationships.
A recent, very interesting area of investigation has focused on social factors modulating
empathy for physical pain, specifically how membership of a group might affect empathy for
pain. Avenanti et al. (2010) and Azevedo et al. (2012) collected data showing how empathy
for pain is more likely in situations where same race members are involved than in situations
where there are people of other races. In particular, in the latter study (Azevedo et al., 2012)
the experimental conditions compared responses to pictures of other-race hands versus own-
race hands, other-race hands and own-race hands which had been colored violet, receiving
pain. First, the researchers observed the reduction in the levels of resonance responses (in
terms of hemodynamic responses recorded by means of fMRI) to the other-race members‘
pain and it correlated with the individual level of an implicit attitude towards the other race.
In addition, a reduction in the levels of resonance responses were observed also when the
stimulus were the own-race hands colored violet. More in details the researchers observed
similar reduced responses in the areas involving in the affective component of empathy
(anterior insula) when the stimulus receiving pain was an other-race hand and when the
stimulus was an own-race hand colored violet, but different activation in the areas related to
the motivational and volitional aspect of pain processing (anterior cingulate cortex). This
induced the authors to conclude: ―decreased aMCC [anterior Mid-Cingulate Cortex] and
autonomic activity to violet models‘ pain [i.e., when the stimulus was the own-race hand
colored violet] suggest less motivation to respond to the pain of model with particularly
dissimilar and unfamiliar/implausible features‖ (Azevedo et al., 2012, p. 11). To sum up, it
seems that in pain situations, people resonate preferentially with those more similar to
themselves and that race-bias and degrees of familiarity and similarity features of the stimuli
both influence the empathic responses of the observer.
 Empathy: Angel or Devil? 273

Sharing of Other Peoples‟ Pain: Observations Regarding the

Phenomenological Level

Moving from the neural level of analysis of empathy for pain to a more
phenomenological level, it is still not clear exactly how influences resulting from
understanding another person‘s experience, the influence of trait-like tendencies or attitudes,
and the influence of empathic responses might interact (Issner et al., 2012). However, it has
been demonstrated that the expression of pain is a crucial signal that motivates soothing and
caring behaviors (Jackson et al., 2005), especially when the person suffering is a relative or a
person who has affective ties with the observer. Since this is crucial in order to alleviate the
other person‘s suffering (as Watt, 2005, 2007 suggested that this was an intrinsic component
of an affective empathy response), the matter of what is entailed for the empathizer when they
share the emotions of another person is immediately and even hugely relevant.
A study that has attempted to elucidate these relationships was conducted by Issner et al.
(2012) who carried out an exploratory study in order to try to clarify potential links between
the abovementioned variables. The researchers investigated the extent to which empathic
accuracy, empathic tendencies and empathic responses were correlated within the context of
chronic pain. For the study, 57 couples (with at least 1 partner reporting chronic
musculoskeletal pain) were recruited. Following the procedure created by Ickes (2001), at the
beginning the two partners engaged in an interaction which was video recorded. Then they
were evaluated with regard to the following variables:

 spouses‘ empathic tendency assessed by means of the Interpersonal Reactivity Index

(Davis, 1983);
 individual level of empathic accuracy (a variable related more to theory of mind or
perhaps affective theory of mind), assessed according to the procedure created by
Ickes (2001): each partner watched the interaction with his/her spouse, the task being
to detect other‘s thoughts and feelings;
 the frequency of empathic versus un-empathic responses to the partner‘s emotional
expressions (the interactions were coded by independent judges who used a coding
system that utilizes context, voice tone and physical feature to measure the partner‘s
behavior: Issner et al., 2012).

Couples also completed questionnaires to assess the severity of the pain, marital
satisfaction (assessed by means of the Diadic Adjustment Scale, Spanier, 1976), and
perceived behavioral responses to their partner‘s pain (i.e., concrete help or punishing
responses). The data collected showed that scores in spousal empathic responses and their
empathic accuracy were not related to one another, nor were they related to spousal empathic
tendency levels. The authors suggested that this lack of correlation might be due to the fact
that some couples could be actually motivated to be inaccurate in order to protect their
relationship which would be perceived as threatened by the chronic pain condition that their
partner was experiencing: when a person cannot alleviate the pain of his/her partner, he/she
may be induced to protect the relationship from distress by inhibiting a more accurate
understanding of their partner‘s thoughts and feelings.
274 Anna Maria Meneghini, Laura Cunico and Riccardo Sartori

Moreover, Issner et al. (2012) observed that, among the participants, the spouses who
reported high empathic tendency levels and who were more prone to take the perspective of
the other person, were also more likely to report that they engaged in concrete help responses
(e.g., ask how they can help, encouraging the partner to rest). Nevertheless, Issner et al.,
(2012) noted that the degree of satisfaction as regards the marital relationship influences how
the spouses behave during the video recorded interaction referring to the empathic/un-
empathic responses. Indeed, data collected suggest that spouses with greater marital
dissatisfaction were more likely to engage in a larger number of un-empathic responses
toward their partner. Finally, spouses with pain of their own were less emotionally responsive
toward their partner‘s emotions, and although mechanism remains to be clarified, presumably
they may have been distracted by their own pain as the above-mentioned study by Bufalari et
al. (2007) showed.
To sum up, these findings suggest that the relationship between the variables influencing
situations involving suffering people are actually quite complex, and the relationship between
the elicitation of empathy and possible cognitive processes involved, conscious or
unconscious (e.g., the appraisal of incoming sensory information) needs to be better
understood. In addition, the study conducted by Issner et al. (2012) in a marital context has
shown that to explain empathy in these real world contexts, it is crucial to take into account
the quality of the relationship between the empathizer and the target, consistent with the basic
model of Watt (2007).

Clinical Applications within Helping Professions of Empathy Concepts

How might individual and situation-dependent variables interact during professional

encounters between nurses and patients? With reference to the study conducted by Klein and
Hodges (2001), the results showed that according to the various motivations of the
participants‘ individual accuracy in detecting a target‘s emotions could differ (see also: Duan,
2000; Ickes, Gesn & Graham, 2000): what happens when the motivation is driven by the
professional role of an empathizer? What happens when his/her professional status requires
recurring helping responses and empathic interaction with patients in pain? Otten et al. (1991)
reported that the therapists involved in their study offered professional help as well as being
in any case prone to empathy. Conversely, when they were called on to offer non-professional
help, the individual characteristics (levels of empathic trait and responsiveness) and their
previous experience with the target modulated their propensity to help. As regards other
professionals who face situations involving pain on a daily basis, specifically nurses, it is
interesting to investigate how they might manage situations requiring empathic responses and
how they cope with the risk that chronic involvement with suffering patients can lead to
professional ‗burnout‘ that might subsequently impair empathic responsiveness.
Empathic responsiveness and emotional regulation skills (to cope with the risks of high
levels of emotional contagion) are particularly important in professions where the helping
relationship is the central element, as in nursing. Nursing is a highly stressful occupation and
chronic stress of any kind can be detrimental to job satisfaction, psychological well-being and
physical health. Chronic stress can lead to burnout and nurses are at high risk for burnout
because they continually care for people who are frequently in pain, and also emotionally
distressed. Burnout in nursing is a topic of enormous individual and organizational concern
 Empathy: Angel or Devil? 275

with ramifications for professional well-being, job performance, absenteeism and turnover.
Research carried out in nursing populations has revealed that burnout and work-related stress
are negatively associated with job satisfaction, staff support and involvement with the
organization, while they are positively associated with role conflict and a sensation of
discomfort (Albini et al., 2001). Following Maslach‘s well-known model of burnout, Cherniss
(1980) defines three stages of development: in the first stage, the operator becomes aware of
an imbalance between the demands of the job and the resources available; in the second stage
the operator manifests a feeling of physical fatigue, psychological fatigue and lack of
motivation, and, finally, there may be a third stage in which the operator develops attitudes of
cynicism and emotional detachment. The road to burnout often begins insidiously and the
early stages of this process are typically difficult to discriminate from a more nonspecific and
occasionally unavoidable ―having a bad day.‖
A central risk for nurses is to be simply overwhelmed by the suffering of patients,
including caring for patients in various types of acute as well as chronic pain. Daily contact
with suffering activates defensive attitudes when nurses feel themselves more at risk of
contagion and this practice is also developed through work experiences. Continued exposure
to the suffering of patients and families over time can develop emotional stress and fatigue in
nurses working closely with terminally ill patients, patients suffering from chronic pain, sick
children, people with mental disease or chronic diseases, etc. A crucial challenge for nurses is
the ability to grasp and respond to patients‘ expressions of emotion, worry, various emotional
and physical needs, physical as well as psychic pain, and many other sources of perceived and
immediate need in the patient. These presses are often communicated implicitly through cues
or hints (Levinson et al., 2000; Butow et al., 2002; Zimmermann et al., 2007).
Nurses interviewed in the study by Bradham (2009) reported that burnout, as well as
other factors such as difficult patients, create clear impediments to empathy. All of the
interviewees recognized compassion and empathy as key characteristics of nurses. Each nurse
appeared to have his/her own theory regarding the dynamics of the nurse/patient relationship
but that empathy was an assumed central ingredient. Qualitative data analyses revealed that
several of the nurses participating in the study had experienced professional ‗burnout‘ in the
past and had learned mechanisms for coping with this. This study highlights the importance
of the nurse‘s own psychological state as a key element in both resilience to burnout and the
capacity for empathy (Bradham,, 2009). A recent study carried out by Sartori and Rappagliosi
(2011) on the basis of previous research by other authors of the same team (Favretto et al.,
2009; Favretto & Rappagliosi, 2009) showed that people experiencing work-related stress and
burnout sometimes develop personal coping strategies which are not always effective. Data
consistently show that people in helping professions (teachers, nurses, physicians, etc.) should
be trained and directed towards the most effective coping strategies to first identify and then
effectively deal with work-related stress and burnout.
It is accepted (Alligood, 2005; Reynolds, 2000) that an empathic response is necessary
for nurses to deliver adequate pain relief and therapeutic care; nurses are taught that
regulation of this response is important to protect themselves against the traumatic effects of
seeing patients in pain. However, it is clear from all of the previous literature review that
aspects of empathic arousal related to contagion are both automatic as well as having
potential autonomic impact in the direction of sympathetic arousal, and therefore impossible
to fully control; this may have important implications for understanding clinician
vulnerability and empathic failure in clinical situations (Campbell-Yeo et al., 2008). A result
276 Anna Maria Meneghini, Laura Cunico and Riccardo Sartori

in contrast with expectations was found in the study by Watt-Watson et al. (2000).
Cardiovascular patients were interviewed after heart surgery about the intensity of their pain
and their perception of the empathic responses and analgesic administration of the emergency
room nurses. Nurse participants were evaluated for their empathy, and their knowledge and
beliefs with regard to pain. Nurses were rated as moderately empathic, and their responses did
not significantly influence their patients‘ pain intensity or analgesia administered. Patients
reported moderate to severe pain but received only 47% of their prescribed analgesia.
Patients‘ perceptions of their nurse‘s attention to their pain were not positive, and empathy
explained only 3% of variance in patients‘ pain intensity. Deficits in knowledge and
misbeliefs about pain management were evident for nurses independent of empathy rating,
and knowledge explained only 7% of variance in analgesia administered. Hospital sites varied
significantly in analgesic practices and pain inservice education for nurses. Empathy ratings
were not associated with patients‘ pain intensity or analgesic administration. The authors
conclude that ―patients‘ perceptions of their nurses as resources with their pain were not
positive,‖ suggesting that essential clinical skills on the part of attending nurses that are
largely dependent on empathy and awareness of physical pain in relationship to a common
form of surgery in this sampling were not consistently available to patients.
The research by Latimer et al. (2011) aimed to develop and validate a new video
instrument – the Empathy for Infant Pain video program (EIPvp) – designed to be used for
training and research purposes in order to examine the role that empathy may play in nurses‘
assessment and management of procedures related to infant pain. Fifty female participants (25
nurses and 25 allied health controls) were asked to score the infant procedural pain level
displayed in the EIPvp using a visual analogue scale (VAS) and a composite score of known
infant pain cues. Participants also scored their own perception of painful events. The nurse
and control groups rated the video clips similarly in all the three pain level categories (no, low
or high pain); however, even though the mean scores for both groups were within the
expected pain level category, nurses consistently scored pain higher on all the three scale
scores (limb, facial and vocal) and on the global rating scale (VAS) as compared to the
control group. Overall, facial expressions were the most significant indication of pain
experience, showing a small effect size assessed by both groups and highly correlating with
overall pain (r = 0.65, p < 0.001). To determine whether the two groups were different in their
own perception of pain for typical pain events, the participants were asked to complete the
SPQ (Situational Pain Questionnaire). Results showed that nurses scored their perception to
low pain events significantly higher than the control group, with the variable of nurses
showing a moderate effect size (r = 0.31). Nurses also scored the high pain event items higher
than controls; however, this difference did not reach the significance threshold (F[1,48] =
2.271; P = 0.138). There was a small effect size for the group (r = 0.21). In summary, nurses
scored behavioral ratings of perception of painful events in themselves and situational
empathy for pain in others (i.e., the infants in the video clips) consistently higher than the
control group. The fact that nurses detect pain more often than controls may have been an
indication that they have greater knowledge of pain cues, or their empathy levels may have
been different as a result of their exposure to, or their perceived relationship with, patients
(Latimer et al., 2011).
 Empathy: Angel or Devil? 277

THE PATIENT-NURSE RELATIONSHIP:

A HELPING RELATIONSHIP
One factor in particular that differentiates the patient-nurse relationship from social
relationships is that the patient-nurse relationship is a professional helping relationship
established for the benefit of the patient and family, whereas kinship and friendship
relationships are designed to meet mutual needs. It is health-focused and patient-centered and
with defined boundaries. In particular, the aim of the patient-nurse relationship is to help the
patient achieve and maintain health. A successful helping relationship between nurse and
patient thus represents different challenges in terms of basic interaction than that which
occurs in a friendship (Balzer-Riley, 2000). Some patient-nurse relationships only last a few
hours, but others may last days, months, or even years. ―The underlying principles in the
nurse-patient relationship are the same regardless of the length of the contact: respect, the
ability to accept another person‘s beliefs and responses despite your own personal feelings;
genuineness, the ability to be oneself within a professional role, described as congruence;
empathy, a form of understanding and participation in the patient‘s world; trust, essential
when a patient is placed in a vulnerable position, physically and emotionally; confidentiality,
the ability to have an ethical responsibility to protect the patient‘s right to privacy; and finally,
active listening, helping to create a safe environment in which patient can communicate more
easily because he/she feels understood‖ (Sheldon, 2004, p. 41). Similarly, Peplau (1952)
defined the nurse-patient relationship as a primary human connection and ―central in a
fundamental way to providing nursing care.‖ The goals of the nurse-patient relationship are
threefold: 1. to enhance patient well-being, 2. to promote recovery, 3. to support the self-care
functioning of the patient. Healing from an interpersonal perspective requires more than
medicine and the application of treatments since most illnesses affect the whole person, both
in terms of physical as well as psychic/emotional aspects, and many illnesses have both
biological and psychological/affective origins. In health care, human connection is thus
essential to the healing process and effective health care delivery since it addresses the
authentic and genuine needs of the patient, from the perspective of both patients and their
immediate family (Arnold, 2003).
Any caring relationship is characterized as being bound to a particular time and context.
During this period the nurse promises the patient care and in effect the patient‘s experience is
shaped by the participation of the nurse just as each human being is made up of body, soul
and spirit. This unique encounter involves a process which influences both the patient and the
nurse and is of importance for confirmation in a way which enables support for health and
well-being (Berg & Danielson, 2007). However, in Milton‘s (2002) theoretical analysis,
professional nurses valued technical tasks and procedures as their primary obligation even
though studies have shown how important it is for patients to have access to relational care
that is of a high professional standard associated with understanding of the patients‘
vulnerability. This also means acting in a manner which instills trust, through engaging with
patients by means of an empathic presence. Patients typically need to cope with difficult
emotions (mostly negative) related to their health condition (psychological, physical or both)
and the regulation of their emotions may be influenced by empathic communication and have
a positive effect on their mental health and quality of life. Suppression of emotions on the
other hand seems to increase the impact of stress-related negative emotions (Goldin et al.,
278 Anna Maria Meneghini, Laura Cunico and Riccardo Sartori

2008). It is also possible that, by letting patients express health and other concerns, an
empathic nurse can improve affective regulation (Hariri et al., 2000, Lieberman et al., 2007,
Finset & Mjaaland, 2009) and thus create comfort, relief and well-being. Therefore, it is
important that nurses are able to identify, respond helpfully to and comfort patients‘ negative
emotions, which often times are more implicit and not expressed explicitly (Suchman et al.,
1997; Eide et al., 2011). To sum up, in the nursing profession, empathy has been focused on
as a major component of the helping relationship and the essence of caring. Empathy is
presumably a consistent concomitant to genuine caring. Caring means giving attention to,
worrying about and feeling personally responsible for patients or ensuring that their needs are
satisfied by others (Corbin, 2008). This requires an understanding of the health problems of
the person and their family, as well as the requirement to try to improve the patient‘s
psychological, physical and social comfort. It also means communicating in an adequate way
so as to build a supportive relationship (Watson, 2002, Finfgeld-Connett, 2008).

HOW TO COMMUNICATE EMPATHICALLY

The effects of a nurse‘s intervention may be compromised or even aversive to the patient
if he/she cannot demonstrate the ability to experience and express emotional empathy. For
this reason, effective communication is never neatly separable from empathy and at the same
time this capacity to feel empathy enables the ability to sense and understand another person‘s
feelings as if they were one‘s own (Cunico et al., 2012). In the first part of this paper we dealt
with the various component processes and functions of empathy, according to empathy
researchers and theorists. However, from the standpoint of clinicians, Carl Rogers (1951)
contributed to a clinical understanding of empathy for helping professionals prior to much of
the more formal research that has taken place in the last 10 years. A synonym for empathy
emphasized by Rogers was ―communicated understanding.‖ According to Rogers, when we
are convinced that others fully understand us without judging us for how we are feeling,
questioning why we are reacting that way, or advising us to feel differently, we experience a
positive sense of emotional acceptance. The process of empathy involves the positive
unconditional acceptance of the individual in need of help, while critical judgments and
evaluation of feelings are not offered (Balzer-Riley, 2000).

Verbal and Nonverbal Elements of Empathy

The ability to express empathy and communicate it verbally demonstrates to another

person that we understand their feelings and the reasons for their emotional reaction. The goal
is to offer a verbal reflection that is accurate, with no exaggeration or minimizing. When we
respond empathically, we should choose our own words and respond in our own style. The
nonverbal features of empathy are equally important. It is possible to articulate a well-
organized and articulated empathic response that meets the criteria for accuracy and
specificity but does not positively affect the other person. Empathic communication requires a
specific and accurate verbal response accompanied by genuine and a perceivable level of
warmth and concern for suffering. From these considerations, an example of empathic
 Empathy: Angel or Devil? 279

response might be as follows: patient to nurse: ―I didn‘t have to take any pain medication last
night for my injured back and I slept right through the night. It was the first good sleep I‘ve
had in four nights‖; the nurse‟s empathic response: ―What a relief for you to have been
comfortable enough to do without your pain medication and you look overjoyed that you
slept so well‖ (Balzer-Riley, 2000, p. 135).

EMPIRICAL FINDINGS
After dealing with various theoretical issues regarding empathy, we now present the
results of a research study carried out in Italy. The principal aims were:

1) to identify the reactions of nurses when faced with suffering patients and the defense
mechanisms/attitudes they might use with the greatest frequency in order to protect
themselves from the danger of intense negative emotions arising from daily contact
with suffering;
2) to assess whether these reactions and the choice of defence mechanisms/attitudes are
predicted by levels of empathic tendency, as measured using the Balanced Emotional
Empathy Scale (BEES).

Participants and Their Characteristics

The participants were 151 nurses, 31 (20.5%) males, 120 (79.5%) females, aged between
20 and 55, living and working in the North of Italy and belonging to various different hospital
departments (Emergency, Medicine, Surgery, etc.). Length of service varied from a minimum
of one year to over 20 years. Out of the 151 participants, 80 were married, 65 were
unmarried, while 6 were divorced, separated or widowed.

Instruments and Procedure

Two questionnaires were administered.

1) An ad hoc questionnaire entitled Helping Relationship Structured Interview which

includes 11 items and developed following the paper by Bonino and Giordanengo
(1993) with the aim of detecting the reactions of the nurses when faced with
suffering and identifying the defense mechanisms/attitudes used in order to protect
them from the danger of intense negative emotions arising from daily contact with
suffering patients. Reactions listed in the questionnaire are (with more than one
choice available): I am open to understanding and communication; I let the situation
overwhelm me; I immerse myself in patients‟ suffering; I try to rationalize the
situation; I deny patients‟ feelings; I get anxious; I try to distract myself by doing
something else; I seek patients‟ verbal contact; I seek patients‟ physical contact; I
have an escape reaction. Defense mechanisms/attitudes listed in the questionnaire
280 Anna Maria Meneghini, Laura Cunico and Riccardo Sartori

are (with more than one choice available): I have denied patients‟ feelings; I have
used my profession as a defense; I have tried to distract myself by doing something
else; I have had an escape reaction; I have broken off eye contact with the patient.
2) The Italian version of the Balanced Emotional Empathy Scale (BEES) by Albert
Mehrabian, which is a scale, composed of 30 items designed to reduce social
desirability and acquiescence biases (Sartori 2005). Fifteen items are worded so that
agreement with them shows higher emotional empathy. The remaining 15 items are
worded so that disagreement with them shows higher emotional empathy. In
Mehrabian‘s original version (1996, unpublished data), a nine-point scale was used,
from – 4 to + 4. In the Italian version by Meneghini et al. (2006, 2012), the rating
scale has been reduced to seven points (from -3 to +3) in line with a series of
methodological considerations. Completion required about 15 minutes.

Data Analysis

Frequencies and percentages were calculated and means and standard deviations were
also computed. BEES total scores were computed and transformed into z points in order to
build up four different groups on the basis of participants‘ empathic tendency levels: low,
medium-low, medium-high and high. Comparisons between groups were conducted by
carrying out chi-square tests, t-tests or ANOVAs where appropriate.

Results

The following data refer to empathic tendency levels:

1) Low: 13.4% in total (25.9% of total males, 10.7% of total females, p < .001);
2) Medium-low: 33.1% in total (59.3% of total males, 26.8% of total females, p < .001);
3) Medium-high: 57.3% in total (7.4% of total males, 44.6% of total females, p < .001);
4) High: 16.2% in total (7.4% of total males, 17.9% of total females, p < .05).

Not surprisingly, females statistically present significantly higher levels of empathic

tendency than males, consistent with much previous empirical work (Lennon & Eisenberg,
1987; Batson et al., 1996; Schieman & Van Gundy, 2000; Toussaint & Webb, 2005; Smith et
al., 2010). Also the difference between males and females in the BEES total score is
statistically significant (p < .001), which is consistent with data from literature.
In terms of basic reactions of nurses when facing suffering patients, the most frequent
are:

1) I am open to understanding and communication: 79.5% in total (66.7% of males,

82.2% of females, p < .05);
2) I seek patients‟ verbal contact: 49% in total (56.7% of males, 47.5% of females,
n.s.);
3) I try to rationalize the situation: 40.4% in total (50% of males, 36.4% of females, p <
.05);
 Empathy: Angel or Devil? 281

4) I seek patients‟ physical contact: 32.5% in total (30% of males, 33.1% of females,
n.s.);
5) I immerse myself in patients‟ suffering: 15.2% in total (10% of males, 16.1% of
females, n.s.).

These results show that the only statistically significant differences across genders for
such common clinical postures and attitudes as ―I am open to understanding and
communication‖ (more common for females than males) and ―I try to rationalize the
situation” (more common for males than females). Moreover, the first two in the list above
are reactions chosen by participants regardless of their empathic tendency (p > .05, no
significant statistical difference), while for the last three reactions differences have been noted
on the basis of participants‘ empathic tendency: these three reactions are more frequent when
the empathic tendency is also high, while in the case of low empathic tendency the ―I try to
rationalize the situation‖ posture is the most common (more common in males whose
empathic tendency levels are lower than females). It is also interesting to note that the higher
the empathic tendency, the higher the frequency of reaction number 5, ―I immerse myself in
patients‟ suffering‖ (the relation between the four levels of empathic tendency and the
frequency of this reaction is positive and statistically significant, p = .049).
Regarding the defense mechanisms/attitudes participants use in order to protect
themselves from the danger of emotional contagion arising from daily contact with suffering,
the most frequently chosen are:

1) I have used my profession as a defense: 39.7% in total (32% of males, 42.2% of

females, p < .05);
2) I have broken off eye contact with the patient: 25.9% in total (36% of males, 22.2%
of females, p < .05);
3) I have tried to distract myself by doing something else: 15.5% in total (8% of males,
17.8% of females, n.s.);
4) I have had an escape reaction: 10.3% in total (8% of males, 11.1% of females, n.s.).

In this case, statistically significant differences are observed only for such defence
mechanisms/attitudes as ―I have used my profession as a defense‖ (used more by females than
males) and ―I have broken off eye contact with the patient‖ (used more by males than
females). The use of the ―profession as a defence‖ and the ―interruption of eye contact‖ when
considered in relationship to empathic tendency levels suggest that when the BEES score is
low nurses protect themselves principally by using their ―profession‖ (especially in the case
of females). In the case of high empathic tendency levels, a more frequent use of ―interruption
of eye contact‖ is noted (especially in the case of males).

DISCUSSION
Besides a general expectation, as discussed above, that a nurse be fundamentally
empathic, and that empathy is positively valued in general (Hodges & Biswas-Diener, 2007),
sharing others‘ emotions may be emotionally costly, and this seems to apply both if one is
282 Anna Maria Meneghini, Laura Cunico and Riccardo Sartori

‗too empathic‘ and also if one is not empathic enough (Shipper & Petermann, 2013).
Evidence from many studies in psychological and neuroscientific domains have stated that
empathy in everyday situations is a multifaceted phenomenon, implying both affective core
components (Eisenberg et al., 1994; de Vignemont & Singer, 2006; Watt, 2007; Decety et al.,
2012) and some degree of associated cognitive processes, particularly theory of mind and
perspective taking. These various facets are intertwined/related and may vary depending on
the situation (Davis, 1983; Klein & Hodges, 2001; Watt, 2007; Hodges & Biswas-Diener,
2007; Decety et al., 2012). Empathic responses, as discussed in many of these models, are
affected by some situation-dependent variables that may either enhance or impair the
motivation to respond in a supportive way to a suffering person. Watt (2007) suggests that
genetically ‗highly contagion‘ people, i.e., individuals who are particularly prone to the
primitive initial cascades of the empathic process but who also have developed an optimal
social/developmental trajectory through successful relationships in their early family life,
become exceptionally empathic and supportive adults well suited to helping professions such
as psychotherapy, teaching or nursing. As emotional contagion is a potent eliciting process in
many situations of intense emotion (Watt, 2005, 2007), the successful modulation of these
vicarious feelings is particularly challenging when other person‘s suffering is particularly
intense, and negative emotions and related processes (e.g., physical pain) occur frequently.
This vulnerability to contagion presents particular challenges in terms of the relationship
between nurses and patients and in helping relationships in general. This also suggests that
‗high contagion‘ individuals may be more vulnerable to burnout and emotional exhaustion,
particularly if their efforts at reducing distress and pain, for any number of potential reasons,
are not particularly successful.
The aim of the study here reported was to investigate how nurses react to the suffering
situations that are typical of their work environment and to ascertain whether the type of
regulatory strategies that each participant in the study habitually uses is related to their
individual level of empathic tendency or not. In other words, in the specific case of nurse-
patient relationships, our purpose was to investigate whether an individual characteristic such
as empathic tendency, affecting the subject‘s propensity to immerse him/herself in another
person‘s feelings (Mehrabian & Epstein 1972; Meneghini & Sartori, 2011), influences the
choice of strategies to modulate the empathic process. A consideration for nurses‘ reactions to
suffering situations is that they are called on to be supportive and empathic because such
behaviours are expected from them as a part of their role. As Otten et al. (1991) reported in
the case of therapists, the professional help offered seems to be uncorrelated to individual
tendencies to be empathic. The researchers measured empathic concern for the client,
willingness to provide therapy (professional help) and nonprofessional help (the client asked
for help that was not pertinent to the therapist‘s profession). They found that in the case of
request of nonprofessional help the therapists‘ levels of empathic tendency affected their
decision to engage in helping behaviours towards client, whereas the therapists showed
intention to provide therapy and to behave empathically independently from their levels of
empathic tendency, even if they perceive that the client was hostile, appeared unmotivated
towards the therapy and did not believe in its potential advantage. As a consequence, given
the expectation that nurses are motivated to be empathic because of their work status, we
suggest that nurses frequently need to moderate their involvement in others‘ emotions in
order to avoid being overwhelmed. For this reason it might be that many professional helpers
develop individual strategies in order to modulate the vicarious emotions elicited. Therefore,
 Empathy: Angel or Devil? 283

it is highly likely that, in the relationship with patients, nurses perform some kind of
automatic or voluntary emotion regulation and that emotional regulatory abilities are
professionally critical for them.
First, the data in our study showed that, as expected in traditional role definitions, clinical
nurses do not back away from patients‘ requests for emotional sharing as they do not deny
suffering. When faced with suffering, the most common reactions reported by the nurses are
―willingness to understand and to communicate‖ and ―seeking for verbal contact.‖ But in
order to cope with continuous exposure to emotional situations associated with suffering
(entailing the risk of being overwhelmed by intense negative emotions), the participants seem
to attempt to protect themselves by resorting to regulatory strategies designed to protect them
from excessive involvement in the relationship and thereby reducing the ‗cost‘ of empathy.
It is worth noting that the data we collected among the general population in Italy which
included a large sample of nurses (Meneghini et al., 2012; Cunico et al., 2012) have
highlighted that these two groups (nurses versus other type of jobs) did not meaningfully
differ in terms of average levels of empathic tendency. Moreover, some studies (Cunico et al.,
2012; Meneghini et al., 2012) have shown that female nurses have higher levels of empathic
tendency than males according to the general distribution of empathic trends in the
population. It therefore does not seem that a special empathic predisposition necessarily
characterizes the profession of nursing but simply that nurses are specifically called on to be
sensitive to patients‘ feelings as part of their professional role. In addition to this, the
participants‘ use of various strategies vary according to their level of empathic tendency (high
or low): their responses suggest that, when the level of empathic tendency is low, they protect
themselves principally by using their ―professional role.‖ In contrast, the use of ―interruption
of eye contact‖ (i.e., avoiding a relevant perceptual stimulus) increases when the level of
empathic tendency is high.
With regard to the importance of levels of empathic tendency in terms of helping or
hindering supportive or prosocial behaviour, an interesting suggestion has been proposed by
Schipper & Petermann (2013). They hypothesized that deficits in empathy might trigger
emotion dysregulation. According to Decety (2010), they emphasize that ―emotion regulation
next to affective arousal and emotion understanding is one of the macro components involved
in human empathy […]. Because affective arousal and emotion understanding develop before
the emotion regulation component, their functioning seems to build a prerequisite for an
efficient development of emotion regulation‖ (Schipper & Petermann, 2013, p. 103).
Therefore, they speculated that both low empathic abilities and a high amount of empathy
might trigger emotion dysregulation, i.e., they hypothesized that the relationship between
empathy and emotion regulation is non-linear. In other words, when the individual tendency
to share another person‘s emotions is extremely low or high, it affects the ability to adaptively
regulate emotional engagement. As a consequence, it could be speculated that, in order to act
effectively, a nurse needs both an optimal level of empathic tendency and emotion regulation
skills in order to modulate his/her emotional involvement.
It might also be that, as the most of the participants in our study reported greater length of
professional service, they had learned ways to manage patient suffering and to modulate their
vicarious emotions, in order to avoid being overwhelmed by intense negative, painful
emotions. The participants used various different strategies according to varying lengths of
service: the ―long-standing‖ nurses seemed to show a greater capacity to manage the helping
relationship, focusing their attention on the other person but also on themselves. Thus, a
284 Anna Maria Meneghini, Laura Cunico and Riccardo Sartori

further important matter arises from these conclusions: which type of regulatory processes do
nurses use in order to manage stressful emotions and avoid burnout?

MANAGING THE EMOTIONS IN THE WORKPLACE:

THE CHALLENGES OF CLINICAL NURSING
In the past, emotional dynamics relating to both the work and the emotional state of
workers and their well-being have been relatively neglected. As stated by Mitchell & Smith
(2003) the management of feelings during the relationships with patients (called emotional
labour by Hochschild, 1983) is ―part of the image of nursing.‖ Strauss et al. (1982) referred to
nursing as ―sentimental work‖ because if a nurse is overcome with negative emotions, his/her
self-esteem and self-efficacy might be affected. Mann (2005) suggested a model of emotional
labour for health-care workers and nurses in particular which considers dealing with pain
(that from our perspective means being sensitive and therefore empathic and supportive
towards the patient) as one of the events inducing emotional labour. Thus, as empathy ―is not
an all or none phenomenon, nor is it automatic or reflexive, as many social and contextual
factors affect its induction and expression‖ (Decety et al., 2012, p. 45), according to the
aforementioned studies on empathy for pain, it may be hypothesised that nurses need to
engage in regulatory strategies in order to meet their job role sensitivity requirements. In a
general sense, it is acknowledged that children learn to emotionally deal with various social
situations in an adaptive way during their early experiences (attachment) of social
interactions. Throughout ontogenetic development, human beings internalize the social rules
of their own culture and these rules induce them to behave in a socially competent way in
many life situations, including job situations. This is because these shared social rules drive
individual emotional expressions in interpersonal settings (display rules: Ekman & Friesen,
1975). However, job requirements occasionally necessitate further management of genuine
individual emotions which exceed the general rules due to differences in personal
characteristics or some specific features of the job. In such circumstances, in order to respond
to job requirements, to perform as expected and to satisfy a self-image of being a ‗good
worker,‘ people engage in regulatory strategies (Gross, 2001, 2007) so that they are able to
express the emotions expected. The goal of regulatory processing of emotion is to achieve
levels of dynamics, which promote adaptive and effective responses to the variable demands
of physical and social environments and some strategies might be more effective than others
in terms of affective, cognitive and social functioning (Gross, 2007).
Recently Aldao (2013) reviewed many studies on emotion regulation and emphasised
that the features of the context of the regulation process play an essential role. Following her
suggestion and taking into account both the regulatory process related to empathy and the
data we collected as regard to the nurse-patient relationships, it might be suggested that the
characteristics of an individual (e.g., traits, temperament, etc.), the type of outcomes that the
person wants to achieve and also the type of stimuli involved in the situation influence the
choice of strategy which the nurse engages in and the related behaviour. Nevertheless,
according to the features of the context and the type of stimuli that elicit the emotions certain
regulation strategies might be more effective than others. When nurses interact with patients,
as in many other situations in real life, their emotions are elicited by means of the perceptual
 Empathy: Angel or Devil? 285

and cognitive features of the stimuli that involve respectively bottom-up generation processes
and top-down generation processes of emotions (see: Ochsner et al., 2009). Thus, nurse is call
to cope with negative emotion that can be elicited by direct exposure to painful expressions or
injured bodily parts or that arises as a result of cognitive operations (e.g., imagining the
suffering of another person. As a consequence various regulatory processes might be used, as
the data collected seem to prove and these processes might be more or less effective
according to the situation. Moreover, it might be taken into account that a worker is motivated
to regulate his/her emotional reaction depending on the requirements of his/her job and that
he/she has learned to do this (probably automatically) as a result of the length of time in
service. The results of our study have shown that individual levels of empathic tendency may
also have a role in the choice of strategy to avoid being overwhelmed.
To sum up, empathy can be costly in terms of the well-being of the nurse if he/she does
not have effective regulatory processes to modulate intense, negative, vicarious emotions.
This suggests that it might be useful for nurses to undergo specific training (during their
academic course as well as during service) aimed at improving empathic and regulatory skills.
This would assist them to deal with the demands of their job.

HOW TO IMPROVE EMPATHIC RESPONSES IN NURSES:

SUGGESTIONS RESULTING FROM PRACTICE
Educators of nurses have the possibility of improving the empathy skills of student
nurses, and this has been the subject of several studies with various outcomes. In fact, all
these studies highlight the fact that empathy can be developed (Wheller & Barrett, 1994,
Cutcliffe & Cassedy, 1999, Ancel, 2006, Ozcan et al., 2010). However, they do not offer clear
indications of content, methods, outcomes or timing of training for increasing the empathic
and emotion regulatory abilities of nurses.
We conducted a cohort longitudinal study (Cunico et al., 2012) to test whether empathic
tendencies improve in student nurses during a three year undergraduate course and whether
this improvement might be enhanced by mean of a specific training. The didactic pathway
employed in training plans centred on small groups in accordance with the Bion learning
experience model (1962) which promotes among the students a circular communication of
feelings experienced and the ‗here and now‘ (hic et nunc) emotional difficulties in the
laboratory. The Dokmen Empathy Classification is also used (Ancel, 2006). This comprises a
process, at the first stage called ‗Other,‘ where people answer questions referring to social
stereotypes (what others think and feel), rather than concentrating on the real problem. This
first stage of the process is inadequate and of little value; at the second stage, ‗I,‘ people
respond to a critical situation involving others, giving advice and evaluating the problem by
means of a personal interpretation and by transferring their own feelings and experiences; at
the third stage, labelled ‗You,‘ people put themselves in the other‘s shoes to understand the
problem, emotions and feelings the patient is going through, subsequently reflecting on what
they have learned with the aim of giving understanding and support.
A crucial aspect in developing empathic competences is a result of the growth of
awareness of cognitive processes and emotional processes. There are two ways of developing
self-awareness: direct and indirect (Strepparava, 2006). In the case of the indirect approach,
286 Anna Maria Meneghini, Laura Cunico and Riccardo Sartori

the Medical Humanities studies are frequently used, as learning comes from shared
reflections on the narrative experiences of disease (films and literature). In the direct approach
the role playing technique is used. The training course that was planned for the student nurses
involved in our study (Cunico et al., 2012) included both direct and indirect techniques: in the
first year of University, the basic principles consist of nurturing the idea that controlled
exercise of the mechanisms concerning the sharing of emotions leads to emotional adaptation
during contact with the patient. This is a process that arises from identification with the
characters in the film (‗that is me‘ and ‗I feel like him/her‘) and the empathic process is thus
developed (how can I help him/her with these sensations I share?). The direct approach, on
the other hand, involves working ‗directly‘ (in first person) on relationships and/or
communication using role-playing methods. This approach is generally used in the second
and third years, because students are able to develop a better understanding of their own
abilities by changing roles in a relationship. The goals are varied each year. Our results
showed that empathic tendencies in student nurses improve during the three years of the
academic course and this improvement can be enhanced by means of an extra training course
involving role playing techniques (Cunico et al., 2012, Meneghini et al., 2013).
As mentioned earlier, a crucial aspect in developing empathic competences is the growth
of awareness of cognitive processes and emotional processes. Though this is very important
for student nurses during their education, it is also important for nurses caring for patients.
Several studies have shown that professional experience as a nurse diminishes the ability to
imagine the patient‘s pain. Burnout is a form of stress that commonly occurs in nurses. To
reduce the possibilities of this occurring, nurses must develop awareness and balance, make
appropriate choices, maintain focus and allow time for self. In addition, the practice of
supervision with an expert could be a winning strategy for emotional work and will assist in
maintaining a balance during continuous exposure to the suffering of other people. Becoming
more aware of their own emotional skills helps nurses to be empathic and to relate better with
themselves and with others. This is also crucial for the consolidation of the correct emotional
distance from the patient, emotional involvement that can become difficult to handle. The
ability to decode and handle emotions helps to promote personal well-being and the ability to
recognize the limits of everyday human and professional support with the implementation of
a relational and communicative style which is more functional and effective.

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In: Psychology and Neurobiology of Empathy ISBN: 978-1-63484-446-8
Editors: Douglas F. Watt and Jaak Panksepp © 2016 Nova Science Publishers, Inc.

Chapter 11

ENHANCING EMPATHY IN
THE HELPING PROFESSIONS

Gail Kinman1 and Louise Grant2

1
Professor of Occupational Health Psychology,
University of Bedfordshire, Bedfordshire, UK
2
Principal Lecturer in Social Work,
University of Bedfordshire, Bedfordshire, UK

ABSTRACT
Human empathy is generally considered to be an extension of more ancient
mammalian emotional contagion which enables one person to perceive, understand and
share some of the emotional and mental states of another person (Watt, 2007). The
demonstration of empathy is a pre-requisite for ―helping‖ professionals, such as nurses,
social workers, psychotherapists and physicians, as it underpins authentic person-centred
care. Nonetheless, the negative implications of ―uncontrolled‖ empathy have been
highlighted. This chapter explores the empathy construct in helping contexts and
discusses the implications of over- or under-identification with patients and clients for the
well-being and performance of helping professionals. Particular focus is placed on the
concept of ―accurate‖ empathy which refers to the requirement for helping professionals
to forge empathic and authentic connections with patients and clients whilst maintaining
clear personal and emotional boundaries. The advantages of utilising extended models of
empathy that encompass competencies such as reflective ability, emotional literacy and
social competence are discussed. Also considered are ways in which empathic skills can
be developed in order to manage the emotional demands inherent in helping professions
more effectively.

EMPATHY IN HELPING PROFESSIONALS: POSITIVE IMPLICATIONS

Empathy is widely acknowledged to be an essential quality for ―helping‖ professionals
such as nurses (Williams & Stickley, 2010), midwives (Siddiqui, 1999), physicians (Halpern,
298 Gail Kinman and Louise Grant

2003), dentists (Nash, 2010), social workers (Gerdes & Segal, 2011) and psychotherapists
(Jensen, Weersing, Hoagwood & Goldman, 2005). It is a fundamental component of the
delivery of compassionate care and is generally considered to be therapeutic in its own right
(Hojat, 2007). Indeed the mere presence of a supportive person, such as an empathic care
provider, has been found to buffer the cardiovascular stress response (Christenfeld & Gerin,
2000). Studies have found strong links between empathy demonstrated by helping
professionals and many positive outcomes for clients and patients. Empathy is considered to
be a fundamental determinant of quality in medical care in particular (Neumann et al., 2009;
Wright, Kern, Kolodner, Howard & Brancati, 2010). A systematic review that examined
associations between empathy and patient outcomes in cancer care found significant
relationships with patient satisfaction and wellbeing (Lelorain, Brédart, Dolbeault & Sultan,
2012). More empathic physicians tend to elicit greater disclosure from their patients and
experience higher levels of compliance and adherence to treatment, fewer appointment
cancellations, and are less likely to be the subject of litigation for malpractice (DiMatteo,
Hays & Prince, 1986; Squier, 1990; Hickson, Gayton, Githens & Sloane, 1992; Epstein,
Siegal & Silberman, 2008). Empathy has also been associated with objective ratings of
physicians‘ overall clinical competence and more accurate diagnosis and prognosis
(Dubnicki, 1977; Hojat et al. 2002). Moreover, it has been related to improved clinical
outcomes: for example, a study of diabetic patients found that physicians‘ levels of empathy
made an independent positive contribution to glycaemic control (Hojat et al., 2011). There is
also evidence that empathic interactions between clinicians and patients can reduce levels of
self reported pain and post-surgical recovery time (Berk, Moore & Resnick, 1977; Olson et al.
1989). Mechanisms responsible for these physiologic effects of empathy are still relatively
uncharted, but work by Panksepp (1998) suggests a potential opioidergic basis, with empathy
reducing both pain and separation distress through shared peptidergic controls (see chapter in
this volume by Watt and Panksepp).
Research with other helping professionals has found strong associations between
empathy and a wide range of benefits for patients and clients. Empathy is considered a
particularly important – if not seminal – quality for psychotherapists (Bohart & Greenberg,
1997; Lambert & Barley, 2001). Indeed, it is a basic building block of the therapeutic bond
and necessary to facilitate deep and lasting change in the lives of their clients (Rohr, 2012).
Studies of other helping professionals, such as social workers and nurses, have also found
associations between empathic skills and key outcomes for clients and patients such as
enhanced psychological wellbeing and quality of life, and reduced antisocial behaviour, anger
and aggression (Olson, 1995; Weisner & Silbereisen, 2003; Fields et al. 2004; Olson &
Hanchett, 1997; Bonvicini et al. 2009). Empathic connections with professionals can also
help people manage feelings of alienation and help them feel understood and accepted
(Shemmings, Shemmings & Cook, 2012). As well as improving outcomes for patients and
clients, there is evidence that empathic relationships can also enhance the wellbeing of
helping professionals. Helping transforms people from ―victims to survivors‖ and can be
personally fulfilling and engender ―compassion satisfaction‖ (Radley & Figley, 2007: p. 207).
Research with social workers, in particular, has demonstrated that empathic interactions with
clients can enhance feelings of personal accomplishment and consolidate professional identity
(Yiu-Kee & Tang, 1995). As with physicians discussed above, there is evidence that
objectively-rated empathic interactions between social workers and their clients facilitate the
disclosure of information and reduce resistance to interventions (Forrester, Kershaw, Moss &
 Enhancing Empathy in the Helping Professions 299

Hughes, 2007). Empathy has also been found to protect helping professionals from work-
related stress and enhance their emotional resilience (Sullivan, 1990; Kinman & Grant, 2011).
A framework developed by Lilius (2012) also highlights the restorative nature of empathic
interactions for helping professionals, as they can replenish levels of motivation and energy
that may be depleted by chronic work demands.

EMPATHY IN HELPING PROFESSIONALS: NEGATIVE IMPLICATIONS

Although empathy can undoubtedly enhance the quality of helping relationships, it can
have negative implications for professionals. Some degree of emotional contagion/affective
resonance is generally considered essential in order to forge a true empathic connection with
others (Watt, 2007), but this may be under- or over- amplified by too little or too much
identification/emotional resonance with a client or patient. This can have potentially serious
consequences for the helping professional and the quality of the service they provide. Firstly,
an empathic response may not always arise spontaneously with certain patients or clients, as
their personal or situational characteristics may fail to resonate positively with the helping
professional, and may even provoke negative reactions in the other party. Under such
conditions, considerable effort will be required by the helping professional to regulate
negative emotions in order to not contaminate the emotional climate within a helping or
therapeutic relationship. Secondly, if the problems of patients and clients ―over-resonate‖
with helping professionals (the helping professional over-identifies with the patient or client
due to shared traumas or other emotional difficulties), emotional boundaries can be breached
and ―uncontrolled‖ empathy can occur. These issues and their implications for the wellbeing
and job performance of helping professionals will be examined in this section.

Emotional Labour

Engaging empathically with patients and clients could be considered a form of emotional
labour (Larson & Yao, 2005). This has been defined as the effort, planning, and control
required to display the organisationally or professionally appropriate emotions during
interpersonal interactions (Morris & Feldman, 1996). Although most employees are required
to perform some degree of emotional labour, it is thought to be intrinsic to human service
work (Henderson, 2001; Mann, 2004; Dollard, Dormann, Boyd, Winefield & Winefield,
2006). Empathy involves both concern for suffering and motivation to reduce it (Watt, 2007),
but this may not always arise spontaneously. For example, a social worker may need to
expend a considerable degree of emotional effort to forge an empathic connection with a child
sex offender while contending with and managing their own negative emotions and inhibiting
their expression through standard affective channels such as facial expression, body language
and tone of voice.
An emotional regulation framework is adopted by Ashforth and Humphrey (1993) who
maintain that that employees perform emotional labour in different ways: a) through ―deep
acting,” where people endeavour to regulate their internal experiences: this involves the
automatic or consciously controlled generation of genuine empathy-consistent emotional and
300 Gail Kinman and Louise Grant

cognitive reactions during interactions with patients and clients; and b) ―surface acting,”
where professionals ―fake‖ their emotional displays by engaging in observable empathic
interactions with the patient or client without experiencing the authentic emotional and
cognitive reactions. Deep acting corresponds with ―true‖ empathy as, although effort may be
involved to regulate emotions, some emotional contagion occurs within the interaction. On
the other hand, surface acting is likely to occur where interactions with clients or patients are
driven by ―duty‖ rather than genuine concern (Larson & Yao, 2005).
Performing emotional labour can have positive consequences for employees, especially
when it is believed to be performed for philanthropic reasons (Bolton & Boyd, 2003). There
is evidence, however, that outcomes are contingent upon whether the employee engages in
‗deep‘ or ‗surface acting.‘ Studies have found that ‗deep acting‘ can increase job satisfaction
and well-being, as well as enhance patients‘ and clients‘ perceptions of rapport, nurturance
and supportiveness (Brotheridge & Lee, 1998; Yang & Chang, 2008). Nonetheless, there is
evidence that ‗surface acting‘ can impair the well-being of employees, due to the effort
required to manage the dissonance between emotions that are genuinely experienced and
those that are considered appropriate to display during empathic interactions with patients and
clients (Brotheridge & Lee, 1998). Studies have found that emotional dissonance, executive
inhibition of inappropriate emotions and suppression of inappropriate emotions can impact on
job performance, absenteeism, retention and work-life balance, engender feelings of self
estrangement, and impair physical and psychological health (Bono & Vey, 2005; Bakker &
Heuven, 2006; Chau, Dahling, Levy & Diefendoff, 2009; Cheung and Tang, 2009; Diestel &
Schmidt, 2010).

Burnout

Burnout has been defined ―as a syndrome comprising emotional exhaustion,

depersonalisation and reduced personal accomplishment that can occur among individuals
who work with people in some capacity‖ (Maslach, Jackson & Leiter, 1996, p. 4). It is
particularly prevalent in the helping professions (Maslach & Goldberg, 1998). Research in
various professional helping contexts indicates that attempting to fulfill the emotional
demands intrinsic to such work can engender compassion fatigue and emotional exhaustion in
employees: this can lead to professionals‘ attempting to conserve their emotional resources by
reducing their emotional investment in relationships with patients and clients which is likely
to engender feelings of cynicism and derpersonalising behaviours. In turn, such feelings can
lead to a perceived lack of personal accomplishment and professional efficacy, as the
practitioner becomes unable to identify with their patients and clients and make genuine
empathic connections with them (Maslach et al., 1996; Schaufeli & Enzmann, 1998).
Another route to burnout is via uncontrolled empathy which can be engendered in
situations of high emotional contagion/affective resonance, a history of overlapping or similar
personal trauma, or indeed both (Rothschild & Rand, 2006). It has frequently been observed
that people who are highly altruistic or empathic are drawn towards caring work (Figley,
2002). Such people are considered at particular risk of over-identifying emotionally with
patients or clients, which can lead to the absorption of their stress, as well as compassion
fatigue, and emotional exhaustion (Williams, 1989; Stebnicki, 2007; Austin, Goble, Leier &
Byrne, 2009). People who have experienced personal trauma also tend to be attracted to the
 Enhancing Empathy in the Helping Professions 301

helping professions (Neumann & Gamble, 1995). The risks of this have been highlighted in
several studies, for example: a study of social workers conducted by Macritchie and
Leibowitz (2010) found that those who had experienced childhood trauma were more
susceptible to personal distress and secondary trauma when required to empathise with
similarly distressed clients. This may emerge from effects of early attachment difficulties on
subsequent emotion regulation abilities, and may prime over-identification with individuals
with similar traumas, engender rescue fantasies, and lead to blurring of boundaries between
―helping‖ versus ―saving‖ (Watt, 2007). A clear distinction between ―self‖ and ―other‖ is
therefore required in these situations.
Uncontrolled empathy also has potentially negative implications for job performance, as
over-identification with patients‘ and clients‘ traumatic experiences can impair professional
judgment and decision making (Pearlman & Saakvitne, 1995; Bride, Radley & Figley, 2007).
Over-confidence in one‘s interpersonal and empathic skills can also backfire; if people
prematurely believe they have developed a deep insight into what another person is
experiencing, they may be less inclined to ask, listen and learn (Weiner & Auster, 2007). In
this sense, a degree of humility and mild uncertainty may actually aid empathic listening and
inquiry. Although these findings are useful, many studies are based on cross-sectional
correlational data. In order to gain further insight into the impact of ‗uncontrolled‘ empathy
on wellbeing and performance-related outcomes, more complex, interactive models are
required that should be tested in longitudinal studies.

INDIVIDUAL AND CONTEXTUAL DIFFERENCES

Clearly, all helping professions do not require the same type or degree of empathic skills:
this will vary considerably by occupation and role. Compassion and empathic skills are
widely considered fundamental – indeed essential – to the effective practice of nurses,
psychotherapists and social workers (Hunter, 2012). Within medicine, primary care
physicians, in particular, are also expected to possess well developed empathic skills (Arnold,
Calkins & Willoughby, 1997). Indeed, in the UK, empathy is one of the core competencies
utilised to select general practitioners (Irish & Patterson, 2010). For a cardiac surgeon,
however, other clinical skills will be more salient than the ability to engage in compassionate
interactions with patients and their families. Hojat et al. (2002) has observed that physicians
working in Psychiatry, Family Medicine, Pediatrics and Emergency Medicine generally
report the highest levels of empathy, whereas Neurosurgeons, Radiologists and Orthopedic
Surgeons (highly technical fields where a contribution to patient care is largely mediated
through technology or invasive procedures) score the lowest (Hojat et al., 2002). Nonetheless,
with the exception of Psychiatry, some of these differences are likely explained by the fact
that women (who are typically more empathic) tend to be employed within the ―more
empathic‖ medical specialties (Hojat et al. 2002). This may also reflect a simple selection bias
– individuals with more empathic capacities may choose fields where face-to-face clinical
interaction with patients is more frequent.
Insight into the factors that amplify or inhibit the development of appropriate empathy
and, accordingly, that might encourage under- or over-identification with patients and clients,
is required in order to safeguard the well-being of professionals and the people they care for.
302 Gail Kinman and Louise Grant

The role played by several individual and contextual variables has been highlighted in the
literature. Responsiveness to emotional contagion, personal trauma history, and emotion
management style have been discussed above, but other individual difference factors that
facilitate the development of appropriate empathy include motivation, patience, curiosity and,
last but not least, the level of fatigue (Regan & Totten, 1975; Firth-Cozens, 1987; Larson &
Yao, 2005; Brazeau, Schroeder, Rovi & Boyd, 2010; Dunn, Iglewicz & Moutier, 2008).
Empathy is an intrinsic component of emotional intelligence which comprises intra- and inter-
personal emotion management strategies such as attention to affective experiences, the clarity
of such experiences, and the ability to maintain positive mood states and repair negative ones
(Salovey, Mayer, Goldman, Turvey & Palfai, 1995). The coping strategies utilised to manage
the demands of maintaining empathic relationships with patients and clients will also impact
on the wellbeing of practitioners. People with a repressive coping style typically fail to
recognise and manage their own emotional responses (Weinberger, 1990), whereas others
with poor affective regulation abilities may resort to substance abuse with its punitive impact
on overall health (Wallace & Lemaire, 2013).
Lilius (2012) has developed a framework that can provide further insight into the role
played by aspects of caregiver interactions with patients and clients. This comprises several
factors that predict the perceived quality of the interaction: the nature of the task (such as
complexity, significance and degree of emotional challenge); the relationship between the
professional and their patient or client (such as the strength of rapport, or the quality of the
emotional connection) and the outcome of the interaction (such as the degree of cooperation
and progress made). The model predicts that during low quality interactions there will be
greater dissonance between the emotions that are required and those that are authentically
experienced (i.e., ‗surface acting‘ or under-identification), whereas interactions that are
perceived to be higher quality will engender genuine empathic concern (i.e., ‗deep acting‘).
The framework developed by Lilius has the potential to inform interventions to enhance the
perceived quality of interactions with patients or clients at different levels. It could also be
augmented with various individual difference and contextual factors: for example,
expressions of gratitude from patients and clients can provide positive feedback which
reinforces the perceived pro-social impact of helping professionals‘ efforts and the
appropriateness of the empathic connection (Sherman & Cohen, 2006).

HOW HAS EMPATHY BEEN CONCEPTUALISED

IN THE HELPING PROFESSIONS?

Empathy has been described as an elusive, mysterious and intellectually challenging

concept (Pike, 1990). While considerable advances have been made at the theoretical level,
with some exceptions, such as Hojat‘s (2007) work with physicians, these theoretical
advances and insights have not informed approaches to empathy adopted by those responsible
for training helping professionals. Dictionaries are often used by nurses and social workers to
elucidate complex concepts, but they tend to define empathy simplistically and somewhat
idealistically. For example, a nursing dictionary defines the concept as ―the ability to
understand the thoughts and emotions of another person‖ (Martin, 2008). Such definitions do
not reflect the more nuanced and multidimensional conceptualisations emerging from the
 Enhancing Empathy in the Helping Professions 303

contemporary literature which comprise both cognitive and affective elements, including
perceiving, understanding, and sharing some of the emotional and mental states of others and
being intrinsically motivated to reduce suffering (Watt, 2007). Models are required that have
clear potential to help practitioners, and those who train them, gain insight not only into the
inherent complexity of the empathy construct, but also how appropriate empathy many be
engendered.
Studies of helping professionals have utilised several measures of empathy in an attempt
to assess levels of this capacity and potential outcomes. The capacity for empathy has
typically been conceptualised as a relatively stable character trait, rather than in terms of
empathic reactions to specific situations and types of suffering. One of the most popular
measures designed specifically for helping professionals is the Jefferson Scale of Physician
Empathy, a primarily cognitive instrument comprising two dimensions: compassionate care
(understanding the role of emotions in therapeutic relationships) and perspective-taking
(paying attention to patients‘ personal experiences and trying to understand their frames of
reference) (Fjortoft, Winkle & Hojat, 2010). This measure has been used in many studies in
clinical settings to examine levels of empathy in physicians, medical students and nurses
(Ward et al., 2009) as well as associations with clinical outcomes such as patient satisfaction
(Glaser et al. 2007).
Various empathy scales have relevance to assessing empathy competencies in the helping
professions more generally. Although not designed specifically for the purpose, The Hogan
Empathy Scale has also been widely used in various helping contexts. This instrument
considers empathy to be a predominantly cognitive phenomenon: ―the intellectual or
imaginative apprehension of another‘s condition or state of mind‖ (Hogan, 1969: p. 308).
This scale has been utilised to assess levels of empathy in groups of helping professionals and
how this relates to individual outcomes such as burnout, professional values and social
functioning (Cliffordson, 2002; Yu & Kirk, 2008), as well as clinical outcomes such as
patient distress (Reid-Ponte, 1992). Another context-free scale developed by Mehrabian &
Epstein (1972) sees empathy in more affective terms, emphasising the concepts of contagion
and affective resonance discussed above. From this perspective, empathy is defined as ―a
vicarious response to the perceived emotional experiences of others‖ (p. 525). Although this
measure is uni-dimensional, it comprises several subcategories that recognises negative as
well as positive aspects of empathy: ―susceptibility to emotional contagion,‖ ―appreciation of
the feelings of unfamiliar and distant others,‖ ―extreme emotional responsiveness,‖ ―tendency
to be moved by others‘ positive emotional experiences,‖ ―tendency to be moved by others‘
negative emotional experiences,‖ ―sympathetic tendency,‖ and ―willingness to be in contact
with others who have problems.‖ This measure may be particularly useful in helping contexts
as it acknowledges the risks of inappropriate empathic responses reflecting excessive
contagion/ over-identification. This measure has been used in samples of helping
professionals to predict key outcomes such as burnout (e.g., Williams, 1989) as well as the
impact of interventions to enhance empathy in clinical contexts (Herbek & Yammarino,
1990).
Many theoretical reviews of the concept suggest that that empathy should be understood
as encompassing a cognitive as well as an affective component (Decety & Jackson, 2004),
suggesting that an ideal empathy scale should probe both dimensions. The Interpersonal
Reactivity Index developed by Davis (1983: p. 55-57) comprises four distinct subscales that
include a mixture of affective and cognitive elements: 1) ―perspective taking: the tendency to
304 Gail Kinman and Louise Grant

spontaneously adopt the psychological view of others in everyday life,‖ that is related to
theory of mind; 2) ―empathic concern: or the tendency to experience feelings of sympathy or
compassion for unfortunate others‖ that is related to general prosocial attitudes; 3) ―personal
distress: or the tendency to experience discomfort in response to extreme distress in others‖;
which is a clear reference to emotional contagion; and 4) ―fantasy: or the tendency to
imaginatively transpose oneself into fictional situations.‖ The final element could be said to
reflect an aspect of perspective taking, but may also relate to affective arousal, and is not
reflected in other models of empathy. Like Mehrabian and Epstein‘s measure described
above, this IRI scale developed by Davis could be considered particularly appropriate to
helping professionals as it acknowledges that empathy has the potential to lead to states of
emotional distress via a contagion-type mechanism. The Interpersonal Reactivity Index has
been used widely with helping professionals to assess levels of empathy (Yarnold, Bryant,
Nightingale & Martin, 1996) and their relationship with outcomes such as secondary trauma
(Badger, Royes & Craig, 2007) and job performance (Riggio & Taylor, 2000). It has also
been used to investigate longitudinal variations in perspective taking, empathic concern and
empathic distress in helping professionals (Bellini, Baime & Shea, 2002). When investigating
empathy in helping contexts, multi-dimensional models of empathy that incorporate cognitive
and affective elements are useful and help to identify the risks, as well as the benefits, of
delivering compassionate care. Such models also have the potential to identify optimum
empathic profiles that are appropriate to the specific working context and inform the
development of interventions to enhance controlled or accurate empathy to safeguard the
wellbeing of employees and their patients and clients.

ACCURATE EMPATHY
Over several decades, various terms, such as ―objective compassion,‖ ―compassionate
detachment‖ (Thomas & Otis, 2010) and ―detached concern‖ (Lief & Fox, 1963), have been
used to describe the need for helping professionals to demonstrate empathic engagement,
whilst simultaneously maintaining some emotional separation from service users. As
discussed above, this ―controlled‖ empathy is required to modulate the symptoms associated
with compassion fatigue, vicarious traumatisation and burnout. The term ―accurate empathy‖
was first utilised by Rogers (1957) to refer to the ability of caring professionals to
communicate empathic understanding during interactions with patients and clients, but avoid
adverse emotional consequences from such encounters. Empathic accuracy requires a balance
between a ―sense of knowing‖ the experiences of others and avoiding personal distress and
burnout by regulating emotional reactions effectively (Goubert, Craig & Buysse, 2009).
Drawing on the work of Decety and Jackson (2004), Gerdes, Lietz and Segal (2011 p. 116)
have highlighted three main features of accurate empathy in helping contexts:

1. Affective sharing: being mindful of the patient‘s or client‘s experience and conscious
of the barriers to empathic contagion;
2. Self-other awareness: a sense of self which is separate from the patient or client;
3. Self-emotion: the conscious effort involved in regulating emotion.
 Enhancing Empathy in the Helping Professions 305

All three components of empathy are essential as, for example, affective resonance
without much self-other awareness is likely to lead to over-identifying with the emotional
experiences of the patient or client. For helping professionals, accurate empathy is required to
not only protect personal wellbeing, but also to optimise job performance. As highlighted
above, the compassion fatigue, depersonalisation and burnout that can stem from ‗inaccurate‘
empathy can lead to excessive rumination, feelings of confusion and ambivalence, defensive
withdrawal promoting apathy and boredom, cognitive impairments such as reduced
concentration and memory emerging from chronic stress, as well as other psychological and
physical health problems (Johne, 2006). These all have serious implications for decision
making, planning and professional judgement, as well as personal wellbeing. Without the self
awareness, boundary maintenance and affective regulation skills inherent in more accurate
empathy, there is also a risk that professionals will try (consciously or unconsciously) to
inhibit the expression of emotions by patients and clients in order to protect themselves from
the personal distress that such disclosure may cause (Mullins, 2011). The impact of this on
the quality and outcome of relationships in therapeutic settings is evident.

WHAT ARE THE FACTORS THAT UNDERPIN ACCURATE EMPATHY?

In order to develop interventions to enhance accurate empathy in helping professions,
insight is required into the factors that underpin this capability. As discussed earlier in this
chapter, emotional intelligence, self awareness and emotional regulation skills are generally
considered to be the key determinants of accurate empathy: indeed, Decety and Moriguchi
(2007, p. 13) have argued that ―…without them there may be no true empathy.‖ The findings
of a study of 359 trainee social work students (Grant, 2013) provide some insight into the role
played by self-awareness in predicting accurate empathy in helping contexts. The study
utilised three dimensions of Davis‘s model of empathy (1983): i.e., perspective taking,
empathic concern and empathic distress. Levels of self-reported perspective-taking and
empathic concern were generally high, but a moderate degree of empathic distress was also
found. Empathic concern and perspective taking were negatively related to empathic distress,
suggesting that these competencies are key elements of accurate empathy. Building on the
widely-held premise that reflection is a key component in developing self awareness and
emotional regulation skills, this study also explored the contribution of different aspects of
reflective ability in predicting empathy: self reflection (i.e., introspection; exploration;
understanding and appraisal of experiences); empathic reflection (i.e., taking into
consideration the situation of others; openness to different ways of thinking; contextual
understanding and appraisal) and reflective communication (reflective behaviour; openness
for feedback and discussion; taking responsibility for own statements and actions; ethical
accountability (Aukes, Geertsma, Cohen-Schotanus, Zwiestra & Slaets, 2007, p. 180).
The findings of Grant‘s study revealed that trainee social workers rated themselves fairly
highly on the self-reflection dimension, whereas levels of self-reported empathic reflection
and reflective communication were somewhat lower. Those who rated their reflective abilities
more favourably tended to report more empathic concern and perspective taking.
Emphasising the importance of reflective ability in underpinning accurate empathy, all three
elements (most notably empathic reflection) were negatively related to empathic distress.
306 Gail Kinman and Louise Grant

Interestingly, empathic distress had strong negative associations with psychological wellbeing
more generally Clearly this model should be tested with experienced social workers using a
longitudinal design to establish the direction of causality, but these findings highlight the
important role played by reflective abilities in protecting helping professionals from the
negative effects of delivering compassionate care. Although evidence was found that
empathic concern and perspective taking may underpin accurate empathy in helping
professionals, particularly high levels may signify over-involvement with patients or clients
and a tendency for their experiences to over-resonate with the helping professional. Further
research is required to establish optimum levels of these capacities in different helping
contexts in samples that comprise trainee and more experienced staff. This is particularly
important as levels of empathy have been found to decline over time in helping professionals
(see below).
Research conducted by Kinman and Grant (2011) also highlights the role played by other
competencies in underpinning accurate empathy in social workers. In addition to reflective
ability, findings revealed that a combination of emotional intelligence, social confidence and
flexible use of coping strategies were strong predictors of accurate empathy. The study also
found that resilience had a particularly robust positive relationship with perspective taking
and empathic concern, whereas more resilient social workers tended to report less empathic
distress. These findings indicate that accurate empathy might underpin resilience as well as
protect helping professionals from psychological distress. The findings also suggest that
coping flexibility is a key predictor of accurate empathy as well as wellbeing more generally
(Cheng, 2001. Longitudinal research, possibly using daily diary methodology, with helping
professionals from different occupational context is required to test the hypothesised
relationships and the long term implications for wellbeing and job performance.
 Enhancing Empathy in the Helping Professions 307

HOW CAN ACCURATE EMPATHY BE ENHANCED?

Although accurate empathy is fundamental to forging therapeutic relationships with
patients and clients, this quality is not necessarily well developed in helping professionals
(Reynolds & Scott, 2000). A study that examined the empathic interactions between non-
physician clinicians (NPCs) and patients with advanced cancer found that, on average, NPCs
responded to emotional disclosure with empathic language only 30% of the time (Alexander
et al., 2011). Several studies have also indicated, rather disconcertingly, that empathy and
altruistic attitudes tend to decline as helping professionals progress through training (e.g.,
Hojat et al. 2009; Nunes, Williams & Stevenson 2011). Evidence-based interventions
designed to assess, as well as enhance and maintain accurate empathic capacities throughout
the working lives of helping professionals, are clearly required. It seems particularly
important to ensure that trainees in different helping contexts do not perceive empathy to be
an unambiguously positive emotional experience, and develop an appreciation of its
complexity and the implications of inaccurate empathy for their personal well-being and that
of their patients and clients. Hojat (2007) has highlighted several approaches that have the
potential to enhance accurate empathy in helping professionals, including exposure to role
models, role playing, recording and deconstructing encounters with service users, shadowing
patients and clients, and studying literature and the arts. Studies on empathy in the helping
professions, however, tend to place greater focus on the need to forge empathic connections
with patients and clients rather than how accurate empathy can be cultivated and maintained
over time (Gibbons, 2011). Gerdes et al. (2011) have posed two important questions in this
regard. Firstly, how can people develop their innate empathic reactions and their capacity to
feel another‘s emotion? Secondly, how can people regulate their emotional reactions to
protect them from empathic distress/effects of excessive contagion?
The seeds of empathic abilities are sown in early childhood in relation to the quality of
early relationships with care-givers, and subsequently developed in friendships and other
intimate relationships (Thompson, 1998). There is some evidence that empathy can be
cultivated in trainee helping professionals, but this appears highly dependent upon the
approaches and strategies utilised (Hojat, 2007). Moreover, any gains may not necessarily be
maintained without practice or reinforcement (Engler et al. 1981). It has been observed that
helping professionals are often taught how to ―do‖ empathy via communication, interpersonal
and counselling training (Trevithick, 2004) Effective communication is undoubtedly a key
component of empathy in helping professionals, in that those whose verbal and non-verbal
communication skills are more developed are generally considered to be more empathic
(Stuart & Laraia, 2005). Nonetheless, as discussed earlier in this chapter, the range of
competencies that underpin accurate empathy is considerably broader, so a wide range of
strategies are required in order to cultivate it. The important role played by self awareness and
emotional regulation skills in developing accurate empathy has been emphasised throughout
this chapter. There is evidence that these abilities can be developed through carefully-targeted
interventions such as experiential learning and emotional writing techniques (Grant, Kinman
& Alexander, 2014).
Cultural awareness has also been highlighted as a crucial element in forging effective
empathic relationships. Insight into the nature of ethno-cultural empathy, defined as empathy
directed towards people from ethnic and cultural groups different from one‘s own group, is
308 Gail Kinman and Louise Grant

required (Wang et al., 2003). It could be argued that Western conceptualisations of empathy
view it from a highly individualised perspective, whereas people from other cultures tend to
utilise a more inter-dependent relationship-focused approach (Pederson, Crethar & Carlson,
2008). A lack of familiarity with the cultural norms and identities of others, or a reluctance to
―de-centre,‖ can impair perspective-taking which, in turn, is likely to impair empathic
understanding (Nelson & Baumgarte, 2004). Moreover, a tendency to distinguish between in-
groups and out-groups may inculcate attitudes that suffering is deserved (Sturmer, Snyder &
Omoto, 2005). Several personal capabilities are believed to underpin cultural awareness, such
as the ability to communicate in a culturally appropriate manner and to understand and
respect the values, beliefs and practices of people from different backgrounds, whilst
simultaneously retaining one‘s own cultural identity (Chung & Bernak, 2002; Shams-Avari,
2005; Carter et al., 2006). Furthermore, gaining insight into structural or personal barriers,
such as poverty, racism or social disadvantage, is likely to improve cultural empathy
(Mullins, 2011). Despite the importance of cultural awareness in underpinning accurate
empathy, little focus has been placed on this capacity in many helping contexts (Hojat, 2007).
Evidence is accumulating, however, to suggest that cultural competence can be enhanced
through techniques such as exploration of critical incidens, role play and simulation
(Hamilton, 2011).
The next section presents four techniques that might be particularly fruitful in enhancing
accurate empathy: mindfulness, reflective supervision, experiential learning and the use of
creative and reflective writing.

Mindfulness

Mindfulness involves ―paying attention in a particular way: on purpose, in the present

moment, and non-judgmentally‖ (Kabat-Zinn, 2004, p. 4). It is argued that the more mindful
people are (in terms of their ability to fully experience their thoughts and feelings), the better
they can appreciate the thoughts and feelings of others (Chaskalson, 2011). Mindfulness
techniques can be utilised to enhance the quality of relationships with patients and clients and
as well as to protect the wellbeing of practitioners. Evidence is emerging from different
professional helping contexts that mindfulness training has the potential to cultivate and
maintain accurate empathy by enhancing perspective-taking skills, improving reflective
ability, promoting emotional regulation and reducing over-involvement with patients and
clients (e.g., Gerdes & Segal, 2011). In the psychotherapeutic literature, particular focus is
placed on the role played by mindfulness in facilitating an open, accepting and non-
judgemental attitude (Germer, Siegal & Fulton, 2005). Indeed, it has been suggested that
mindfulness should be an intrinsic element of counselling and psychotherapeutic training
(Greason & Cashwell, 2009). Studies of helping professionals also provide evidence that
mindfulness can relieve compassion fatigue, burnout and vicarious trauma (Cunningham,
2004; Thomas & Otis, 2011; Kessen & Turner, 2012; Hülsheger, Alberts, Feinholdt & Lang,
2013).
Mindfulness is also thought to facilitate self-compassion (Neff, 2003) as it helps people
take a more balanced approach to their painful thoughts and feelings: neither suppressing
them, nor ruminating excessively upon them. Self compassion also comprises self-kindness
(i.e., understanding and accepting the self when confronting personal inadequacies or failures)
 Enhancing Empathy in the Helping Professions 309

and common humanity (i.e., accepting that imperfection and suffering are part of the wider
human experience). Interventions designed to enhance self-compassion have been found to
reduce stress, anxiety and depression and increase life satisfaction (Neff & Germer, 2012) and
enhance concern for others (Neff & Pommier, 2012). There is also evidence that ‗loving
kindness meditation,‘ which like mindfulness is based on Buddhist philosophy, can engender
feelings of social connectedness and help healthcare professionals maintain an altruistic and
compassionate attitude towards their patients (Kristeller & Johnson, 2005; Hutcherson,
Seppala & Gross, 2008; Boellinghaus, Jones & Hutton, 2012).
Mindfulness Based Stress Reduction (MBSR) is a technique developed by Kabat-Zinn
(2003) that incorporates meditation, yoga and relaxation training. A number of studies have
been conducted amongst various groups of helping professions to examine the effectiveness
of MBSR training on empathy and similar constructs, as well as personal wellbeing.
Mindfulness practice has been associated with enhanced levels of empathic self awareness,
self compassion and emotional resilience in professions such as medicine, nursing and social
work (Shapiro, Brown & Biegel, 2007; Krasner et al., 2009: Pipe & Bortz, 2009; Napoli &
Bonifas, 2011). More specifically, a study of nursing students conducted by Beddoe and
Murphy (2004) found that an eight-week MBSR course also resulted in reduced levels of
empathic distress amongst participants. Acceptance and Commitment Therapy (ACT: Hayes,
1987) is a technique that harnesses the principles of mindfulness; when delivered in
workplace settings, ACT has had some success in enhancing psychological flexibility and
emotion regulation skills and reducing psychological distress and burnout (Lloyd, Bond &
Flaxman, 2013). Incorporating mindfulness techniques into the initial training and subsequent
personal development of helping professions is likely to be beneficial for wellbeing and
professional practice, but more research is required into how interventions might be tailored
to the needs of specific groups.

Reflective Supervision

As discussed earlier in this chapter, reflective abilities have been found to underpin
accurate empathy amongst helping professionals. In professional helping contexts, reflective
abilities are frequently developed through reflective supervision (Rolfe, Freshwater & Jasper,
2001). This technique can help professionals interrogate emotional reactions to practice and
explore doubts, assumptions and beliefs. More specifically, reflective supervision can be
utilised to reflect upon encounters with clients or patients which were particularly challenging
or distressing and subsequently explore alternative ways of managing such situations
(Collins, 2007). Reflective supervision can also be used to discuss encounters that have
engendered positive emotions, such as joy or contentment, as these can be emotionally
restorative and help counteract more negative experiences (Hawkins & Shohet, 2000). A
review of the literature conducted by Brunero and Stein-Parbury (2007) found that clinical
supervision which focused on the development of critical reflective skills led to
improvements in self awareness and accurate empathy, as well as reductions in stress.
Rohr (2012) has argued that group supervision for psychotherapists creates a ―health-
saving support system‖ in which emotional reactions can be explored and regulated and
accurate empathy maintained. More specifically, a study that evaluated a mindfulness-based
role-play intervention incorporated into psychotherapists‘ supervision sessions found
310 Gail Kinman and Louise Grant

improved rapport with clients in general, and enhanced empathy and/other awareness in
particular (Andersson, King & Lalande, 2010). Reflective supervision could also be used to
provide a more person-centred approach towards enhancing the competencies found to
underpin accurate empathy that have been discussed earlier in this chapter. It might be
particularly fruitful to utilise the framework developed by Lilius (2012) discussed earlier in
this chapter during reflective supervision in order to explore the aspects of encounters with
patients or clients that are experienced in positive and negative terms, their short-term and
longer-term consequences for wellbeing and service provision and ways in which
competencies might be developed.

Experiential Learning

The use of vignettes, exploration of patients‘ and clients‘ experiences, role play and
psychodramatic role reversal have been found to increase accurate empathy as well as
enhance emotional regulation skills, reflective ability and self awareness (Braun, Cheang &
Shigeta, 2005; Cunningham, 2004; Gair, 2011; Yanniv, 2012). A study of first-year medical
students conducted by Henry-Tilman et al. (2002) found that opportunities to ―shadow‖ a
patient during their oncology treatment generally increased empathic attitudes towards
patients in general. A study of social work trainees conducted by Edwards, Peterson and
Davies (2006) found statistically significant improvements in levels of empathy following the
use of case studies in teaching sessions. More recent research with trainee social workers
conducted by Grant, Kinman and Alexander (2014) observed improvements in levels of
accurate empathy and associated capabilities, such as emotional intelligence, reflective ability
and social competence, following an intervention, whereby experienced social workers
disclosed their personal emotional reactions to practice and subsequently discussed these
issues with the group. Interestingly, the study also found that levels of resilience and
psychological wellbeing increased post intervention. Interventions that expose helping
professionals to various forms of experiential learning are, therefore, likely to be useful in
fostering accurate empathy and the factors that underpin this. Such interventions may be
particularly valuable for helping professionals who feel that disclosing negative emotional
reactions to practice and difficulties in developing an empathic relationship with patients and
clients is unprofessional and inappropriate (Sorenson & Iedema, 2009). The use of
experiential learning for enhancing accurate empathy is still under-developed, however, and
more research is required to develop evidence-based vignettes and role-play scenarios that are
appropriate to various professional helping contexts. Experiential techniques are also likely to
be useful in helping trainees develop ―cultural intelligence‖: an aspect of emotional
intelligence that is likely to be of particular relevance to helping professionals in multi-
cultural contexts as discussed above (Dominelli & Hackett, 2013).

Creative and Reflective Writing and the Arts

Emotional or expressive writing has frequently been used to help people process complex
emotional experiences more effectively and improve physical and psychological health in
occupational, community and clinical samples (Pennebaker & Seagal, 1999; Lepore,
 Enhancing Empathy in the Helping Professions 311

Greenberg, Bruno & Smyth, 2003). Although little systematic research has yet been
conducted, evidence is accumulating to suggest that developing creative and reflective writing
skills can help professionals enhance self awareness and develop empathic relationships with
patients and clients (Webster, 2010), as well as improve self and other awareness (Olson,
2002). Bolton (2010) has highlighted the benefits for helping professionals of writing a
narrative of their personal experiences as if they were fiction and sharing this with others.
Many studies have found that engagement in the arts can enhance feelings of social
connectedness and empathy. Shapiro and Rucker (2004) have documented the ―Don Quixote
effect‖ in physicians, whereby watching movies that display compelling images of suffering
and healing can promote emotional idealism that helps enhance empathy and altruism. Such
techniques have strong potential to be used in medical education and the training of other
helping professionals. Reading fictional literature has also been found to enhance the quality
of empathic connections, increase social competence and reduce social anxiety (Mar, Oatley
& Petersen, 2009; Djikic, Oatley & Moldoveanu, 2013). A study conducted by Konrad (2010)
found that reading fiction could help social work trainees learn how to balance empathy with
self-awareness and self care. Fiction has the potential to enhance accurate empathy in helping
professionals, most likely by expanding their emotional repertoire and providing insight into
the backgrounds, experiences and motivations of people who are very different to themselves.
Nonetheless, experimental research suggests that ―emotional transportation‖ into the story is
required for any gain to occur (Bal & Veltkamp, 2013. This suggests that great care is needed
to select fictional literature that will engage the reader and is appropriate for the context.

CONCLUSION
The development of accurate empathy is a key competency for those working in the
helping professions. Qualified staff and those in training require insight into the complex
nature of empathy and the potential for empathic distress, compassion fatigue and burnout if
emotional regulation skills and self awareness are not developed and boundaries are not
maintained. More research is required to inform the development of evidence-based
interventions to enhance accurate empathy and associated competencies. In particular, a
greater appreciation of the role of reflection as a protective factor in developing self and other
awareness and in managing the emotional labour of practice is required. Although the helping
professions could be considered intrinsically emotionally challenging, the use of techniques
such as mindfulness and experiential learning have the potential to safeguard the wellbeing of
employees and enhance the service they provide to others.

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EMPATHY IN CLINICAL DISORDERS
In: Psychology and Neurobiology of Empathy ISBN: 978-1-63484-446-8
Editors: Douglas F. Watt and Jaak Panksepp © 2016 Nova Science Publishers, Inc.

Chapter 12

EMPATHY DYSFUNCTION: DECONSTRUCTING

SOCIAL FUNCTIONING IN AUTISM SPECTRUM
DISORDERS AND CONDUCT DISORDER

Sara Paloma Vilas Sanz, BSc, Amanda Ludlow, PhD,

and Renate Reniers, PhD
School of Psychology, University of Birmingham, Birmingham, UK

ABSTRACT
Empathy is a multidimensional construct that can be understood as the ability to be
perceptive of and vicariously experience the feelings of other people (affective
components of empathy), while at the same time being able to build a working model of
their emotional states (cognitive components of empathy). The ability to empathize has
critical social functions in that it helps us to respond appropriately to perceived feelings
of others, thereby facilitating successful social interaction. The importance of empathy is
particularly apparent in disorders on the autism spectrum, where the ability to form social
relationships and communicate with others is impaired. In addition, empathy is
considered to be equally crucial in conduct disorder, which is characterized by reduced
responsiveness to the distress of others in association with callous-unemotional traits.
While both disorders are thought to be characterized by problems in empathy, social
interaction and adaptation, these disorders reflect distinct problems in relationship to
others within a social milieu. Individuals with either condition can appear uncaring and
poorly attuned towards others, suggesting that empathy dysfunction should be considered
one of the hallmarks to both conditions. It has been suggested that individuals with
autism spectrum disorders show more difficulties with cognitive empathy but less so with
affective empathy. In clear contrast, it has been argued that individuals diagnosed with
conduct disorder demonstrate low affective empathy and normal levels of cognitive
empathy in that they show relatively preserved ability to understand other people‘s states
of mind but do not share or care about these feelings. This chapter addresses empathy
dysfunction observed in disorders on the autism spectrum and conduct disorder.
Mechanisms associated with empathy dysfunction are discussed and common and
differentiating factors between the disorders are identified. In particular, four mechanisms
vital for an appropriate empathetic experience are treated: shared affect, emotion
324 Sara Paloma Vilas Sanz, Amanda Ludlow and Renate Reniers

recognition, perspective taking and self-other differentiation. Implications for social

functioning of these individuals are discussed.

INTRODUCTION
The capacity to experience empathy is an important and necessary ability in the repertoire
of human social behaviors as it allows us to share and understand the emotional states of
others (Rameson, Morelli, & Lieberman, 2012; Reniers, Corcoran, Drake, Shryane, & Völlm,
2011). It plays an essential role in both emotional communication and regulation of
relationships by helping us to appropriately predict, comprehend, and respond to the
perceived feelings and actions of another person (Bernhardt & Singer, 2012; Decety &
Moriguchi, 2007; Decety & Svetlova, 2012; Smith, 2009b). Therefore, empathy can be
understood as an inner human capacity based on social, affective and cognitive competences,
and hence it is considered indispensable for our ability to function successfully in the social
world (Decety & Svetlova, 2012; Pouw, Rieffe, Oosterveld, Huskens, & Stockmann, 2013).
The importance of empathy in social interaction can be informed by studying individuals
with known difficulties in socio-emotional functioning (Clark, Winkielman, & McIntosh,
2008). One such group is individuals with Autism Spectrum Disorders (ASD), a group
primarily characterized by impairments in social relations and social communication, and
unusually repetitive behavior that impedes the development of adequate daily functioning
(DSM 5; American Psychiatric Association, 2013). These individuals show deficits in socio-
affective functioning (Berthoz, Lalanne, Crane, & Hill, 2013) as well as in several empathy-
related processes, including rapid and spontaneous mimicry of emotional expression and
emotional contagion (Kasari, Sigman, Yirmiya, & Mundy, 1993; McIntosh, Reichmann-
Decker, Winkielman, & Wilbarger, 2006; Moody & McIntosh, 2006). While the cause of
these empathy deficits is still unknown, one possibility is that they relate to mechanisms that
enable the perception, understanding and processing of other‘s cognitive and emotional states,
as well as related impairments in social functioning, difficulties which appear intrinsic to the
disorder (Green, Gilchrist, Burton, & Cox, 2000; Greimel et al., 2010; Schwenck et al., 2012;
Smith, 2009b).
This idea of a deficit in emotional functioning has also been central to the development of
the concept of psychopathy, such that deficits in prosocial attitudes and behaviors, as well as
a lack of concern about emotional reactions from others are often present (Blair, Peschardt,
Budhani, Mitchell, & Pine, 2006). Importantly, developmental precursors to adult
psychopathy are thought to exist in children with a diagnosis of Conduct Disorder. Conduct
disorder (CD) is characterized by disruptive behavior that consistently violates social rules
and generates deficits in daily functioning (DSM 5; American Psychiatric Association, 2013).
Individuals with CD tend to be impulsive, hard to control or redirect, and not concerned about
the feelings of other people. They also exhibit evidence of basic empathy dysfunction
involving both poor capacities for affective resonance or unresponsiveness towards others‘
emotions and a fundamental lack of concern for others‘ welfare that may help to generate
their anomalous social learning (de Wied, Goudena, & Matthys, 2005; Green, et al., 2000;
Schwenck, et al., 2012). Individuals with a more severe array of social deficits, mainly
characterized by the manifestation of callous and unemotional symptoms in socio-emotional
 Empathy Dysfunction 325

functioning, are now encompassed in a conduct disorder specified group, named with a
―limited prosocial‖ specifier (DSM 5; American Psychiatric Association, 2013).
Interestingly, both ASD and CD share difficulties marked by basic deficits in emotional
and social functioning, such as problems in social interaction and adaptation as well as in the
perception of others (Green, et al., 2000; Jones, Happé, Gilbert, Burnett, & Viding, 2010;
Schwenck, et al., 2012). Furthermore, individuals with both disorders can show a callous
indifference to the feelings of others as a consequence of their empathy dysfunction (Jones, et
al., 2010; Schwenck, et al., 2012). This shared impairment in empathy is considered one of
the key hallmarks to both conditions (Banaschewski, 2010; Schwenck, et al., 2012) although
perhaps with important differences between the two disorders. This chapter systematically
addresses work defining these empathy dysfunctions observed in ASD and CD. Mechanisms
of empathy will be discussed and common and differentiating factors between the disorders
will be identified. Finally, implications for social and emotional functioning of individuals
with ASD and CD will be considered.

THE EMPATHY CONSTRUCT

It is generally accepted that empathy is a complex, multidimensional construct (Davis,
1983) that plays a fundamental role in prosocial behavior (Decety & Michalska, 2010;
Eisenberg, 2007; Leiberg & Anders, 2006; Masten, Morelli, & Eisenberger, 2011). Empathy
is commonly understood as the ability to share and comprehend the emotional state of others
(Cohen & Strayer, 1996; de Wied, et al., 2005). In addition, empathy can be defined as the
ability to be sensitive to and vicariously experience other people‘s feelings and to create an
operational model that represents their emotional states (Reniers, et al., 2011). However, there
is still no general agreement in precisely how empathy should be defined and characterized.
For example, there still active debate about the degree of overlap in concepts such as
sympathy, compassion and empathy. It is also acknowledged that the capacity to empathize
can be influenced and partially explained by individual differences, so that some individuals
may empathize more easily than others (Leiberg & Anders, 2006; Walter, 2012). Features
such as affective resonance (contagion), valuing another‘s welfare and an intrinsic motivation
to reduce suffering are also thought to be essential components of empathy (Watt, 2007).
However, possible relationships between these components are still under discussion and
debate (Batson, Eklund, Chermok, Hoyt, & Ortiz, 2007; Decety & Meyer, 2008; Pavey,
Greitemeyer, & Sparks, 2012 - see first chapter of this volume by Watt and Panksepp for
more extended treatment).

COMPONENTS OF EMPATHY
Previous studies suggest that there are two main components in empathy, namely
cognitive empathy and affective empathy. Cognitive aspects include the capacity to build a
working model of the emotional states of another person in order to comprehend his/her
feelings, whereas affective aspects refer to the ability to be perceptive of and vicariously
experience the feelings of this other person (Reniers, et al., 2011).
326 Sara Paloma Vilas Sanz, Amanda Ludlow and Renate Reniers

Affective Empathy

Affective empathy has usually been considered an emotional experience where the
feelings of another person are shared through basic affective resonance/contagion
mechanisms (Kerem, Fishman, & Josselson, 2001). It has also been described as the vicarious
experience of feelings that are compatible with those of another person (de Wied, et al.,
2005). It involves prosocial attitudes and concern for the other party and their potential
suffering. Despite lack of agreement amongst authors, most agree that it requires some
version of shared affect.
Two main forms of affective empathy have been dissociated (Blair, 2005). The first form
involves an immediate response to the emotional display of another person, including
unconscious rapid mimicry of facial and vocal expressions and body movements (contagion).
It is triggered by innate or acquired stimuli and determined by both mental simulations and
emotional images (Hatfield, Cacioppo, & Rapson, 1992; Hatfield, Cacioppo, & Rapson,
1993; Hatfield, Forbes, & Rapson, 2013). We automatically and continuously mimic and
synchronize other‘s expressions and behaviors, thereby affecting our own emotional
experience and enhancing the perception and feeling of a reflection of others‘ emotions
(Hatfield, et al., 2013; Schoenewolf, 1990). Affective empathy appears dependent on this
rapid emotion driving the evocation of an emotional response. The emotional response can be
expressed from both verbal and non-verbal expressions and by showing sympathy or a kind of
shared distress with the suffering party (Gleichgerrcht et al., 2012; Leiberg & Anders, 2006;
Reniers, et al., 2011; Sze, Gyurak, Goodkind, & Levenson, 2011; Walter, 2012).
The second form of affective empathy involves a more cognitively-mediated process that
enables an affective response to other emotional stimuli, such as a response to an emotional
phrase of another person (e.g., ―Adam just lost his house‖). The perception of an emotional
person automatically elicits an internal representation of that emotional state, which allows
the observer to identify the emotions of this person and to display the corresponding
autonomic, somatic, and motor responses (Leiberg & Anders, 2006; Preston, 2007), by using
gestures or facial expressions. In this sense, affective empathy can be understood as a
momentary resonance with the emotional state of another person (Kerem, et al., 2001)
through the vicarious experience of the other person‘s emotion that is congruent and
comparable with but not necessarily identical to the emotion of the other person (Eisenberg &
Strayer, 1990; Walter, 2012).
Notably, affective empathy entails more than basic affective sharing/resonance processes.
Helpful, comforting or sympathetic responses are also typically activated, self-other
differentiation has to be maintained, and an intrinsic motivation to reduce other‘s suffering is
present (Watt, 2007).

Cognitive Empathy

Cognitive empathy is commonly understood as the ability to infer another person‘s

mental states, including their feelings by means of representation of the person‘s internal
mental state (Gleichgerrcht, et al., 2012; Reniers, et al., 2011) through Theory of Mind (ToM)
or more advanced perspective taking mechanisms (de Wied, et al., 2005). Cognitive empathy
is deemed to be a higher-order and more cognitive process that encompasses conscious
 Empathy Dysfunction 327

comprehension of the internal state of another person, while assuming a basic differentiation
between self and others (Brook & Kosson, 2013). Visual, auditory, semantic and contextual
information is processed and used to represent and reconstruct the cognitive and emotional
state of this other person. Subsequently, ideas about the other person are generated, compared
and adjusted consistent with one‘s own cognitive and emotional state and with incoming
information (Reniers, et al., 2011). As a result, a more cognitive model of the internal states
of this person is developed, which does not necessarily indicate that the perceiver experiences
an affective state similar to what is observed (Walter, 2012).
Cognitive empathy has often been defined as basically equivalent to ToM (Blair, 2005).
Others, however, have suggested that cognitive empathy is part of a broader cognitive
concept including both ToM and the process of mentalizing about emotional states of others
(‗affective ToM‘) (Shamay-Tsoory, Harari, Aharon-Peretz, & Levkovitz, 2010; Walter,
2012). Whereas cognitive empathy specifically involves comprehension and attribution of
other people‘s feelings, ToM focuses on less affective and more cognitive internal states
(intentions, attitudes and beliefs). Therefore, although overlapping processes are thought to
facilitate both cognitive empathy and ToM, the two constructs are potentially partially
discriminable on a psychological level (Reniers, et al., 2011).
While cognitive ToM involves a cognitive understanding to infer other‘s mental states
(desires, beliefs, or intentions) and differentiate them from one‘s own, affective ToM may
require empathic abilities to recognize other‘s emotional states (feelings) (Bodden et al.,
2013; Kalbe et al., 2010; Shamay-Tsoory, et al., 2010). Support that the two subcomponents
can be considered different constructs on a neural level is shown by activation in different
brain areas (Abu-Akel & Shamay-Tsoory, 2011; Bodden, et al., 2013), suggesting that
affective ToM may be related to the ventromedial and orbitofrontal cortex, the ventral
anterior cingulate cortex, the amygdala and the ventral striatum (Hynes, Baird, & Grafton,
2006; Shamay-Tsoory & Aharon-Peretz, 2007; Shamay-Tsoory, Aharon-Peretz, & Levkovitz,
2007) whereas cognitive ToM may be associated with dorsolateral and prefrontal regions
such as the dorsomedial prefrontal cortex, the dorsal anterior cingulate cortex and the dorsal
striatum (Kalbe, et al., 2010; Montag, Schubert, Heinz, & Gallinat, 2008).

AUTISM SPECTRUM DISORDERS

The Pervasive Developmental Disorders are a group of syndromes with severe
impairments in certain areas of development (Gleichgerrcht, et al., 2012). Thus far, the family
of autism spectrum disorders has included several subtypes of autism in current classification
schemes: Autistic Disorder, Asperger‘s Syndrome (thought to be a milder version of autism
and distinguished by the absence of significant language delay and general intellectual skills
in the normal range) and Pervasive Developmental Disorder Not Otherwise Specified (PDD-
NOS). Although Childhood Disintegrative Disorder was also included, it differed from the
other three subtypes in aspects such as its degenerative/deteriorating phenotype, its later onset
and its different course (Kerig, Ludlow, & Wernar, 2012). Importantly, the terms Asperger‘s
Syndrome and PDD-NOS have disappeared in the DSM 5, and these subtypes have been
subsumed into the diagnosis of Autism Spectrum Disorder (ASD). In this review, we describe
328 Sara Paloma Vilas Sanz, Amanda Ludlow and Renate Reniers

research exploring the origins of empathy in both autism and Asperger‘s Syndrome. The
collective term of ASD is used when referring to both.
ASD encompasses a whole range of conditions from mild to severe (Zwickel, White,
Coniston, Senju, & Frith, 2011) and is characterized by persistent deficits in social
communication and interaction. In addition, restricted, repetitive patterns of behaviors,
interests and activities are characteristic and limit or impair everyday functioning (DSM 5;
American Psychiatric Association, 2013). This lifelong disorder is diagnosed in childhood
and its behavioral expressions may differ across individuals and development (Hill & Frith,
2003; Sucksmith, Allison, Baron-Cohen, Chakrabarti, & Hoekstra, 2013).
Regarding communication patterns, individuals with ASD may suffer from mutism to
non-communicative speech with language disturbances such as echolalia (the reiteration of
words or phrases previously pronounced by another person as an echo and without
understanding their meaning) or idiosyncracy (statement of irrelevant phrases or sentences).
Furthermore, their speech can be literal, pedantic, and monotone. They are unable to
comprehend humor, irony or sarcasm and have noticeably difficulties with developing non-
verbal communication (Kerig, et al., 2012).
Individuals with ASD are also characterized by social withdrawal and isolation (Frith,
1989; Riby & Hancock, 2008), incapacity to develop normal and successful relationships with
their peers, as well as inability to use nonverbal communicative cues that complicate their
social interactions (Smith, 2009b). They may show extreme social isolation and difficulties in
face-to-face social situations since their joint attention and social orienting are impaired.
Difficulties in emotional functioning are also observed with individuals with ASD showing
limited evidence for attachment and social connectedness and poor self-reflection, as well as
deficiencies in emotional expression and regulation. Accordingly, impairments in processing
one‘s own emotions are presented in individuals with ASD (Berthoz, et al., 2013).
Social, communicative and behavioral impairments in individuals with high functioning
forms of autism (HFA) or Asperger‘s Syndrome are thought to be associated with deficits in
ToM and certain aspects of empathy (Gleichgerrcht, et al., 2012), such as impaired affect
recognition and perspective-taking abilities (Hirvelä & Helkama, 2011).

Impairments in Affective Empathy

Different theories have been proposed regarding the status of both cognitive and affective
empathy in individuals with ASD (Hirvelä & Helkama, 2011). For instance, the ―extreme
male brain theory‖ (Baron-Cohen, 2002) suggests that individuals with ASD have weak
affective empathy (Smith, 2009a). The extreme male brain theory considers ASD as an
extreme of the normal male profile and suggests that individuals with ASD not only have a
weak capacity to empathize but also have a strong capacity to systemize (the drive to analyze
information to derive the underlying rules that govern behavior) (Baron-Cohen, 2002; Smith,
2009b). Evidence is not consistent, however, as e.g., Dziobek et al. (2008) showed that
individuals with Asperger‘s Syndrome present with reduced cognitive empathy but analogous
levels of empathic concern for the suffering of others. It may be that impairments in affective
empathy relate to deficits in the cognitive ability to recognize and process others‘ and one‘s
own emotions, rather than to the capacity for experiencing emotional distress or concern
towards others (Hirvelä & Helkama, 2011). In sharp contrast with the previously mentioned
 Empathy Dysfunction 329

theories, the ―empathy imbalance hypothesis‖ (Smith, 2006, 2009b) and the ―intense world
hypothesis‖ (Markram, Rinaldi, & Markram, 2007) postulate that individuals with autism
have not only heightened affective empathy but are over-aroused and hyper-reactive in
emotional situations (Smith, 2009a).
Deficits in the unconscious imitation of observed facial expressions, and hence in
mimicry processes, have been reported in individuals with ASD (McIntosh, et al., 2006).
Furthermore, a lower frequency of emotional contagion responses to emotional stimuli has
been found, suggesting a reduced capacity to elicit emotions and diminished emotional
responsiveness in these individuals (Scambler, Hepburn, Rutherford, Wehner, & Rogers,
2007). This mimicry deficit may impair the vicarious experience of others‘ affective states
and subsequent opportunities for social learning (Helt, et al., 2010; McIntosh, et al., 2006).
These findings are not consistent as several studies have in fact shown good imitation
capacities in individuals with ASD (Bird, Leighton, Press, & Heyes, 2007; Hamilton, 2013;
Hamilton, Brindley, & Frith, 2007). Hamilton (2013) claims that these mixed findings may be
better explained by the social top-down response modulation (STORM) model. It
encompasses two components; a basic visual-to-motor mapping and a topdown modulation
system, and suggests that imitation responses are highly dependent on learned associations
(past experience) and modulated by social cues and signals. ASD may be associated with a
weakened top-down control resulting in a reduced, but not completely absent, imitation of
social cues. Further empirical research is needed to fully understand emotional contagion and
imitation deficits in ASD.
A relation between reduced empathy and alexithymia has been reported in individuals
with autistic disorders, highlighting the overlap between empathy and alexithymia.
Alexithymia is a subclinical disorder characterized by difficulties in recognizing and
describing one‘s own emotional state. It is thought to be associated with deficits in emotional
regulation and difficulties in differentiating one‘s own emotional state from those of others
(Cook, Brewer, Shah, & Bird, 2013; Moriguchi & Komaki, 2013). Although ASD and
alexithymia are independent constructs, both conditions have overlapping comorbidity (Cook,
et al., 2013) and share several features. For example, both are associated with emotional
deficiencies such as impaired emotion recognition (Kano et al., 2003; Parker, Taylor, &
Bagby, 1993) and reduced empathy capacities (Decety & Moriguchi, 2007; Feldmanhall,
Dalgleish, & Mobbs, 2013). Importantly, socio-emotional and empathy deficits associated
with ASD may be better explained by the presence of coexisting alexithymia than by autism
per se (Berthoz, et al., 2013; Cook, et al., 2013; Silani et al., 2008). For example, eye-tracking
studies found that attention to the eyes and mouth (eye/mouth fixation) when seeing social
stimuli can be predicted according to the degree of alexithymia in individuals with autism
(Bird, Press, & Richardson, 2011). Also, an association has been found between the degree of
alexithymia and reduced brain activation in the insula (a structure involved in empathetic
processes) when both individuals with and without ASD empathized with other‘s pain (Bird,
et al., 2010; Moriguchi & Komaki, 2013). Deficiencies in insular activation thus appear to
predict deficits in empathy related-activity, and seem to be more related to alexithymia than
other ASD traits. Therefore, the degree of alexithymia rather than the severity of ASD has
been suggested as a predictor of empathy deficits in individuals with ASD (Cook, et al.,
2013).
330 Sara Paloma Vilas Sanz, Amanda Ludlow and Renate Reniers

Impairments in Cognitive Empathy

Individuals with autism are impaired in the basic understanding that people have internal
mental states (Hill & Frith, 2003; Zwickel, et al., 2011). In relation to this, they struggle to
perceive and correctly understand social aspects such as second-order belief, irony, metaphor,
deception or ‗white lies‘ (Smith, 2009b). Studies have shown that individuals with ASD not
only have overt impairments in the process of deducing their own and other people‘s mental
states (Golan, Baron-Cohen, & Golan, 2008; Greimel, et al., 2010) but also show deviant
activation patterns in the neural network for ToM (Castelli, Frith, Happé, & Frith, 2002;
Pelphrey, Morris, & McCarthy, 2005; Wang, Lee, Sigman, & Dapretto, 2006, 2007),
including problems processing facial expressions (Greimel, et al., 2010). The lack of
understanding of the correspondence between inner states and affective expressions has
significant implications for the emotional development of these individuals (Kerig, et al.,
2012).
Emotion Recognition. Individuals with ASD show delayed development of emotion
recognition abilities, which are necessary for the comprehension of others‘ emotional and
mental states, and which are core social cognitive functions (Adolphs, 2001, 2003).
Impairments in this ability have been found in ecological life-like tasks and in recognition of
facial expressions, vocal intonation, and body language (Golan et al., 2010). However, while
the recognition of complex social emotions such as pride and embarrassment from facial
expressions is impaired (Capps, Yirmiya, & Sigman, 1992; Heerey, Keltner, & Capps, 2003),
recognition of basic emotions such as anger, fear, disgust and happiness may be less affected
(Adolphs, Sears, & Piven, 2001; Tracy, Robins, Schriber, & Solomon, 2011). Some studies
have reported impairments in the recognition of specific negative facial expressions, such as
fear (Howard, Sparkman, Cohen, Green, & Stanislaw, 2005) and disgust (Golan, et al., 2010),
whereas others have shown deficits for all negative basic emotions (Ashwin, Chapman, Colle,
& Baron-Cohen, 2006). Importantly, even when individuals with ASD can discern emotional
expressions they are still found not to process the emotionally expressive face in the same
way others do. This may emerge from impairments in social attention, specifically, the ability
to prioritize socially relevant information such as the eyes and face, suggesting that many
social cues about others emerging from these facial expressions may be missed in their
immediate social environment (Dawson et al., 2004; Swettenham et al., 1998).
Deficits in the recognition of complex emotions have also been associated with a failure
in perceptual, cognitive and neural processes (Tracy, et al., 2011). Frith (2003) explains this
as a predisposition to pay attention to and process individual facial details discreetly, instead
of as a whole or gestalt. This complicates the understanding of a situation, especially when
emotions are briefly shown and the observer‘s concentration is reduced (Tracy, et al., 2011).
In addition, Baron-Cohen (2006) suggests that a preference for observing mouths rather than
eyes may explain emotion recognition deficits, as paying attention to the mouth may be a less
efficient strategy for face recognition and understanding expressions than paying attention to
the eyes (Golan, et al., 2010; Tracy, et al., 2011). In line with this, it has been argued that
these impairments in terms of reduced attention to the eyes emerge from a dysfunction in
amygdala activity (Bons et al., 2012), with a suggestion that disinhibited amygdala and
autonomic activity may characterize ASD, while conduct disordered individuals have
hypoactivity in these limbic and autonomic areas.
 Empathy Dysfunction 331

Perspective Taking. Numerous studies regarding ToM impairments in ASD have

empirically demonstrated that among those with ASD there are specific difficulties with
understanding and predicting other people‘s thoughts, feelings, intentions and behaviors as
well as impairments in their perspective taking ability (Hirvelä & Helkama, 2011). This latter
ability has been broadly studied with particular focus on the capacity of individuals with
autism to take another person‘s visuospatial viewpoint, which is known as visual perspective-
taking. This ability entails two dissociable mechanisms: first-level (VPT-1) and second-level
(VPT-2) visual perspective-taking. VPT-1 refers to the capacity to see an object by following
their line of sight whereas VPT-2 entails the ability to understand what another person
experiences when he/she sees an object (Brunyé et al., 2012; David et al., 2010; Hamilton,
Brindley, & Frith, 2009). Studies regarding VPT-1 in individuals with autism have
demonstrated that this ability is intact whereas experimental outcomes regarding VPT-2 have
been inconsistent. For instance, Yirmiya, Sigman, & Zacks (1994) found impairments in
VPT-2 ability in adolescents with autism whereas Reed & Peterson (1990) and Tan & Harris
(1991) did not. Hamilton, Brindley & Frith (2009) suggest that the specific deficits in VPT-2
found in children with ASD are linked to mentalizing ability.
Self Other Differentiation. The self is a complex and highly multidimensional construct
indispensable for our successful functioning in the social world. A sense of self as well as the
self other boundary is obviously vital for accurately metalizing, empathizing and
consequently adequate social behavior (Lombardo et al., 2010). The development of the self-
other boundary begins early in life and continues evolving throughout the lifecycle.
Individuals with ASD struggle to reflect on mental states (Frith & Happé, 1999), resulting in
difficulties establishing psychological relationships and differentiating between self and other
(Hobson, 2010; Hobson & Meyer, 2005). Atypical representation of the self, rather than a
complete lack of self, may give cause to these impairments (Lombardo, et al., 2010; Morin,
2006) and may be enhanced by attentional problems (Lyons & Fitzgerald, 2013).

CONDUCT DISORDER
Conduct Disorder (CD) is a severe childhood-onset disorder (Buitelaar et al., 2013; de
Wied, Gispen-de Wied, & van Boxtel, 2010; Pardini & Frick, 2013) defined by a recurring
and persistent pattern of behavior that breaches the rights of others or major societal norms
(DSM 5; American Psychiatric Association, 2013). A childhood or adolescent onset can be
differentiated in individuals with CD according to the manifestation of the first symptoms
(before or after the age of 10 respectively). The degree and extent of antisocial behaviors is
assumed to index the overall severity of this disorder (Berkout, Young, & Gross, 2011).
Symptoms associated with this disorder include lying, meanness and cruelty towards others
including physical cruelty, and violence, disobedience and refusal conducts regarding social
rules, and truancy (Berkout, et al., 2011; Decety, Michalska, Akitsuki, & Lahey, 2009). CD is
considered a childhood antecedent to antisocial personality disorder and persistent criminal
behavior in adulthood (Decety, et al., 2009; Pardini & Frick, 2013). Notably, a behavioral
pattern of persistent antisocial behaviors can be developed as a result of acquired brain lesions
affecting the inner or ventromedial prefrontal cortex. This condition, known as ‗acquired
sociopathy,‘ involves disturbances in moral emotions, lack of concern for the welfare of
332 Sara Paloma Vilas Sanz, Amanda Ludlow and Renate Reniers

others and a lack of guilt (Mendez, 2010; Pemment, 2013). This repertoire of socio-emotional
deficits is shared with individuals with CD.
Together with attention deficit hyperactivity disorder (ADHD) and oppositional defiant
disorder (ODD), CD is deemed part of an externalizing disorders group known as disruptive
behavior disorders (DBD). These disorders are characterized by failure in the process of
socialization as well as aggressive, antisocial, and rule-breaking behaviors. ODD is
characterized by angry or irritable mood, argumentative or defiant behavior, and
vindictiveness that echo both emotional and behavioral symptomatology. Frequency and
severity of symptoms are important for the diagnosis of this disorder (DSM 5; American
Psychiatric Association, 2013). CD can be preceded by and presented with ODD. CD can also
be comorbid with callous-unemotional symptoms such as lack of remorse or guilt, lack of
concern about the feelings of others, lack of concern over poor or problematic performance in
important activities and developmental tasks such as schoolwork, and reduced or shallow
affect (Buitelaar, et al., 2013). Lately, the strong association of CD with the comorbid
presence of callous-unemotional traits (CU) has resulted in a division of individuals with CD
in two main groups. A first group, CD with high CU traits, is described by proactive
aggressive manifestations, impairments in emotional processing, low fearful inhibition and
diminished emotional responsiveness. The second group, CD with low CU traits, is
characterized by reactive aggressiveness, lack of impulse control and impairments in the
processing of social cues (Anastassiou-Hadjicharalambous & Warden, 2008a; Frick, Cornell,
Barry, Bodin, & Dane, 2003; Frick & Ellis, 1999; Frick & Moffitt, 2010; Herpers, Rommelse,
Bons, Buitelaar, & Scheepers, 2012; Pardini & Frick, 2013).
Evidence for genetic markers associated with CD symptomatology has been found (Dick
et al., 2010). Importantly, significant gene-environment interactions have been reported in CD
(Gelhorn et al., 2005) and externalizing disorders with late adolescence-onset (Hicks, South,
DiRago, Iacono, & McGue, 2009). Whereas individuals with CU are minimally affected by
environmental influences, individuals with antisocial behavior but without CU are more
strongly influenced by their environment (Viding, Blair, Moffitt, & Plomin, 2005), suggesting
some preserved capacities for social learning and perhaps a better prognosis.
Impairments in empathy have been found in individuals with CD (Schwenck, et al.,
2012), who seem to have reduced concern for the welfare and feelings of other people (de
Wied, et al., 2010). Studies with children and adolescents with CD have reported abnormal
anterior cingulate activation during the exhibition of pictures with negative valence (Sterzer,
Stadler, Krebs, Kleinschmidt, & Poustka, 2005), diminished functioning of the amygdala and
reduced interconnectivity to the orbitofrontal cortex throughout the processing of fearful
expressions (Marsh et al., 2008), and reduced activation in posterior cingulate and
temporoparietal regions during error processing (Rubia et al., 2008). Early orbitofrontal
dysfunction has been associated not only with deficits in the recognition of anger and disgust,
but also with a set of impulsive and aggressive behaviors (Fairchild, Van Goozen, Calder,
Stollery, & Goodyer, 2009). Not surprisingly, an inverse relationship is found between
empathy and aggression towards others, suggesting that basic empathy processes inhibit
aggressive behavior (Decety, et al., 2009). Since empathy is understood as a motivational
factor for prosocial behaviors (Sze, et al., 2011), empathy impairments may be considered
predictive in relationship to developing disorders such as CD.
 Empathy Dysfunction 333

Impairments in Affective Empathy

Impairments associated with affective empathy have been reported in individuals with
conduct problems and CU traits (Anastassiou-Hadjicharalambous & Warden, 2008b). More
specifically, these individuals show reduced vicarious arousal (measured through heart rate)
(Anastassiou-Hadjicharalambous & Warden, 2008b; de Wied, et al., 2010) and lower
empathy levels in various forms of self-report (Cohen & Strayer, 1996; Lovett & Sheffield,
2007). In addition, these individuals display significantly fewer socially congruent emotions
as well as reduced feelings of fear and empathy for people who have been attacked, reduced
response to sadness and anger, and an abnormal processing of negative emotions (de Wied, et
al., 2010; de Wied, et al., 2005; Jones, et al., 2010; Lovett & Sheffield, 2007). For example,
juvenile psychopaths with high CU traits show impairments in empathy in response to other‘s
pain coupled with a relative insensitivity to actual physical pain, despite understanding the
intentions of the transgressor. Their affective understanding may be key to the levels of
aggressive behaviors they display (Cheng, Hung, & Decety, 2012).
Individuals with CD show abnormalities in the global regulation of motivation and affect
(Rubia, 2011). They are found to assess negative pictures as less arousing and aversive than
typically developing individuals (Herpertz et al., 2005). Furthermore, lower levels of guilt and
fear and higher levels of excitement and happiness have been observed after describing moral
transgressions. In addition, the number of symptoms and recidivism correlated with emotional
responses (guilt, happiness, excitement, and fear) to vignettes of criminal acts, suggesting a
relationship between emotional responses and offending behaviors (Cimbora & McIntosh,
2003).

Impairments in Cognitive Empathy

Individuals with CD are commonly thought to have intact cognitive empathy but
impaired affective empathy. However, studies have reported mixed results regarding
cognitive empathy deficits (Bons, et al., 2012; Schwenck, et al., 2012) suggesting that further
empirical investigation is needed.
Emotion Recognition. Several studies have demonstrated that individuals with CD have
impaired facial emotion recognition abilities and show specific deficits in the recognition of
anger, disgust, fear, sadness, and surprise (Fairchild, Stobbe, van Goozen, Calder, &
Goodyer, 2010; Fairchild, et al., 2009). It has been suggested that individuals with CD have
mainly difficulties with the recognition of negative emotions (Bons, et al., 2012) with
evidence that a malfunctioning in the amygdaloid networks generates impairments in facial
mimicry regarding these negative emotional expressions. These deficits may be associated
with either biased perception of emotions (Cadesky, Mota, & Schachar, 2000) or reduced
attention to the eyes (Bons, et al., 2012). However, there is division of opinion on this point
as others have concluded that there is no evidence of impaired emotion recognition in
individuals with CD (Pajer, Leininger, & Gardner, 2010; Schwenck, et al., 2012).
The time of onset of CD may influence the ability to recognize emotions. Passamonti et
al. (2010) reported reduced amygdala activation in individuals with childhood onset CD
compared to those with adolescence onset CD and controls. Likewise, Fairchild et al. (2009)
found impairments in the recognition of fear in boys with adolescent onset CD whereas
334 Sara Paloma Vilas Sanz, Amanda Ludlow and Renate Reniers

childhood onset CD was associated with deficits in the recognition of anger, disgust, fear and
happiness (Cadesky, et al., 2000; Collin, Bindra, Raju, Gillberg, & Minnis, 2013; Syngelaki,
Fairchild, Moore, Savage, & van Goozen, 2012).
Perspective Taking. The ability to take another person‘s perspective acts as an inhibitor
for antisocial behaviors (Anastassiou-Hadjicharalambous & Warden, 2008a). Findings
regarding perspective taking abilities in CD are inconsistent. For instance, Happé and Frith
(1996) observed intact perspective taking abilities while Chandler, Greenspan and Barenboim
(1974) and Waterman et al. (1981) reported diminished perspective taking abilities. Recent
findings suggests that impairments in cognitive perspective taking, referred to as the capacity
to perceive and understand other people‘s thoughts in order to take another person‘s
perspective, are specific to children with CD and low CU traits, whereas deficits in affective
perspective taking, defined as the capacity to infer the emotions generated by these thoughts,
may be present in both subgroups of CD (high and low CU). This suggests that individuals
with CD and high CU traits may have at least certain capacities for cognitive perspective
taking and a possible dissociation between affective and cognitive perspective taking abilities
is implied (Anastassiou-Hadjicharalambous & Warden, 2008a).
Self Other Differentiation. There are limited studies investigating self-other
differentiation in individuals with CD but Miller, Atlas and Arsenio (1993) found that
adolescents with CD may have greater difficulty differentiating self from others, relative to
individuals with disorders on the psychosis spectrum, suggesting that these deficits may
predict more conflicted interpersonal relationships.

Deficits in Affective and Cognitive Empathy in ASD and CD

Deficits in empathy have been found to underlie both ASD and CD. The research
findings so far highlight that empathy in these two disorders should not be viewed simply as a
global deficit, but rather empathy should be considered in light of their difficulties in the
components of empathy, namely affective and cognitive empathy. Despite the term ‗empathy
dysfunction disorders‘ applied to both ASD and CD, both disorders can be discriminated in
terms of the subtype of empathy deficit demonstrated (Blair, 2005).
Amongst the most common findings from studies addressing both disorders is the
existence of a double dissociation between affective and cognitive empathy (Dziobek, et al.,
2008; Shamay-Tsoory, Aharon-Peretz, & Perry, 2009). While ASD is consistently reported
with problems in cognitive empathy, affective empathy has been inconsistently reported as
relatively intact (Dziobek, et al., 2008; Hirvelä & Helkama, 2011) or selectively impaired
(Mathersul, McDonald, & Rushby, 2012; Rogers, Dziobek, Hassenstab, Wolf, & Convit,
2007; Shamay-Tsoory, Tomer, Yaniv, & Aharon- Peretz, 2002). Individuals with CD show a
contrasting pattern. For example, Schwenck et al. (2012) found that boys with ASD exhibit
deficits in cognitive empathy and display good affective empathy abilities, whereas children
with CD and high CU traits have impaired affective empathy but intact cognitive empathetic
abilities. Three tasks were administered for this study: 1) an animated-shapes-task to assess
emotional perspective taking; 2) the morphing task; to measure the capacity to recognize
emotions with neutral and emotional facial expressions from the Karolinska directed
emotional faces set, and 3) the video sequences task; to assess both cognitive and affective
empathy by visualizing nine film-clips with people in different emotional situations. In the
 Empathy Dysfunction 335

third task, children were asked to identify the emotions observed in the videos and describe
protagonist‘s feelings by taking his/her perspective. They were also asked to report their level
of emotional affection. Results revealed that boys with ASD showed impairments in their
ability to take another person‘s perspective in both the animated-shapes task and the video
sequences task whereas children with CD did not display any difficulty for emotion
recognition nor for basic perspective taking tasks. While individuals with CD and high CU
were less moved by the emotional situation of another person when watching the scenes of
the video sequences task, children with ASD reported to be more emotionally affected by the
video scenes than children with CD.
Bons et al. (2012) reported that juveniles with CD and high CU traits may show lack of
normal emotionality (impairments in affective empathy) with these deficits being more
noticeable in relationship to sad and fearful emotional expressions. More specifically,
individuals with CD show reduced facial mimicry and clear impairments in emotion
recognition associated with negative emotions that seem to be particularly predictive of a
comorbid presence of high CU traits. The authors of this study claim that even though results
regarding emotion recognition abilities in individuals with ASD are somewhat inconsistent,
this ability seems to be impaired for all basic emotions (deficits in cognitive components of
empathy), especially when individuals are tested through tasks with complex or low intensity
emotions, which might elicit more subtle deficits in emotion recognition. According to this,
facial mimicry may be partially inhibited in relationship to static emotional expressions, and
also the ability to attend to the eyes is diminished, thereby complicating emotion recognition
processes.
These outcomes are consistent with the empathy imbalance theory proposed by Smith
(Smith, 2006, 2009b). Smith suggests that the capacity to empathize in disorders such as
autism or antisocial personality disorder/psychopathy (adulthood disorders closely related to
CD) can be separated in two different systems: emotional (defined as the vicarious sharing of
emotion consistent with basic contagion concepts) and cognitive (described as mental
perspective taking). In addition, Hansman-Wijnands and Hummelen (2006) propose that
autism involves a cognitive deficit represented by an inability to take another‘s perspective
whereas psychopathy implicates more an emotional impairment related to insensitivity,
manipulation and exploitation of others. Similarly, Robbins and Jack (2006) suggest that
while psychopathy is mainly characterized by lack of concern for the suffering of others,
which may be related to particular impairments in their affective empathetic responses to
others (―hot‖ or ―instinctive‖ empathy), individuals with autism show the opposite profile
exhibiting poor abilities in mentalizing and deficits in their cognitive empathetic responses
(―cold‖ or ―intentional‖ empathy). Based on this evidence, Smith proposes that individuals
with ASD show low cognitive empathy, making the social world unpredictable and
confusing. Smith also suggests that even though an insensitivity to affective components is
clear, individuals with antisocial personality disorder show intact cognitive empathy abilities
(Smith, 2006, 2009b), a suggestion supported by Blair (2005).
Further verification for the dissociation of the two empathy subcomponents has been
found through recent studies such as Jones et al. (2010). They showed that boys with
psychopathic tendencies show deficits in areas associated with affective empathy, including a
reduced concern about the consequences of their aggressive behaviors towards others.
Furthermore they seem to attribute considerably less fear to themselves, but no deficits in
336 Sara Paloma Vilas Sanz, Amanda Ludlow and Renate Reniers

their perspective taking abilities were found. In contrast, individuals with ASD show deficits
in perspective taking ability but not in affective components of empathy.

Socio-Emotional Impairments Related to Empathy in ASD and CD

Although empathy has been broadly studied, little is known about the social factors that
may be influenced by affective and cognitive empathy. Several psychological, social and
moral aspects of human development such as pro-social and aggressive behaviors have been
associated with empathy (Batanova & Loukas, 2012), deeming empathy as a potential
inhibitor of aggression (Stanger, Kavussanu, & Ring, 2012). For instance, positive
relationships between empathy and prosocial behaviors as well as negative associations
between empathy and physical aggression were found in a sample of Mexican American
college students (Carlo, McGinley, Hayes, & Martinez, 2012). In addition, a positive
relationship between empathy and a willingness to help others, was found among
empathetically aroused individuals, suggesting that empathy induces an altruistic response in
order to alleviate others‘ pain (Paterson, Reniers, & Völlm, 2009; Reynolds & Scott, 2000;
Stocks, Lishner, & Decker, 2009).
An association between prosocial behavior and empathy-related activity in both the
anterior insula and medial prefrontal cortex has been found, suggesting that any relationship
between empathy and prosocial behavior may rely on prefrontal cortex and related paralimbic
activity (Masten, et al., 2011). This relationship has been addressed further in studies showing
reduced activation in the prefrontal cortex in individuals displaying antisocial behavior
(Glenn, Yang, & Raine, 2012). For example, antisocial boys who abuse drugs, break laws,
and act recklessly have been shown to have significantly reduced activation in the
dorsolateral prefrontal cortex (Raine, 2002).
Social variables such as positive relationships with parents, teachers and peers are
thought to be connected to both positive affect and perspective taking in adolescents. For
example, pre-scholars who show disruptive behavior also show poor emotion understanding,
especially for negative emotions, and are thought to have problems in their peer relations,
families, and society (Hughes, Dunn, & White, 1998). These findings may indicate that
appropriate social relationships in family and school environments enhance levels of
empathetic concern and perspective taking, whereas conflicted and changing relationships
with parents, teachers and peers influence negatively how individuals respond to others
(Batanova & Loukas, 2012).
Dodge (1980) found hostile attribution biases regarding their interpretation of other
people‘s actions in aggressive children. Similar findings were also found by Arsenio & Fleiss
(1996). They reported a poor understanding of the emotional consequences of transgressions.
Drawing from these studies, Arsenio and Fleiss (1996) suggested that the delay in
understanding emotional consequences of social and moral transgressions may contribute to
the violation of social rules and norms. In contrast, Hughes et al. (1998) observed
impairments in inhibitory control that suggest that interpersonal problems of disruptive
children may be caused by failure in behavioral regulation rather than by problems in social
understanding (Hughes, White, Sharpen, & Dunn, 2000). However, these notions may be
different mainly at a semantic level as they may index different aspects of fundamental
affective and regulatory deficits in conduct disordered children.
 Empathy Dysfunction 337

Overall, individuals with CD show less empathetic prosocial responses, deficits in

emotional functioning and reduced autonomic responsiveness (Fairchild, et al., 2010). They
more frequently misattribute hostile intentions to others, have problems with the perception of
others and display anger-related behaviors and delictive conducts (Blake & Hamrin, 2007;
Green, et al., 2000; Happé & Frith, 1996). Similar to those with CD, individuals with ASD
also show lack of peer relationships, low capacity to form relationships and severe difficulties
in their social interactions as well as interpersonal difficulties (Green, et al., 2000).
Both ASD and CD are associated with features such as loneliness (more common in CD),
poor attention, aggression (more common in CD) and externalizing symptoms (Green, et al.,
2000). These characteristics, especially aggressive behaviors, impairments in social
relationships and interactions, deficits in emotional understanding and deficits in moral
development, have clearly been associated with empathy problems in both disorders. They
make a case for further investigation and comparison of the nature and extent of these
empathy deficits and pave the way for informing diagnosis and treatment. However, it
remains unclear if these deficits are caused by empathy dysfunction or whether the inability to
develop empathy contributes to these socio-emotional deficits seen in individuals with these
disorders. The findings from this review highlight the need for more developmental studies on
ASD and CD looking at the earliest emergence of these deficits, particularly given the
overlapping symptoms between the two disorders. Further research in the domains of
empathy, and social functioning in particular, should be viewed as a high priority area in
relationship to these disorders as fundamental empathy dysfunction disorders.

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Editors: Douglas F. Watt and Jaak Panksepp © 2016 Nova Science Publishers, Inc.

Chapter 13

ONE BUT NOT ALL DOORS CLOSED TO EMPATHY:

IMPAIRED RESONANCE INDUCTION IN PATIENTS
WITH HUNTINGTON’S DISEASE

Iris Trinkler
Institut du cerveau et de la moelle épinière,
Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France

ABSTRACT
Patients with Huntington‘s Disease (HD), a rare, inherited neurological disorder,
causing motor, cognitive and emotional dysfunctions, are impaired at recognizing
emotional facial expressions. I will argue that this impairment closes one important door
to empathy for them. If they cannot decipher other‘s emotional expressions correctly,
they can no longer resonate normally with other‘s emotional states. However, all doors to
empathy might not be motor, and other ways of affect sharing might be spared. In a series
of experiments it is shown that the representation of an emotional gesture appears to be
lesioned in HD. As a consequence, recognition of an emotion expression in another
individual is impaired, as well as voluntary emotional expressivity, and micro-mimicry of
facial expressions. Importantly however, these impairments do not go along with affect
understanding in self, and/or with affect sharing on purely verbal-communicative and
cognitive levels. Indeed, HD patients perform normally on empathy and alexithymia
questionnaires. Such a differential view is essential to guide patients and caregivers in
finding and strengthening their tools for affect sharing and communication.


Corresponding author: Iris Trinkler. Physical address: Institut du cerveau et de la moelle épinière, Centre
Hospitalier Universitaire Pitié-Salpêtrière, 47/83 Boulevard de l‘Hôpital, 75013 Paris, France. Tél: +33 1 57
27 41 89, electronic mail: iris.trinkler@ens.fr.
350 Iris Trinkler

INTRODUCTION
Whether one defines empathy plainly as the ―ability to share the feelings of others‖
(Bernhardt and Singer, 2012), or whether one includes in the definition of empathy the
intrinsic motivation to relieve the distress of another person (Watt, 2007), the main concern
here is with the perceptual entry to empathy before the sharing and potential additional
motivated intervention can take place: How does information reach the brain‘s empathy-
mediating systems, where we then process information not only about the feelings of the
other person, but also what this motivationally means to us, depending on who we are, how
we feel (generally and right now), who the other person is and how we feel about the other
person (generally and right now), see Watt (2007). How, if (let us state) we would like to, are
we able to resonate with the other person‘s feeling state? This chapter is thus concerned with
what has been referred to as ―primary process empathy‖ (Panksepp and Panksepp, 2013), or
―resonance induction‖ (Watt, 2007) in the specific case of patients with Huntington‘s Disease.
Huntington‘s Disease (HD) is rare. Why should the study of affect sharing in HD be of
relevance to the understanding of empathy in healthy individuals?
As I will try to show, experiments conducted on HD and other neurological cohorts can
indeed help us understand better the many sub-components of affect sharing that might be
differentially spared or damaged. The study of affect sharing in Huntington‘s Disease came
about out of a sense of frustration: Although there are numerous of studies on emotion
recognition impairments in HD, see below, a shear bulk of data documenting over and over
their difficulties in recognizing emotional gestures, no explanatory mechanisms has been put
forward. Further, emotion recognition impairments have not been clearly linked to the clinical
observation of altered social behaviour in people with HD, their reported lack of sympathy
and empathy (Snowden et al., 2003). Yet, by bringing the work on emotion recognition
impairments into the field of empathy research, intriguing new questions have emerged,
yielding fruitful empirical investigations, with important applications for patient and
caregiver‘s care. I will first consider, purely theoretically, the perceptual portals to affect
sharing. Next I will briefly sketch the condition of HD, with a particular emphasis on what is
known about their emotion recognition impairments, before presenting a series of
experiments exploring different levels of emotion processing in self and others. The findings
are then integrated with other comparable clinical studies. From the ensuing discussion it will
hopefully become clear how many doors to empathy there exist, and how some might be
obstructed in neurological disorders, while others are left open, and how this could help
patients and caregivers to share affect better and thereby facilitate the communication of
empathic concern.

ENTRANCE DOORS TO AFFECT SHARING

Which are the ways we can understand the emotional states of other individuals? As
operationalized in recent neuroimaging experiments on resonance induction by pain in
humans (summarized by Lamm et al., 2011), one way individuals can share another person‘s
affective state is by merely viewing an abstract cue indicating that another person is being
 One But Not All Doors Closed to Empathy 351

hurt—e.g., receiving a painful stimulus. Another path is by observing directly that the other
person‘s body is being injured, or by watching the painful expression on another‘s face.

Interoceptive Basis

In such studies, common neural activation reflecting resonance-induction has typically

been found in anterior insula (AI) and anterior/mid cingulate cortex (A/MCC). This might be
referred to, metaphorically, as the reception room to affect sharing, a psychological space that
can be reached by several different ―doors.‖ The insular cortex is known to integrate diverse
forms of ―interoceptive‖ information (Craig, 2002; Critchley et al., 2004; Kurth et al., 2010),
i.e., the ensemble of information about the visceral and physiological states of the body
including itch, coldness, hunger, sensation of fatigue after physical exercise, pain, etc. and
also visceral affective states (Craig, 2002). Interoceptive information, mapped to more
posterior insular segments, is subsequently re-represented in the AI, where it may become
more consciously accessible. This enables various subjective affective experiences and global
(homeostatic) feeling states (Craig, 2002, 2009). The cingulate cortex may represent the
motivational-premotor counterpart for the sensory-perceptual affective feelings integrated by
the insula, conjointly implementing general monitoring and control processes across multiple
domains (Paus, 2001). The A/MCC is in the position to promote adaptive responses in nearby
motor centers responsible for expressing affect and executing goal-directed behaviors
(Shackman et al., 2011). In other words, afferences of global emotional feeling states from the
AI are re-represented in A/MCC to provide preparation, selection and control of appropriate
responses (Medford and Critchley, 2010). Thus, a shared attribute of affect sharing
paradigms, regardless of the perceptual input to the system, is strong activation of brain
systems where interoceptive, including subjective affective states are integrated and
cognitively accessed.
The merit of this literature has been to show us how viscerally we seem to be able to
share affect with other individuals, as long as no further cognitive regulation takes place. But
it is important to note that AI-A/MCC only stand as neuroanatomical markers of more
extensive and complex networks that include brainstem, hypothalamus and thalamus and
posterior midline cortices (Damasio et al., 2013). Note further that beyond the interoceptive
brain representations that might be shared between emotions, which have been seen for
empathy for pain as well as pleasant affect, social exclusion, disgust and anger (Bernhardt and
Singer, 2012), additional differential neural representations presumably exist, tied to each
emotion‘s intrinsic psychobiological functions.
Since we are most interested in general affect sharing, it would go beyond the scope of
this chapter to discuss all possible emotional states, but let us consider the examples of
disgust and anger briefly here, and also see the discussion of the case of fear below. Focal
lesion studies have shown an important role of the ventromedial prefrontal cortex (Blair and
Cipolotti, 2000; Calder et al., 2001) and ventral striatum (Calder et al., 2004) in recognising
anger. Patients with lesions in these areas typically show aggressive and disinhibited
behaviour. The ventromedial prefrontal cortex may gauge one‘s energy to confront emotional
challenges (which might be constructive in the face of a cow obstructing a hiker‘s path, but
destructive behind a slow car in Parisian traffic). In contrast, disgust is not so much a primary
emotion as a primary homeostatic affect, possibly related to mild nausea. Indeed, not all
352 Iris Trinkler

affective ―feelings‖ are ―emotional.‖ Disgust may be more a sensory or homeostatic feeling
than a true ―emotional‖ one1. In line with its visceral role, disgust was shown in neuroimaging
studies to be represented in insula and basal ganglia in healthy individuals (Calder et al.,
2000; Phillips et al., 1997; Small et al., 2003; Sprengelmeyer et al., 1998; Wicker et al.,
2003). Patients with focal insular lesions show deficits in feeling and perceiving disgust,
while the other basic emotional feelings remain intact (Adolphs et al., 2003; Calder et al.,
2000).
Before information about another individual‘s affective state can resonate within our own
affective repertory however, it has to be decoded as such in order to enter the abovementioned
interoceptive basis. Thus, we will now consider by which neural routes such information may
travel. This background information is essential for providing a conceptual neuroscientific
framework for understanding why and how we sought to empirically analyze empathic
deficits in Huntington‘s Disease.

Mentalizing Network and Shared Action Representation System

The following differential networks of neural activations have been reported, depending
on the type of stimuli used to convey the affective state of other individual (as summarized by
Lamm et al. 2011): Ventral medial prefrontal cortex (vmPFC), superior temporal gyrus
(STG), temporo-parietal junction (TPJ) and precuneus/posterior cingulate activity has been
found to support the inference of pain in another individual from abstract contextual cues. In
contrast, dorsolateral and dorsomedial prefrontal cortices, inferior parietal cortex and inferior
frontal cortex are involved when pain is inferred from facial expressions and bodily cues. The
first network is prominently referred to as supporting theory of mind or mentalizing and as
such supports thinking about another person‘s intentions and points of view (e.g., Frith and
Frith, 2003; Saxe and Kanwisher, 2003). It is congruent with what Blair (2005) called the
―cognitive empathy‖ network. The second network refers to the often eagerly termed ―mirror
neuron network‖ (Gallese et al., 2004; Keysers and Gazzola, 2007; Rizzolatti and Craighero,
2004), which here I will refer to as a shared action representation system. This usage refers to
converging theories on common coding of actions between self and others on the basis of
behavioral studies undertaken in the 1990‘s which found that the observation of actions in
others influences our own (Jeannerod, 1999; Prinz, 1997). Similar conclusions were reached
at around the same time from the observation of neurons in the macaque monkey premotor
cortex that code the execution as well as the mere observation of the same actions (Rizzolatti
and Sinigaglia, 2010). This has spurred a wealth of research on this shared action
representation system2, the detailed functioning of which is thought to be as follows (as

1
It seems to get forgotten often that the ―basic emotions‖ most widely used to study emotion recognition in humans
are called ―basic‖ because their facial expression has been found universally all over the world (e.g., Ekman,
1999), and not because they are basic in any sense relating to the affective repertory of social interactions.
Indeed, other authors have put forward alternative and potentially more useful classification systems
(Panksepp, 1998/2005).
2
As Christian Keysers pointed out (2010) at an international symposium of dancers and neuroscientists, such shared
action representation systems were a revolution for theorists, whereas they were intuitively assumed for a long
time by professionals working with the body and through the body, especially post-modern dancers. In fact,
somewhere in the mid 20th century cognitive psychology started to use the computer analogy of mental
processes. Such abstract computer and calculator metaphors lured psychologists into thinking of body and
 One But Not All Doors Closed to Empathy 353

envisioned by Carr, 2003, and also see the ―motor empathy‖ network of Blair, 2005): Via
various neural inputs, the superior temporal cortex (STC), is fed information from multiple
modalities (Hein and Knight, 2008), among which prominently higher order visual cortices,
specifically information coding gaze, expression, lip movement (Atkinson and Adolphs,
2011; Halgren et al., 2000; Haxby et al., 2000; Kesler-West et al., 2001; Pizzagalli et al.,
2002; Said et al., 2011), as well as biological motion in general (Giese and Poggio, 2003).
Information from STC is forwarded to posterior parietal neurons. These are assumed to code
the precise kinesthetic aspect of a movement. From there, information is sent to inferior
frontal (BA 44/45) neurons, which supposedly code action goals. Recently, it was suggested
that the somatosensory cortex also plays an important part in the network, perhaps by
representing aspects of the body and body surface, again of one‘s own as well as of others‘
(Keysers et al., 2010; Keysers et al., 2004). Note that these neuroanatomical scenarios are still
largely hypothetical postulates based on observations mostly from human neuroimaging,
which await further corroboration from studies in animals and observations of neural-
constitutional relevance, as in brain-lesioned patients. Nonetheless, such scenarios coax us to
reflect on the number of manifestations and detection-portals to affect sharing that there
might be.

Direct Sensory-Perceptual Affective Route

Indeed, one further door was not explicitly discussed by Lamm and colleagues (2011):
Emotional information that is not conveyed by the interpretation of body postures or actions
may enter more directly via specialized sensory-perceptual routes, which are intrinsically
devoted to affect sharing (cf. what Blair, 2005, referred to as ―affective empathy‖ network). It
may include auditory, tactile and visual channels, but here I focus just on the visual
components.
There are two visual pathways -- one cortical (retinogeniculostriate-extrastriate-fusiform)
and one subcortical (retinocollicular-pulvinar-amygdalar) -- by which affective information
may be conveyed directly (―directly‖ as in not requiring mentalizing or other elaborate
cognitive processing). The subcortical route may provide a faster/coarser and the cortical
route a more precise stimulus-encoding permitting finer discrimination learning (Armony et
al., 1997; LeDoux, 2000). The amygdala plays a key role in both. In interaction with the
pulvinar and superior colliculus the basolateral amygdala might support the preparation for
adaptive behaviour, such as automatic fear behaviours and autonomic responses (e.g.,
increases in heart rate and blood pressure) (see De Gelder, 2006). Its role might be described
as evaluating incoming stimuli in terms of their (positive or negative) relevance for survival

action representations as abstract, disembodied phenomena, whereas, in fact, the representing brain is situated
in the body, where it links sensors and effectors. Evolutionarily, organisms with very little, indeed hardly any
brains, moved to better perceive the world and perceived to better move, in order to survive (see also Wolpert,
2011). The brain, grown more and more complex is yet still the facilitator between sensors and effectors, eyes
and legs, and the whole is one sophisticated sensory-motor loop. From such an embodied stance (Gallese,
2007; Niedenthal, 2007) however, it follows necessarily that all action representations are always tied to our
own actions and likewise all body representations to our own bodies. The shared action representation and
mirror neuron discoveries have proven (Grezes & Decety, 2001; Jeannerod, 1999; Keysers & Gazzola, 2007;
Prinz, 1990; Rizzolatti & Sinigaglia, 2010) what movement and body workers knew and used all along.
354 Iris Trinkler

in the large sense, including danger, safety, food, rank challenge, and so on (Davis and
Whalen, 2001; Panksepp and Biven, 2012).
Further, as part of this network, subregions of the superior colliculus have been shown to
support defensive reflexes like freezing, withdrawal, flinching and exaggerated startle (Dean
et al., 1989). The role of the ventral striatum, as part of a wider neural circuit devoted to
learning, seems to be ―pedagogical,‖ namely it links intrinsic emotional actions and feelings
to brain memory mechanisms (Panksepp and Biven, 2012). On the one hand it serves the
function of inhibiting irrelevant or risky actions, see also its abovementioned involvement in
anger, and on the other hand it guides behaviour based on reward function (e.g., Berridge and
Kringelbach, 2008; Lammel et al., 2012). Beside integrating emotions with motivations,
allowing emotional signals to be used as incentives (Rolls, 2000), the ventral striatum may
further play a role in the representation of emotions related to achievement or defeat,
including higher emotions such as regret, gloating and envy (Coricelli et al., 2007).
Indeed, oftentimes a stimulus by its nature, e.g., both motor and primary affective, is
processed by two routes simultaneously in the healthy functioning brain. Such is the case
prominently for fearful facial (e.g., Adolphs et al., 2005) and body (De Gelder, 2006)
expressions which might directly convey imminent danger via the affective subcortical route
(see also Mineka and Cook, 1993) and arouse fearful states in the observer (as is evident in
animals, see Panksepp and Panksepp, 2013), as well as activate a shared action
representation.

INTERIM SUMMARY: THE MANY WAYS TO EMPATHY OBSTRUCTION

In summary, based on the above analysis, the following obstructions of the neural paths
to empathy can be imagined: Firstly and most evidently, if the central sharing component AI-
A/MCC is damaged, a person would be expected to be incapable to resonate with the feeling
states of another person. Indeed, the inability to identify and describe one‘s own emotions, a
subclinical disorder that was coined alexithymia as in ―no words for emotions‖ (Sifneos,
1996), also impairs the understanding of emotional facial expressions (Berthoz et al., 2002;
Lane et al., 1996), and ratings of pain in others (Moriguchi et al., 2007). Moreover, AI
activity in a task in which individuals had to internally reflect on their feelings was correlated
to people‘s trait alexithymia and empathy self-report scores, in both normal healthy and
individuals with high-functioning Asperger spectrum disorder (ASD) (Silani et al., 2008).
Similarly, neural responses in the AI for cue-based affect sharing was strongly influenced by
the degree of alexithymia in controls and individuals with ASD (Bird et al., 2010). Indeed, the
greater the participants‘ deficits in understanding their own emotions, regardless of whether
they were control subjects or patients, the less activation they showed in AI while sharing
affect with people present in the same room undergoing painful experiences (Bernhardt and
Singer, 2012). These findings emphasize that understanding your own feeling states may be a
critical prerequisite to engage in vicarious simulation of situations, which in turn may allow a
better understanding of other people‘s feeling states.
However, even in the case of intact levels of emotional awareness and understanding of
one‘s own and other people‘s feeling state, the door to empathy might be closed. When the
stimuli conveying emotional arousals in other people can no longer be adequately deciphered,
 One But Not All Doors Closed to Empathy 355

impairments in emotional resonance induction might result. These might stem from either
disruptions of the mentalizing network, or the shared action representation network, or of the
―direct sensory-perceptual affective route.‖ These reflections provide a critical background
and conceptual-empirical starting point for our research on affective resonance induction
impairments in Huntington‘s Disease.

HUNTINGTON‟S DISEASE
HD is a rare, inherited autosomal dominant neurodegenerative disease with onset at about
40 years of age and patients dying from it within 10-15 years, often because of respiratory
and/or swallowing-related complications.
It is well known that neurodegeneration in HD affects the striatum following a dorsal to
ventral gradient (Douaud et al., 2006; Vonsattel et al., 1985). However, thanks to novel, more
subtle brain atrophy measuring techniques (Ashburner, 2007; Ashburner and Friston, 2000),
recent studies on large cohorts found out that significant atrophy spreads throughout the
cortex even at early stages of the disease (Tabrizi et al., 2009). Increased cortical thinning is
found in the posterior frontal region even in early presymptomatic gene carriers, extending to
involvement of occipital, parietal, superior temporal and superior frontal lobes in
presymptomatic HD gene carriers who may be approaching disease onset. Only anterior
frontal and lateral temporal regions seem to be relatively spared.
The first overt signs of HD are often motor. Patients suffer from involuntary choreic
movements, but also from voluntary movement impairments. Less visible, cognitive functions
(memory, attention, executive function) are affected, too (Ho et al., 2003; Snowden et al.,
2001). Furthermore, explicit psychiatric problems are soon observed including mainly
personality changes, mood disorders and emotion recognition deficits.

EMOTION RECOGNITION DEFICITS IN HD

Using facial expression stimuli of the six basic emotions, the first study on emotion
recognition impairments in HD found an overall reduction in performance which was
particularly marked for disgust (Sprengelmeyer et al., 1996). Numerous studies have
examined mainly if HD causes impairment that are specific to disgust (Calder et al., 2010;
Gray et al., 1997; Hennenlotter et al., 2004; Johnson et al., 2007; Milders et al., 2003;
Montagne et al., 2006; Sprengelmeyer, 2007; Sprengelmeyer et al., 2006). Much of this work
was inspired by repeated observations that disgust recognition deficits are common after basal
ganglia injury among healthy individuals (Calder et al., 2000; Phillips et al., 1997; Small et
al., 2003; Sprengelmeyer et al., 1998; Wicker et al., 2003). However, since many studies
failed to find specific disgust deficits in HD, the perspective emerged that general, non-
specific negative emotion recognition impairments may characterize both symptomatic and
presymptomatic HD gene carriers (Henley et al., 2011; Henley et al., 2008; Johnson et al.,
2007; Milders et al., 2003; Snowden et al., 2008). One study even demonstrated impaired
recognition of positive emotions from vocal stimuli (Robotham et al., 2011). Typically, these
studies have only assessed the perceptual recognition aspects of emotion processing, with
356 Iris Trinkler

little focus on deficits in affect sharing that is critical for empathy. Thus, my goal here is to
apply the neurological model summarized above to the various possible deficits in affect
sharing that may characterize HD. For instance, on the basis of the prominent motor
symptoms of HD, one plausible hypothesis is that shared action representation systems are
impaired in HD. In the following, I will first share some research that tested this hypothesis.
The resulting empirical findings will be discussed in the context of other work concerning the
various other subcomponents of affect sharing as depicted above -- namely, patients‘ abilities
to utilise ―interoceptive,‖ ―mentalizing‖ and ―direct affective‖ routes to understand and
resonate with the feelings of others.

AFFECT SHARING VIA THE SHARED

ACTION REPRESENTATION SYSTEM IN HD
On the basis of a shared action representation hypothesis, one might ask whether both the
perception and the execution of emotion expressions are impaired in HD. Hayes and
colleagues (2009), focussing on disgust, explored the execution of facial expressions in HD
and reported an impairment of the spontaneous expression of disgust (albeit other emotions
were not evaluated), as well as impaired posed expressions of all emotions, with the largest
impairment being evident for disgust, followed by anger. Trinkler and colleagues (2013)
compared recognition and voluntary expression of the six basic emotions (Ekman, 1999) in a
group of HD patients and a group of age- and education-matched control participants.
Recognition was measured using a combined set of 120 faces from the Ekman series and the
Karolinska battery which subjects viewed on a computer screen, reporting verbally which of
six emotion words best represented each stimulus (see Figure 1a).
For emotion production (see Figure 1b), participants were seated at a table face to face
with the experimenter and given a set of cards displaying emotion words (colère, dégoût, joie,
peur, surprise, tristesse — namely anger, disgust, joy, fear, surprise and sadness). They were
filmed as they viewed one card after another and tried to experience and mime the denoted
emotional expressions to the experimenter. External raters then performed a recognition test
on these video clips. Their average recognition rates served as participants‘ emotion-
production scores.
Results showed that patients were as severely impaired producing emotion expressions as
recognising them across most emotions, and the two scores were highly correlated (Figure 2)
suggesting a global emotion recognition and expression deficit. Together, these two studies
indicate that both the perception and expression of emotions is impaired in HD, beyond
disgust, which is consistent with past data on joint global expression-recognition deficits in
Parkinson‘s Disease (Jacobs et al., 1995) as well as in patients with vascular lesions to the
basal ganglia (Cancelliere and Kertesz, 1990).
A critical point to consider is that tests of voluntary expressions may not be directly
comparable to spontaneous emotional facial expressions, especially since the neural
circuitries underlying such expressions differ (Bowers et al., 2006) albeit they also interact
(Rinn, 1984). For instance, it is well known that there are limbic, subcortical pathways for
spontaneous expressions, and more frontal cortical networks for voluntarily initiated
expressions. Indeed, Parkinson‘s Disease was long thought to impair spontaneous but not
 One But Not All Doors Closed to Empathy 357

intentional facial expressions, leading to the so called ―masked face‖ appearance. Further, in
patients with facial paralysis, either due to cortical or peripheral neural lesions, dissociations
are observed between posed and spontaneous expressions (Keillor et al., 2002; Rinn, 1984;
Rinn, 2007).

Figure 1. Experimental setups for the study of a) emotion recognition and b) production of facial
expressions in patients with Huntington‘s Disease (Trinkler et al., 2013). a) The subject (S) sees
emotional facial expressions on the screen and selects the corresponding emotion from a list of emotion
words. b) Subject (S) and experimenter (E) are sitting face to face. S takes an A6 card from a deck with
emotion words (i) and tries to produce the according emotion expression towards E (ii). The session is
filmed and later external raters perform a recognition test on the video clips.
358 Iris Trinkler

See Trinkler et al. (2013).

Figure 2. Recognition performance and voluntary production of emotional facial expressions are both
impaired and significantly correlated in patients with Huntington‘s Disease.

However, the relevance of those studies for HD is unclear, especially since several recent
studies have now reported joint impairments for spontaneous and volitional expressions in
individuals with PD, too (Bowers et al., 2006; Simons et al., 2003; Simons et al., 2004),
which is in line with the abovementioned common co-occurrence of spontaneous with
volitional expression deficits in HD (Hayes et al., 2009), as well as in patients with vascular
lesions of the basal ganglia (Cancelliere and Kertesz, 1990).
Even if we therefore assume that voluntary and spontaneous expression abilities in
patients with subcortical lesions may not be dissociated, the joint recognition-production
impairments reported above might in fact not be due to an impaired shared action
representation system. Instead, it might be due to an impairment on the level of the
―interoceptive basis.‖ If we want to disentangle these two hypothesis, and state that the shared
action representation system for emotion expressions but not the ―interoceptive basis‖ is
impaired in HD, two demonstrations are necessary: 1) We would have to show that patient‘s
―interoception,‖ i.e., access to information about the physiological state of the body is intact.
2) Imitating an emotional gesture (without having to access its ―interoceptive‖ and affective
or cognitive meaning) should be impaired, too. I will first provide some evidence for intact
interoceptive processing in early HD, and further (at least tentative) evidence of intact
mentalizing and intact direct sensory-perceptual affective routes in these individuals. I will
then turn to the critical case of imitation.
 One But Not All Doors Closed to Empathy 359

INTACT INTEROCEPTIVE PROCESSING IN HD

As reviewed above, individuals with alexithymia show impaired emotion recognition
(Berthoz et al., 2002; Lane et al., 1996), less activation in AI-A/MCC during the sharing of
affective states (Bird et al., 2010; Silani et al., 2008), and further, individuals who show
higher activation in AI-A/MCC during affective sharing of pain in a loved one, show higher
scores on a verbal empathy questionnaire (Singer et al., 2004). On the basis of the findings,
alexithymia and empathy questionnaires might be used to assess interoceptive processing
ability. Moreover, one of the most widely used alexithymia questionnaires (TAS20, Taylor et
al., 2003), directly uses items referring to interoception (Pollatos et al., 2008), which is why it
seems justified to use it as a proxy to tap representations of HD patients‘ feeling states. The
same patients that took part in the above-mentioned study on the recognition and production
of emotional facial expressions (Trinkler et al., 2013) also replied to both the TAS20 and the
AI-A/MCC sensitive empathy questionnaires used by Singer and colleagues (2004), the
interpersonal reactivity index (Davis, 1980; Davis et al., 1994), and Mehrabian‘s Balanced
Emotional Empathy scale (Mehrabian and Epstein, 1972). Strikingly, HD patients did not
differ from healthy control participants on alexithymia or empathy scores, see Figure 3.
This conclusion holds under the assumption that such questionnaires are interpretable in
neurological patients. There might be some indications from the literature that in the case of
HD, at least at early stages studied here, the use of such questionnaires is valid: For instance,
HD patients were found to report adequately on the consequences of their own movement
impairments (Snowden et al., 1998), and the judgments of their own memory impairments
correlated better with clinical scores than their family and caregiver‘s (Cleret de Langavant et
al., 2013). Thus, it seems that HD patients‘ difficulty recognising and expressing emotions is
not due to an underlying deficit in describing and identifying emotions. Interestingly, there is
additional evidence that emotions conveyed via a non-motor route, namely via contextual
cues (such as a graveyard implying sadness and dirty underwear being suggestive of disgust),
information that according to our framework might travel either on a mentalizing route or the
direct affective route, are also processed correctly in HD patients (Aviezer et al., 2009).
Furthermore, and even more strikingly, HD patients were shown to be more sensitive to the
affective scenes of the International Affective Picture System than normal controls (Ille et al.,
2011). All of these findings demonstrate that all routes to affective understanding and perhaps
social sharing in HD are not impaired. Let us now turn back to the question of imitation.

IMITATION IMPAIRMENT
Whereas recognition and production of emotional expressions requires the understanding
of the underlying meaning of the affective gestures, the mere imitation of an emotional
gesture does not. Hence, if imitation of an emotional gesture is spared in HD, then we could
not argue for an emotional action representation deficit. Using electromyography (EMG),
Trinkler et al. (2011) investigated both spontaneous and voluntary imitation of emotional
facial expressions and compared them to the voluntary production of emotion expressions
from words using the same technique. Electromyograms sensitively capture electric signals
accompanying muscular contractions.
360 Iris Trinkler

See Trinkler et al. (2013).

Figure 3. HD patients and age- and education-matched control subjects replied to alexithymia and
empathy questionnaires. a) Results from the Toronto alexithymia questionnaire (TAS 20, Taylor et al.
1997). b) Davis‘ (1980, 1994) Interpersonal Reactivity Index. c) Mehrabian and Epstein‘s (1972)
Balanced Emotional Empathy scale. d) Additional alexithymia questionnaire items we invented,
pertaining to specific emotions. There are no differences between HD patients and controls in
alexithymia (a + d) and empathy scores from questionnaires (b + c).

Even if EMG is not very precise in identifying the occurrence of particular emotional
expressions, which are naturally composed of a large array of facial muscle activations
(Ekman and Friesen, 1978), they permit the sensitive and objective assessment of ongoing
emotional motor reactions. Whereas one can readily measure volitional imitation of facial
expressions using EMG (see below), that technique has been mainly used to study
involuntary or unconscious mimicry (famously: Dimberg, 1982). Facial mimicry is defined as
the spontaneous imitation of another person‘s non-verbal displays, and is often
conceptualized as an automatic, reflex-like process (e.g., Hatfield et al., 1993; Hoffmann,
1984; Lipps, 1907), although obviously it can also be volitional. In any event, it has long been
viewed as an index indicative of the existence or communication of affective states (e.g.,
Bavelas et al., 1986, suggest that mimicry may serve to communicate one‘s empathy).
Further, mimicry has been used synonymously with emotional contagion (Hatfield et al.,
 One But Not All Doors Closed to Empathy 361

1993; Watt, 2007). However, this may be misleading and as we will see, we may be wise to
consider that facial mimicry could refer merely to congruent facial reactions, and thus to an
―infectiousness‖ of motor/ expressive components, without any necessary linkage to
underlying affective states. By contrast, emotional contagion implicitly includes reference to
an existing affective state that corresponds to an observed individual‘s emotional displays. As
much as mimicry might occur without emotional contagion, emotional contagion might arise
independent of motor mimicry (see also Hess and Blairy, 2001).
Indeed, not only mimicry but also counter-mimicry effects exist, as reported e.g., by
Lanzetta and Englis (1989) in a competitive task situation. Further, the amount of mimicry is
modulated e.g., by whether or not an observer shares a politician‘s beliefs (Bourgeois and
Hess, 1999). These findings suggest that mimicry is not always simply an automatic-reflex
like mechanism related to affective sharing (Hess and Blairy, 2001). Nonetheless, a number
of studies have found that individuals tend to report emotional states that match the facial
emotion displays they have been exposed to (see Hess and Blairy, 2001, for a review). Early
on, it was thus suggested that expressive emotional imitation can lead, via a physiological
feedback process (e.g., via somatic marker processes, see Damasio, 1994) to emotional-
affective contagion (Levenson et al., 1990; see also Cappella, 1993). This goes back to
Darwin (1872), who viewed the face not only as a signal system for emotion communication
but also as playing a central role in engendering emotional experiences. In the meantime we
know that emotional contagion and mimicry may also occur independently. Indeed, when
participants in one study were watching videos of people expressing emotional states, both
mimicry and emotional contagion were observed, but the two were found to be completely
independent and mimicry was not systematically related to decoding accuracy (Hess and
Blairy, 2001). Finally, in line with the abovementioned counter-mimicry effects (Lanzetta and
Englis, 1989), mimicry might refer to an implicit emotional reaction (e.g., fear) to an
affective stimulus. This stimulus might have travelled on a ―direct affective route,‖ as well as
on a shared action representation route, as might be the case for a fearful face stimulus.
Evidence corroborating such an interpretation comes from studies of patients with blindsight
(De Gelder et al., 2006; Tamietto et al., 2009) for whom the conscious route via the shared
action representation system is blocked, but subcortical affective routes appear to still be
functioning. In sum, mimicry might be the correlate of two different underlying processes
(which, of course, may interact in the normal brain): i) it may relate to activation of a shared
action representation system not necessarily linked to any affective processing, and ii) it may
be a more direct correlate of an aroused affective reaction. Here, again, we are mainly
interested if imitation (both spontaneous, as in mimicry, and volitional) is impaired in HD, in
the presence of intact interoceptive processing. This would suggest several distinct routes to
affect sharing and further that HD might impair the shared action system route predominantly.
This background is critical for the study summarized below:
Twenty-eight early HD patients with only mild motor impairment, scoring 24 ± 15 out of
128 on the Unified Huntington‘s Disease motor Rating Scale (UHDRS, Huntington Study,
1996), and with rather low facial chorea (0.9 ± 0.7 out of a possible score of 4), and 24
matched controls were tested on the following protocol: Three sets of facial electrodes were
placed in accordance with EMG guidelines (Fridlund and Cacioppo, 1986). Two were placed
over the eyebrows, for measuring frowning, and two over the cheeks for measuring smiling as
362 Iris Trinkler

before (Achaibou et al., 2008; Dimberg, 1982)3. Additionally, in a more exploratory vein,
another set of two electrodes were applied to the sides at the back of the nose, to measure
nose wrinkle (as part of the disgust expression). Visual stimuli used were taken from to the
combined Ekman series and the Karolinska battery as used before (corresponding to the best
eight faces each for anger, disgust and joy, see Trinkler et al., 2013). In the initial phase of
testing, participants were instructed to merely watch the faces appearing on the screen ―for
familiarization with the stimulus materials‖ while their spontaneous mimicry was measured
with EMG. Next, they were instructed to imitate the faces they saw appearing on the screen.
And in the final set of trials, they were instructed to produce the facial expressions in
response to various emotion words appearing on the screen (―colère,‖ ―dégoût,‖ ―joie‖ –
anger, disgust, joy). The experimental procedure is summarized in Figure 4.
After the EMG session, participants also underwent an emotion recognition test on all
basic emotions (as before, see Trinkler et al., 2013), and filled in the Toronto alexithymia
questionnaire (TAS, Taylor et al., 1997). Details of EMG data processing are summarized
elsewhere (Trinkler et al., 2011; Trinkler et al., subm.). Briefly, data was recorded at 512 Hz,
with a 0.1-417 Hz band-pass filter, raw data segmented offline into 4500 ms epochs,
including a 500 ms pre-stimulus baseline, filtered with a 20–256 Hz band-pass in Brain
Vision Analyzer (Brain Products GmbH), and bipolar montages were calculated from
electrode pairs for each muscle. The magnitude of the EMG signal was determined by
calculating the root-mean-square over 125 ms interval bins after the onset of each stimulus.
Trials with a mean activity superior to 3 standard deviations of the mean per condition were
rejected.
An impairment of recognition of emotional facial expressions across emotions was
replicated once more (as previously found by e.g., Milders et al., 2003; Johnson et al., 2007;
Henley et al., 2008; Aviezer et al., 2009; Snowden et al., 2008; Trinkler et al. 2013), as was
an absence of differences in alexithymia between HD patients and controls. By contrast,
EMG results were as follows. To start with the participants‘ last block, where they had to
produce emotional facial expressions from words, both patients and controls showed
activations over the relevant facial muscle areas in response to anger, disgust and joy.
Specifically, activations were present in i) cheek muscle-regions involved in the
expression of happy faces, ii) the frown and nose areas for angry faces, and iii) the frown and
nose areas, once again, for disgusted faces, but in ways distinct from anger (see Figure 5).
n
1
ct   p t dt
Trapezoid integral ( n  0 , for further methods see Trinkler et al., subm.) was
calculated for these 5 areas of interest. Results show that patients‘ muscular activities were
significantly lower than controls.‘ This replicates previous findings of impaired voluntary
production of emotional facial expressions in HD (Hayes et al., 2009; Trinkler et al., 2013).
With regards to the most critical tests, concerning imitation, the following was observed:
Voluntary imitation largely resembled the results found for production, see Figure 6. Again,
HD patients exhibited emotion-specific reactions, but of significantly lower intensity than
controls.

3
Strictly, electrodes over the eyebrows will capture activity over an ensemble of ―action units‖ (Ekman & Friesen,
1978) including among many others the corrugator supercilii, typically involved in an angry face.
Complementarily, electrodes over the cheek supposedly capture zygomatic major muscle activity underlying
smiling.
See Trinkler et al. 2011; subm.

Figure 4. Experimental design of an electromyography (EMG) experiment on 28 HD patients and 24 controls. 1) During a first phase participants were
instructed to ―simply pay attention to the visual stimuli for familiarization‖ while spontaneous mimicry was measured. They saw a randomized series of angry,
disgusted or happy faces (8 different identities per emotion x 4 repetitions) during 4000ms each with jittered 1500-3000ms inter-stimulus-intervals. 2) During
imitation they saw the same stimuli again with the task to imitate the expression they saw. 3) During production they saw the emotion words anger (―colère‖)
disgust (―dégoût‖) or joy (―joie‖) in randomized order in 4 repetitions each with the task to try and mime the corresponding emotion.
Figure 5. EMG results of voluntary production of emotional facial expression (corresponding to task 3 in Figure 4, see also Trinkler et al. 2011; subm.): Both
HD patients and control subjects show muscle activation over the corresponding facial area when voluntarily expressing emotions from words, i.e., cheek for
happy faces, frown and nose wrinkle for angry and disgusted faces. However, HD patients show significantly less activation.
Figure 6. EMG results of voluntary imitation of emotional facial expressions in EMG (corresponding to task 2 in Figure 4, see also Trinkler et al. 2011; subm.):
Both HD patients and control subjects show muscle activation over the corresponding facial area when voluntarily imitating facial expressions from images, i.e.,
cheek for happy faces, frown and nose wrinkle for angry and disgusted faces. However, HD patients show significantly less activation.
Figure 7. EMG results for spontaneous mimicry in reaction to passively viewing facial expressions (corresponding to task 1 in Figure 4, see also Trinkler et al.,
2011; subm.) Control subjects show a significant muscle regions by emotion interaction, namely, they show more activity over cheek muscles for happy faces
compared to angry faces, and more frown activation for angry faces compared to happy faces. This modulation is lost in HD.
 One But Not All Doors Closed to Empathy 367

Finally, spontaneous mimicry follows the general trend of impaired motor reactions to
facial expressions in HD, showing that whereas controls show a significant muscle regions by
emotion interaction, patients do not. Namely, controls show more activity over cheek muscles
for happy faces compared to angry faces, and more frown activation for angry faces
compared to happy faces1. This modulation is lost in HD. See Figure 7. Thus, voluntary as
well as spontaneous expressions were found to be impaired. The results, taken together, may
be interpreted as a loss or degradation of the motor-emotional representation underlying a
facial emotion expression, or its adequate selection within the motor-emotional repertory.

GENERAL DISCUSSION
Here, the case of Huntington‘s Disease (HD) -- a motor disease with underlying striatal
(Douaud et al., 2009; Vonsattel et al., 1985) but also distributed diffuse cortical degeneration
(Tabrizi et al., 2009) -- illustrates a pattern of impaired recognition of emotions in others and
an associated impairment in expressing and imitating emotional facial expressions (Hayes et
al., 2009; Trinkler et al., subm.; Trinkler et al., 2013). This is combined with largely intact
understanding of emotions in others on the basis of verbal prompts (Hayes et al., 2007;
Snowden et al., 2008; Trinkler et al., 2013) and situations (Aviezer et al., 2009), as well as
intact identification of emotions in oneself (Trinkler et al., subm.; Trinkler et al., 2013) along
with intact reactions to non-motor affective stimuli (Ille et al., 2011). This provides evidence
for the existence of multiple dissociable pathways to affect sharing, through the
demonstration that motor levels of imitation may be severely disrupted, while ―direct
affective‖ and ―mentalizing‖ routes are relatively spared, as well as interoceptive abilities that
permit HD individuals to viscerally share feelings at an experiential level. Here, the work
focussed mainly on facial emotional expressions. Additional corroborating evidence for a
motor-based deficit in HD comes from a study demonstrating impaired recognition of whole
body emotion expressions correlated to patients‘ Unified Huntington‘s Disease Rating Scale
(UHDRS) motor scores (De Gelder et al., 2008).

NEURAL BASIS UNDERLYING THE SELECTIVE

“MOTOR-EMOTION” DEFICITS
In the case of HD, a candidate underlying neural substrate responsible for the observed
pattern would naturally involve the striatum, given the well-documented neurodegeneration in
this structure from early disease stages onward (Douaud et al., 2006; Vonsattel et al., 1985).
Also patients with Parkinson‘s Disease and patients with focal basal ganglia lesions have
previously been reported to show concurrent impairments in the recognition and expression of
emotions (Bowers et al., 2006; Cancelliere and Kertesz, 1990; Jacobs et al., 1995; Simons et
al., 2003; Simons et al., 2004). This could be taken as further evidence that the basal ganglia
do mediate the motor representations of emotionally expressive facial gestures. Further, in the

1
No mimicry reaction for disgust was found in either participant group, see Trinkler et al. (subm.), but this might
have been related to the fact that the facial muscle tested might not have been the most sensitive to capture
disgust mimicry.
368 Iris Trinkler

abovementioned work, recognition and expression were positively correlated with striatal
atrophy (Trinkler et al., 2013). Henley and colleagues (2008) have also found a direct
relationship between striatal atrophy and emotion recognition impairments in a whole-brain
structural morphometry analysis. This suggests that the impairment we observed in HD may
not be structurally linked to the cortical action representation systems commonly called the
―mirror neuron network‖ noted earlier, which includes the superior temporal cortex (STC),
inferior parietal lobe, inferior frontal and premotor cortices (Carr et al., 2003). Interestingly
however, and without this ever being discussed, some ―mirror neuron studies‖ have reported
striatal activation involved in imitation of emotional facial expressions (see Carr et al., 2003,
and; Dapretto et al., 2006, supplementary materials). Thus, future studies should increasingly
focus on a possible role of the basal ganglia in mediating facial expressions, whether
emotional or not.
However, it is important to raise the possibility that individuals with Huntington‘s
Disease and Parkinsons Disease as well as other basal ganglia disorders, albeit sharing basal
ganglia pathology, may have facial expression deficits with differential underlying neural
substrates specific to each pathology. Furthermore, deficits for recognition and expression
might also have distinct underlying substrates (possibly within the basal ganglia). For
instance, as Rinn pointedly noted: ―The lack of spontaneous facial expressiveness in PD is not
due to the destruction of a motor center for the organization or production of spontaneous
emotional expressions. The basal ganglia circuits that are compromised in PD, under normal
circumstances, simply contribute fluidity and spontaneity to movements throughout the body.
In PD, this loss of fluidity and spontaneity very directly affects spontaneous facial expression,
but it also compromises the fluidity of volitionally induced movements. Thus, in volitionally
posing a facial expression, the Parkinson patient must overcome the sluggishness imposed by
basal ganglia dysfunction‖ (Rinn, 2007, p. 721/722). Even if such a scenario turns out to be
the case, the map of different pathways to affect sharing that we have sketched out here has
served and may serve further as a foundation for the exploration of intact versus obstructed
routes to affect sharing especially in the lesioned brain.
Besides basal ganglia pathology, in the case of HD, it might also be true that brain
atrophy in the classical action representation system accounts for the observed pattern. This
would be in line with reported premotor atrophy in early HD (Douaud et al., 2006; Thieben et
al., 2002), and even more with recent fMRI research in presymptomatic HD gene carriers
showing significantly lower activations in precentral, paracentral and postcentral gyrus as
well as inferior parietal cortex and insula (among other areas) during the viewing of
emotional facial expressions (Novak et al., 2012). Furthermore, preliminary data from a
regression analysis of patients‘ EMG and emotion recognition scores and structural brain
changes have found positive correlations of recognition, imitation and production of emotion
expressions with grey matter volume in the STC (Trinkler et al., subm.). In sum, there seems
to be preliminary evidence of mere motor-based deficits in affect sharing in HD which are
related to brain-structure abnormalities in the classical shared-action representation system
sketched above. It would be useful for future systematic studies employing brain imaging to
compare processing of motor-emotional (e.g., emotional facial or body expressions), motor-
non-emotional (e.g., instrumental actions), emotional-non-motor stimuli (e.g., from the IAPS)
within the same HD population. Also, future studies should aspire to directly ask participants
what kind of psychological states the various emotional stimuli evoke in them; namely,
investigators should aspire to assess feeling states.
 One but Not All Doors Closed to Empathy 369

AFFECT SHARING AND RECEIVING

A final point that deserves attention concerns the consequences of damage to specific
motor pathways in the process of affect sharing. If individuals experience trouble
understanding emotion expressions, a cornerstone for successful social interaction may be
compromised. However, vice versa, individuals who are not able to express emotions
correctly are no longer understood, and their social interaction partners will be unable to
understand and share their affective states correctly. This in turn will lead to further social
difficulties. Another critical dimension in the sharing of emotional processes, beyond
impairment in the expression and recognition of emotional states, is the possibility that these
individuals may overestimate their own empathic and related emotional capacities, especially
if their experiences of affect sharing on an interoceptive level, as well as on the basis of
contextual cues (see Aviezer et al., 2009‘s study) or verbal descriptions remain unaltered. The
failure to understand one‘s lack of access to the affective states in others in everyday
communication, which is largely based on emotion expressions, may contribute substantially
to the worsening of social relationships. Thus, it is vital to sensitize patients and especially
their families and caregivers about the possible dissociations between diverse levels of mutual
understanding. Moreover, re-education schemes should take these levels into account, on the
one hand re-training motor systems wherever possible, and on the other, providing patients
and their social environments with non-motor routes to empathy, such as verbal-conceptual
and various situational aids (see Aviezer et al., 2009). The spectra of deficits may vary
substantially in patient groups with different patterns of brain lesions and/or neuro-
degeneration. Hopefully the perspectives shared here will contribute to the development of an
updated framework by means of which the various pathways to affect sharing and their
obstruction can be tested differentially. Last but not least, the hope is also that this research
will better inform patient care and re-education in the domain of impaired affect sharing.

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Editors: Douglas F. Watt and Jaak Panksepp © 2016 Nova Science Publishers, Inc.

Chapter 14

EMPATHY AND MIRROR-GAZING

Giovanni B. Caputo*
DIPSUM, University of Urbino, Urbino, Italy

ABSTRACT
A relationship between empathy and self-directed behaviour during mirror-gazing
has been hypothesized by some authors. Nevertheless, how these concepts may be
connected is still an argument of debate. Previous research on mirror self-recognition
may not completely account for the fascination produced by mirror-gazing. In fact,
gazing at one‘s own face in the mirror for a few minutes, at a low illumination level, can
produce the perception of bodily dysmorphic visual illusions of strange-faces. Strange-
face illusions may be the ‗projection‘ of the subject‘s unconscious contents into mirror
image on the basis of somatic/motor mimicry and contagion. Motor mimicry and
emotional contagion can operate through the feedback produced by the mirror within the
observed/observing subject. The ‗projection‘ of unconscious content can characterize
empathy, according to early ideas of Einfühlung. Empirical research shows correlations
between susceptibility to strange-face illusions and both the Fantasy and Empathic-
concern subscales of Interpersonal Reactivity Index (IRI).

1. EMPATHY
Empathy is a broad concept that refers to both the emotional reactions and the cognitive
responses of a subject to the observed affective experiences of another subject. Some
researchers define empathy as an umbrella term for states of feeling with or resonating with
the other, which appears to occur at multiple levels, neural to phenomenological, conceptual
to affective (Preston & Hofelich, 2012). In general, ―empathy may bring together both higher
cognitive theory of mind and more primitive resonance induction mechanisms of contagion
and mimicry, under the ‗supervision‘ of a motivated valuing of another sentient creature, a

*
giovanni.caputo@uniurb.it.
378 Giovanni B. Caputo

‗supervision‘ that underlines the intrinsic connections between empathy and attachment
mechanisms‖ (p. 119 Watt, 2007).
Current definitions and concepts of empathy are typically based on a dual model:
emphasizing both an emotional version and a more cognitive version (Decety & Jackson,
2004; Zaki et al., 2009; Shamay-Tsoory, 2011; Bernhardt & Singer, 2012). The ability to
share affective reactions through the observed experiences of others has been described as
‗emotional empathy‘ (Lamm et al., 2011; Fan et al., 2011). Emotional empathy may involve
emotional contagion, mimicry and emotional sharing, which are the common basis of all
forms of empathy, while more cognitive empathy concepts emphasize theory of mind and
perspective taking.
Perception of other peoples‘ emotional states can result in spontaneous emotional
empathy or emotional contagion, that is, elicitation of corresponding emotions and respective
approach/avoidance behaviour in the observer (Hatfield et al., 1994). People unconsciously
and rapidly mimic the expressions presented to them (Dimberg & Thunberg, 1998; Dimberg
et al., 2000; Sonnby-Borgstrom, 2002). These facial responses do not constitute a purely
unimodal sensory imitation, as contagion effects are transmodal. For example, hearing of
either vocal expressions of emotion (Hietanen et al., 1998) or viewing of body postures
(Magnee et al., 2007) of emotions results in corresponding and affectively congruent facial
expressions in the observer. This suggests that contagion effects integrate across sensory
channels and are not simply sensory ‗mirroring.‘ This primitive contagion occurs through
very fast processes based on automatic and continuous nonverbal mimicry and feedback
(Hatfield et al., 1994), including automatic, unconscious mimicry of the other‘s facial
expressions (Lundqvist & Dimberg, 1995), vocal tones (Hatfield et al., 1994) and body
language (Chartrand & Bargh, 1999). Mimicry triggers both affective and cognitive empathic
reactions (Stel & Vonk, 2010). As Watt states in his 2007 review, ―contagion is perhaps most
classically reflected in fear inductions in herd behaviour, but all of the prototype emotions
appear to be ‗catchy,‘ as playful, smiling, lustful, and tender responses all facilitate and
activate the same states in others in close proximity, as of course do the prototype negative
emotions of fear and rage (Hatfield et al., 1994)‖ (page 119). Prototype emotional states can
generate affective resonances in others, resonances possibly modulated or inhibited by higher
cognitive functions, but that may not depend on them entirely. For example, emotional
sharing can involve higher order processes of the subject‘s conscious imitation of the other‘s
emotion.
Therefore, it seems that emotions primarily structure prototypical interactions between
humans and a basic emotional ‗sharing‘ in part through mimicry and contagion mechanisms.
Somatic/motor patterns of basic emotions, in particular prototypical somatic/motor facial
patterns, may define qualitative and discrete ‗primitives‘ for empathy between human beings.
Mimicry and contagion thus produce unconscious affective synchronization and coordination
between individuals. Interpersonal coordination refers to the fact that behaviours in social
interactions are often patterned and synchronized; they are similar or identical in form, or
they occur at roughly the same time (Bernieri et al., 1988). Both the precursors and the
consequences of behavioural mimicry and interactional synchrony are often similar,
suggesting that both serve the goal of interpersonal coordination (Lakin et al., 2003;
Chartrand & van Baaren, 2009; Marsh et al. 2009; Sebanz & Knoblich, 2009) and empathy
(Wiltermuth & Heath, 2009; Kirschner & Tomasello, 2010; Valdesolo & DeSteno, 2011).
People who either dispositionally or temporarily have a pro-social orientation synchronize
 Empathy and Mirror-Gazing 379

their behaviours with interaction partners more than people who have a pro-self orientation
(Lumsden et al., 2012).
In any basic two-system model of empathy, the second system indexes cognitive
empathy. Cognitive empathy describes empathy as a perspective-taking and theory-of-mind
ability, or the capacity to engage in the cognitive process of adopting another‘s psychological
point of view, while at the same time being aware of the causal mechanism that induced the
emotional state in the other (Frith & Singer, 2008; Shamay-Tsoory et al., 2009; Zaki et al.,
2009; Bernhardt & Singer, 2012; Engen & Singer, 2012; Gonzalez-Liencres et al., 2013).
Theory-of-mind describes the ability to extract and understand the goals of others by drawing
on the capacity to understand the other‘s thoughts, intentions, emotions, and beliefs and to
predict their behaviour (Amodio & Frith, 2006; Frith & Frith, 2006; Walter, 2012). A recent
model (Shamay-Tsoory et al., 2010) distinguishes between cognitive-theory-of-mind, which
refers to the ability to make inference regarding the other‘s beliefs, and affective-theory-of-
mind that refers to make inference regarding the other‘s emotions and feelings. According to
this model, cognitive-theory-of-mind is a prerequisite for affective-theory-of-mind, which
also requires emotional and affective aspects of empathy. Therefore, affective-theory-of-mind
places additional demands relative to cognitive-theory-of-mind (Shamay-Tsoory et al., 2010;
Sebastian et al., 2012). Individual differences of empathy could be due to differences in the
balance between affective- and cognitive-theory-of-mind (Cox et al., 2012).
Self/other boundary also appears involved in the conscious processes of cognitive
empathy, with a basic prerequisite of cognitive empathy being the distinction between actions
generated by the self or observed in others (Decety & Chaminade, 2003). The self/other
distinction is also required for distinguishing the subject‘s mental state from the mental state
of others (Decety & Sommerville, 2003). Cognitive empathy can be modulated on the basis of
the characteristics of empathiser, the relationship between the empathizer and the object of
empathy, the features of the other‘s emotional state, and the contextual appraisal (Engen &
Singer, 2012). A relevant factor of modulation of cognitive empathy is the ingroup/outgroup
social relationship between empathizer and empathized (Leach et al., 2003; Xu et al., 2009;
Avenanti et al., 2010; Masten et al., 2010). Moreover, cognitive empathy involves higher-
order cognitive functions of autobiographical memory and self-perspective in the past and the
future (Buckner & Carroll, 2007).
The two-system model has been in part criticized for drawing a fracture between different
forms of empathy. Alternatively, and as noted previously, empathy ―may bring together both
higher cognitive theory of mind and more primitive resonance induction mechanisms of
contagion and mimicry, under the regulation of a motivated valuing of the empathized other‖
(Watt, 2007; Gonzalez-Liencres et al., 2013). Various models of empathy have alternatively
proposed gating mechanisms for resonance induction of basic contagion process (Watt,
2007), or a modified two-system model of empathy with the involvement of regulation and
modulation factors (Engen & Singer, 2012).
From the theoretical viewpoint, simulationist models have been proposed to explain
empathy. According to the perception-action hypothesis (Preston & de Waal, 2002),
perception of behaviour in another subject automatically activates one‘s own representations
of the same behaviour. The perception-action hypothesis has been compared to the simulation
theory, which has been the dominant theory to explain the functioning of mirror-neuron
system in the brain (di Pellegrino et al., 1992). Basic simulation theory suggests that the
neural activity during the subject‘s experience is similar to observing the same experience
380 Giovanni B. Caputo

enacted by another subject (Gallese, 2003, 2007; de Vignemont & Singer, 2006). However,
simulationist models of empathy have been criticized from the philosophical/epistemological
viewpoint (Zahavi, 2008). Moreover, simulationist systems (mirror-neuron networks), which
underpin action imitation, have quite different functional characteristics compared to basic
empathy processes. These differences include: 1) imitation has longer latency than faster
contagion and emotional empathy (Hatfield et al., 1994; Dimberg et al., 2000); 2) imitation
requires awareness while emotional empathy can occur unconsciously (Goubert et al., 2005);
3) imitation can have a different neuroanatomical basis compared to empathy (Fan et al.,
2011) with empathy networks more typically paralimbic and mirroring networks more
neocortical; 4) finally, imitation can serve different evolutionary and adaptive purposes, with
mirror-neuron mechanisms aimed at acquisition of skilled movement, whereas contagion and
emotional empathy is aimed at social cohesion, intimacy, attachment and promotion of social
bonds (Watt, 2007; Gonzalez-Liencres et al., 2013).

2. MIRRORS AND THE PROCESSING OF

ONE‟S MIRROR IMAGE
Some authors (Gallup, 1982; Bischof-Köhler, 1991; Zahn-Waxler et al., 1992; de Waal,
2008) hypothesized that mirror self-recognition and expressions of empathy can co-emerge in
both individual development and phylogeny. The attainment of a developmental stage of
basic self-recognition is commonly gauged through reactions to a mirror (Gallup, 1970;
Amsterdam, 1972; Rochat, 2003; Suddendorf & Butler, 2013). It can be hypothesized that
empathy and self-recognition in the mirror are correlated because both need processing of the
self/other boundary and overlapping. In particular, mirrored-self recognition involves the
connection between the representation of a visual image that is external to the subject and the
representation of the subject‘s self. In other words, the external mirrored image needs to be
empathized by the empathizing subject. This process most probably requires binding of
visual, somatic, kinaesthetic, affective and motor representations into a global representation
of the subject‘s self.
However, in cognitive psychology and neuroscience, self-face recognition has been
studied almost exclusively by using photos. Instead, neurophysiological responses to self-face
photos versus mirrors are largely different (Butler et al., 2012). Therefore, studies of self-
recognition with photos can lack to comprehend the fascination produced by reflective
mirrors.
Mirrors are, by definition, virtually perfect ‗imitators‘ of the observer‘s own bodily face,
since mirror feedback is instantaneous in time and completely coherent in space. In other
words, the mirror creates a sort of ‗closed loop‘ between perception and action within the
observed/observing subject. Unconscious mimicry (basic contagion) can presumably act
within the subject itself that is gazing at its own reflected image, thus producing emotional
resonance. Hence, mirror-gazing can thus presumably activate processes also involved in
empathy. Cognitive empathy, which is based on self/other differentiation, may also take place
during mirror-gazing, producing a form of conscious dissociation of the reflected image from
the subject‘s self. The subject‘s dissociation from its reflected image – a dissociation that is
largely documented in poetry, arts and religion – can occur in some lighting settings,
 Empathy and Mirror-Gazing 381

psychological contexts, consciousness states, personality traits, and/or psychopathological

conditions.
In neuropsychology, delusions of mirrored-self misidentification have been described
(Ajuriaguerra et al., 1963; Breen et al., 2001; Connors & Coltheart, 2011). Patients, when
looking into a mirror, express the belief that the persons they see in the mirror are not their
selves, but strangers. Patients can also interact with the stranger, explaining that the stranger
is an impostor or a duplicate of known persons. Some patients can retain a capacity to self-
recognize in photos (Villarejo et al., 2011) and to recognize their own body in the mirror if
the mirror did not reflect their face (Van den Stock et al., 2012). Mirrored-self
misidentification follows from dementia secondary to Alzheimer‘s disease, particularly in
patients with more right frontal or right hemisphere disease. A two-factor theory of mirrored-
self misidentification has been proposed (Coltheart, 2010). A first factor generates the content
of the delusion and typically involves a neuropsychological anomaly affecting perceptual
and/or emotional processing. A second factor involves a deficit in belief evaluation and
explains why the delusional belief is maintained and not rejected. This second factor is
associated with damage to the right prefrontal cortex (Coltheart, 2010). However, this theory
does not explain processing of the self/other boundary and overlapping, which is likely
involved in mirrored self-face recognition. Feinberg (Feinberg & Roane, 2005; Feinberg,
2010) proposed to group various syndromes that present an alteration in the patient‘s personal
identity or personal relationships between the self and the world within the category of
neuropathologies of the self, which follow from damage to the right medial-frontal and
orbitofrontal cortex. Deficits of these systems produce an alteration in the regulation of the
self-boundaries, either in the direction of the under-relatedness to personally significant
aspects of the self (as mirrored-self misidentification) or in the direction of the over-
relatedness to selected aspects of the world that the patient inappropriately over-incorporates
into the self (Feinberg, 2010). Therefore, it can be hypothesized that the identity between the
subject‘s self and the mirror image requires an appropriate processing of a self-boundary, in
order to incorporate the external image into a ‗projected‘ self representation. On the other
hand, it can be hypothesized that an over-relatedness can provoke dysmorphic changes in the
perception of the mirrored self-face image.
In studies that use hypnosis, mirrored-self misidentification can be directly induced in
selected highly hypnotizable individuals (Barnier et al., 2010; Connors et al., 2011). All these
studies used an explicit suggestion (―The person you see in the mirror will not be you, it will
be a stranger‖) because it was found in a previous work (Barnier et al., 2008) to be the most
effective in producing mirrored-self misidentification. Overall, 70% of participants in the
hypnosis condition perceived a stranger in the mirror. Instead, 22% of participants in the
control condition (without hypnosis) perceived a stranger in the mirror (Connors et al., 2011).
In some participants the stranger in the mirror had new facial features (Barnier et al., 2010).
In these articles, the authors did not describe the lighting conditions in which the experiments
were carried out, the distance between the participant and the mirror and the optical
dimension of the mirror for the viewer. However, it is possible that, with an appropriate
optical setting (in particular, a larger mirror with a lower illumination and the observer placed
in front of the mirror; Caputo, 2010a), strangers could be perceived even in normal
individuals and without an explicit hypnotic suggestion.
Fascination by mirrors has been described in various forms of psychopathology such as
body dysmorphic disorder (Phillips et al., 1993). Some patients with body dysmorphic
382 Giovanni B. Caputo

disorder spend many hours mirror gazing in order to achieve a kind of ‗mental cosmetic
surgery,‘ to modify their body image, and to practice recruiting different facial expressions
(Phillips, 1991). According to a current theoretical view, mirrors can act as a symptomatic
trigger for individuals with body dysmorphic disorder, producing a specific mode of cognitive
processing, characterised by an increase in self-focussed attention and associated distress
(Veale et al., 1996). In studies that used photos of faces, some specific deficits in the
perception of patients‘ facial features (Stangier et al., 2008; Feusner et al., 2010a; Jefferies et
al., 2012) and changes in judgements of facial attractiveness (Mulkens & Jansen, 2009) have
been found. However, the differences in visual perception of photos in patients with respect to
healthy individuals are not so relevant to explain body dysmorphic disorder in front of the
mirror. In a study (Windheim et al., 2011) that used mirror-gazing with high lighting
illumination, self-evaluation measures of cognitive functions gave no univocal differences
between patients and normal individuals. Therefore, from these studies the fact that patients
see distorted (dysmorphic) images when looking in the mirror remains unexplained. A deficit
of self/other boundary and cognitive-empathy is possible, particularly because activity of the
right orbitofrontal cortex in response to faces positively correlate with body dysmorphic
disorder symptom severity (Feusner et al., 2010b). However, to date, there is no specific
study (to our knowledge) that examines empathy or self/other boundary in relation to body
dysmorphic disorder. It can be hypothesized that mirror-gazing in patients with body
dysmorphic disorder involves anomalous processes of self/other boundary that lead to
dysmorphic over-relatedness between the subject‘s self and the empathized mirror image.
Neurophysiological studies of self-recognition used exclusively photos and were aimed to
distinguish between two putative concepts of ‗self,‘ namely, a physical-self and a social-self.
A physical-self is conceptualized in terms of a visual-kinaesthetic representation of one‘s own
body. Correspondingly, simulationist models of motor imitation have been proposed for self-
face (photos) recognition (Uddin et al., 2007; Ramasubbu et al., 2011). However, to date, no
study has yet been done (to our knowledge) to examine mirror-neuron system activity in
response to mirror-gazing. On the other hand, a putative social-self is conceptualized as a
representation of the self that is reflected in the ‗eyes‘ or minds of others. The involvement of
a social-self has been hypothesized on the basis of various findings. Eye gaze can be directed
toward publicly observable aspects of the self and in response to hearing one‘s own name
called (Kampe et al., 2003; Schilbach et al., 2006). A social-self representation can be
activated during a personality-trait judgment of the self (Ochsner et al., 2005) and during self-
conscious emotions, such as guilt and embarrassment (Zahn et al., 2009). A social-self
representation can be recruited during self-face recognition under a rich social context where
multiple other faces (photos) are available for comparison of social values (Sugiura et al.,
2012).

3. MIRROR-GAZING ILLUSIONS
Contrary to the simplistic view that views mirror gazing as equivalent to looking at static
photos, phenomenological investigations sometimes describe a more unsettling encounter
with one‘s mirrored double (Merleau-Ponty, 1964a, 1964b; Rochat & Zahavi, 2011).
 Empathy and Mirror-Gazing 383

Figure 1. The mirror stand used in the experiment of mirror-gazing. The mirror should have a relatively
large dimension (0.4–0.5 m side) and reflect, in addition to the face, a relatively large portion of the
observer‘s body. The mirror can be placed in the centre of a room, at a distance of 0.4 m in front of the
observer. This placement enhances an impression of isolation of the observer‘s reflected image. The
setting needed to produce strange-face illusions requires a room without external light. A uniform
illumination of the face can be obtained in various, not critical ways, and probably the more simple
solution is to place a small lamp on the floor at some distance from the observer‘s back. The task may
be presented to the observer with these words: ―Your task is to look at your face in the mirror and you
should keep gazing at your eyes.‖ Commonly, after about one minute of mirror-gazing strange-face
illusions are generated.

In fact, experiences that occur during mirror-gazing are not always of self-recognition
and self-identity. Strange-face illusions in the mirror have been recently described during
gazing at one‘s own face reflected in the mirror (Figure 1) for a few minutes at a low
illumination level (Caputo, 2010a). Normal observers sometimes see huge distortions of their
own faces, but they often see monstrous beings, archetypal faces, faces of relatives and
deceased, and faces of animals (Caputo, 2010b).
Strange-face illusions often involve the perception of a strange-others who appears
beyond the mirror, thus suggesting the subject‘s dissociation (Caputo, 2010b). Dissociation
phenomena (Holmes et al., 2005) include depersonalization (alterations in the sense of self
such as out-of-body experiences), derealization (alterations in the perception of the world
such as people appearing unreal or as actors in a play), and changes in time estimation (a
speeding up or slowing down of subjective time). In fact, observers have dissociative
experiences during strange-face illusions (Brewin et al., 2013; Rugens & Terhune, 2013). In
general, naïve observers describe their feeling of losing control when strange-faces suddenly
pop out from the mirror (Caputo, 2010b). Brewin et al. (2013) found that dissociative
experiences of strange-face illusions in healthy individuals typically dissipated after 15 min.
384 Giovanni B. Caputo

Consistent with these ideas of a dissociative process, observers wearing a full-face

theatrical mask during mirror-gazing (e.g., a Japanese ko-omote Noh mask; Caputo, 2011)
have described how the facial features of the mask become animated (e.g., opening the
physically closed mouth, as for lip movement or speaking, or shifting the animated eyes) and
strange-faces in place of the physical mask are perceived.
In healthy individuals, strange-face illusions during mirror gazing usually involve the
perception of one strange-face at a time. The duration of the illusion has been reported to be
roughly 7 seconds (Caputo, 2010b). However, there are some normal observers who describe
intense flux or streaming experiences of continuously changing faces of unknown persons;
the stream of new faces can last for a relatively long time. Only a few normal observers
describe the perception of a second face, like a shadow-man/woman, just behind their face
that instead becomes dark and unmoved like an inanimate mask. Alternatively, some
schizophrenic patients describe the perception of multiple-others that fill the mirror surface
surrounding the strange face (Caputo et al., 2012). Feeling of reality of strange-face illusions
was stronger in schizophrenics than in healthy individuals. Indeed, many patients were
convinced that strange-face illusions were truly real. Schizophrenics can identify themselves
with strange-face illusions, differently from healthy individuals who never identify with them
(Caputo et al., 2012). In adolescents, positive and disorganized schizotypy was differentially
related to strange-face illusions that involve depersonalization, like vision of other identity
and vision of non-human identity during mirror-gazing (Fonseca-Pedrero et al., 2015). This
deficit in schizophrenia can be caused by pathological ego dysfunction, which involves
self/world and self/other confusion, and erosion of first-person perspective (Boeker et al.,
2006; Sass, 2013). Intriguingly, most patients with major depression typically do not perceive
strange-face illusions, or they perceive very faint changes of their immobile faces, like ‗death
statues,‘ in the mirror (Caputo et al., 2014). This may possibly reflect effects of affective
inhibition and blunting on the dissociative process which may require at least the potential for
strong affective activation, a potential clearly dampened in depression (Watt and Panksepp,
2009)
Similar or even stronger strange-face illusions can be produced through an interpersonal
setting in which a pair of individuals are facing and gazing at each other in the eyes (Caputo,
2013). In such an intersubjective setting, unconscious synchronization of responses is
apparent in some dyads. On the basis of this finding, it is possible to hypothesize that strange-
face illusions during mirror-gazing enact an interpersonal subject-other interaction in which
the subject is facing its dissociative other located ‗beyond‘ or ‗behind‘ the mirror. Two
possible explanations of stronger strange-face illusions in some dyads with respect to mirror-
gazing can be suggested: an increase of mimicry within the dyad and a facilitation of
dissociation of the subject‘s unconscious contents when they are ‗projected‘ into the other‘s
face. This form of dissociation seems specific to faces (Caputo, 2015) and occurs when the
others‘ faces depersonalize the subject‘s face through projection of its unconscious meanings.
Consistent with these ideas linking affective activations to strange face illusions,
emotional responses to strange-face illusions are usually relatively intense in healthy
individuals, and can be dramatic in some schizophrenic patients. From previous observations,
emotions, which are most frequently described by participants in response to strange-face
illusions, are: surprise, interest and astonishment; other emotions include negative emotions
such as moderate fear, anguish and fright, while positive emotions, such as hilarity and
 Empathy and Mirror-Gazing 385

joyfulness, are rare. At the end of the session, healthy individuals and patients expressed
feelings of intense interest in the phenomena they had experienced and observed.
The mechanisms hypothesized as generative to strange-face illusions may be similar to
some aspects of processes in empathy. Mimicry and contagion, presumed core mechanisms in
empathy, can also potentially operate in the subject resonating with its own face reflected in
the mirror. Prototypical strange-faces could be a consequence of prototypical somatic/motor
facial patterns of basic emotions. Self/other dissociation can facilitate ‗projection‘ of
unconscious contents into an image of an external being in the mirror. In the intersubjective
setting, some dyads can show unconscious synchronization of illusions as a consequence of
synchronized facial mimicry.
In relation to the concept of ‗projection,‘ strange-face illusions can be considered a
technique for ‗imaging of the unconscious‘ and they can contribute to the study of the early
idea of empathy as ‗Einfühlung,‘ which was described by Lipps, Jung and Scheler. Lipps
(1909, chapter 13) hypothesized that ‗Einfühlung‘ is a form of objectification of the subject‘s
vital impulse or activity into an external object that is different from the subject. Hence, the
peculiar ability of Einfühlung is that inanimate targets (like pictorial images or, in our case,
mirrored self-face images) can become animated and appear alive. The targets that are
animated by Einfühlung appear as immediate Dasein and real, since the ego has became
external and self-objective. Jung (1921/1971, chapter 7) hypothesized that Lipps‘s idea of
Einfühlung is at the core of psychodynamic concept of ‗projections‘ of the subject‘s
unconscious dissociative contents into others. Jung proposed an ‗empathic personality trait‘
which may be complemented by an opposite personality trait of abstraction in order to explain
differences among individuals. Scheler (1923/1954) suggested that bodily expressions
provide a direct access to activate Einfühlung (see Zahavi, 2008).
The Jung‘s ideas about empathy versus abstraction are strikingly similar to some of
Baron-Cohen‘s more recent concepts about female versus male brains as empathising versus
systematizing (Baron-Cohen, 2002). Nevertheless, in my opinion, the early ideas, which are
expressed by the concept of Einfühlung or (psychodynamic) ‗projection,‘ have not yet
received adequate review or exploration in contemporary studies of empathy. The ideas of
Einfühlung by Lipps, Jung and Scheler seem to have immediate relevance to
phenomenological descriptions of strange-face illusions. In particular, the evocative power of
mirrors to elicit strange face and other illusions may be due to processes and contents outside
the conscious control. These unconscious contents can only emerge within the subject‘s
consciousness when dissociated from the subject‘s self and ‗projected‘ into the external
mirrored-self image.
A possible explanation is that the ‗projection‘ is a dynamic process that can arise from
the self/other boundary, where perceived faces and other persons are placed in relation to
significant aspects of the self, in a dynamic balance between under-relatedness and over-
incorporation into the self (Feinberg, 2010). It can be hypothesized that processing of the
self/other boundary influences perceptual stages through feedback mechanisms. Anomalous
processing, both in psychopathology (as in body dysmorphic disorders) and in strange-face
illusions, can lead to dysmorphic face perceptions during mirror-gazing.
Another possible explanation is that Einfühlung or ‗projection‘ of unconscious contents
involves processes that are also recruited during fantasy, self-reflective thought, daydreaming
(D‘Argembeau et al., 2005), and narrative comprehension (Schmithorst et al., 2006;
Szaflarski et al., 2012). The brain‘s default network (Buckner et al., 2008) is a brain multi-
386 Giovanni B. Caputo

area system that is preferentially active when individuals are not focused on the external
environment and they engaged in internally focused tasks including autobiographical memory
retrieval, envisioning the future, conceiving the perspectives of others. In general, the brain‘s
default network is active during the mental activities connected to fantasy, imagination,
daydreams and ‗mind-wandering‘ (D‘Argembeau et al., 2005; McKiernan et al., 2006; Mason
et al., 2007; Christoff et al., 2009; Stawarczyk et al., 2011), which together contribute to the
phenomenological experience of a ‗stream of consciousness‘ (James, 1890; Klinger, 1971).
Psychological models of narrative comprehension can be useful to further investigate the
nature of fantasy. For example, the dialogical-self theory (Hermans et al., 1992; Hermans,
2012) conceives the self as a ‗society of minds.‘ The self is extended to significant others in
the environment who populate the self as a dynamic multiplicity of I-positions, among which
relationships may emerge. The dialogical self transcends the restrictive borders between ‗I‘
and you, as demonstrated by the notion of the other-in-the-self and by the definition of the
other as another-I (Hermans & Hermans-Konopka, 2010). Accordingly, the ‗theatre of mind‘
would be animated by the presence of multiple-selves within the subject‘s ‗I.‘
A connection might be presumed between the concepts of ‗multiple-selves within the
subject‘s I‘ and empathy (Einfühlung or ‗projection‘), since empathy is a mental process that
relates to the self/other boundary (Decety & Chaminade, 2003; Decety & Sommerville,
2003). Indeed, we can empathize with another person, an animal, or even an object or natural
landscape (e.g., a pictorial portrait; Lipps, 1909) – only when we put (or ‗project‘) ourselves
within the empathized object do we perceive the feeling object inside ourselves. Such feeling
may be a whole ‗projection‘ of unconscious contents (Jung, 1921/1971).

4. EMPATHY PERSONALITY TRAITS AND

MIRROR-GAZING ILLUSIONS
Differences between individuals in the susceptibility to strange-face illusions are
relevant, as found in previous studies (Caputo, 2010b; Caputo et al., 2012). A simple measure
of susceptibility can be gauged by the number of different strange-face illusions that an
individual perceives during a session of mirror-gazing. A hypothesis is that these differences
are correlated to individual differences in empathic personality traits. This conjecture is akin
to the hypothesis that mirror self-recognition and expressions of empathy co-emerge in both
development and phylogeny (de Waal, 2008).
Differences in empathy between individuals have been explained by various
psychological theories (Eisenberg & Fabes, 1990). A widely accepted theory poses that
individual differences in empathy are produced by multi-factorial empathic personality traits.
The Interpersonal Reactivity Index (IRI) is a widely used multi-dimensional measure of trait
empathy, based on self-report. It consists of four subscales: Fantasy, Perspective-taking,
Empathic-concern, and Personal-distress (Davis, 1980, 1983). Empathic-concern and
Personal-distress measure affective responses of empathy but differ in their targets. Personal-
distress is self-oriented and associated to aversive emotional responses in the observer.
Empathic-concern is other-oriented and related to feelings of compassion and sympathy for
the observed individual. Perspective-taking and Fantasy measure cognitive responses of
empathy. Perspective-taking examines the tendency to think from another perspective.
 Empathy and Mirror-Gazing 387

Fantasy examines participants‘ abilities to transpose themselves into fictional situations (e.g.,
books, movies, daydreams).

(A)

(B)

Figure 2. (Continued).
388 Giovanni B. Caputo

(C)

(D)

Figure 2. Plotting the number of different strange-face illusions perceived by fifteen participants in
relation to the four empathic personality trait subscales of Interpersonal Reactivity Index (IRI).
Correlations were statistically significant for the Empathic-concern (r = .62; p < .015) and for the
Fantasy subscales (r = .66; p < .007).
 Empathy and Mirror-Gazing 389

A number of studies showed that inter-individual differences in personality traits of

affective and cognitive empathy, measured with IRI, are correlated with differences in
regional brain activity (Singer et al., 2004; Saarela et al., 2006; Jabbi et al., 2007; Schulte-
Ruther et al., 2007; Costantini et al., 2008; Zaki et al., 2009; Decety et al., 2010; Klimecki et
al., 2013). Banissy et al. (2012) found correlations between individual differences in
anatomical brain volumes and differences in empathy traits; these correlations were specific
to different brain areas for each trait.
Thus, one could hypothesize that differences of empathic personality traits, measured
with IRI, and differences in susceptibility to strange-face illusions during mirror-gazing may
be associated. In Figure 2, the results are plotted of a research aimed to investigate this
hypothesis (see Appendix for methods). The results show that inter-personal differences in
the number of strange-face illusions are correlated to personality traits of both Fantasy
subscale cognitive empathy and Empathic-concern subscale of affective empathy.
The correlation of strange-face illusions with the Empathic-concern subscale of IRI can
reflect individual differences in vulnerability to contagion and mimicry (Sonnby-Borgstrom,
2002; Saarela et al., 2006; Schulte-Ruther et al., 2007; Decety et al., 2010). The correlation of
strange-face illusions with the Fantasy subscale of IRI might reflect individual differences
vis-à-vis cognitive empathy. The current view is that perspective-taking and fictional
imagination are involved in cognitive processing (Decety & Chaminade, 2003; Jabbi et al.,
2007; Costantini et al., 2008; Zaki et al., 2009; Klimecki et al., 2013). However, cognitive
empathy indexes the subject‘s theory of the mind of the empathized other suggesting that
cognitive empathy probably does not adequately explain strange-face illusions.
Another explanation is that individual differences in strange-face illusions are produced
by different degrees of permeability of the self-boundary (Feinberg, 2010), which, as
hypothesized before, can be correlated to ‗projection‘ of dysmorphic faces according to a
dynamic balance between inclusion into the subject‘s self and dissociation of the strange
other.
An alternative explanation is that mirror-gazing under low illumination for a long time at
the one‘s own face can on the other hand engage ‗mind wandering‘ and fantasy, through the
brain‘s default network and the decrease of externally focused attention (D‘Argembeau et al.,
2005; McKiernan et al., 2006; Mason et al., 2007; Christoff et al., 2009; Stawarczyk et al.,
2011). Personal differences in strange-face illusions can result both from higher activity in the
brain‘s default network or from lower inhibitory control associated with conscious and more
externally directed attention. The findings of archetypal faces, monstrous faces and animal
faces during mirror-gazing – a true ‗theatre of mind‘ animated by ‗multiple selves‘ – seem to
demonstrate the ‗projection‘ of unconscious contents into faces of the external world (in
particular, the subject‘s mirrored image).
In conclusion, strange-face illusions, despite their lack of obvious connection to empathic
phenomena, may provide both an ecological setting and an experimental technique to
investigate affective and cognitive components of empathy.

APPENDIX
Participants. Fifteen healthy volunteers (six men and nine women; mean age 23.7 years,
st.dev. 5.4) participated in the experiment. They were recruited through public advertisement
390 Giovanni B. Caputo

from the scientific faculties of the university (no students of psychology were employed).
They were naïve observers, unaware of the aim of the research. They had never participated
before to psychological studies. They declared no psychiatric disorders.
Assessment of empathy personality traits. Each participant completed the Interpersonal
Reactivity Index (IRI). It consists of four subscales: Fantasy, Perspective-taking, Empathic-
concern, and Personal-distress (Davis, 1980, 1983). Each subscale contains seven items. They
are measured on a five-point Likert-scale ranging from 0 (―Does not describe me well‖) to 4
(―Describes me very well‖). For each subscale, a minimum score of 0 or maximum score of
28 is possible.
Setting. The experiment was conducted in a 4 m x 4 m room, quiet and without external
light. The walls of the room were white and the floor was mid-clear gray. The mirror
measured 0.5 m x 0.5 m. It had no frame and was supported on a tripod. The mirror was
placed in the centre of the room, at a distance of 0.4 m in front of the observer who was
seated in a chair. This setting produces an impression of isolation of the observer‘s reflected
image. A halogen lamp (Osram 12V, 10W) provided a fixed beam illumination. The spotlight
was placed about 0.7 m from the back of the chair and 0.6 m from the nearest wall. The
spotlight beam pointed towards the floor (at a distance of about 7 cm from the floor) in such a
way to produce only indirect, diffuse and relatively uniform lighting within the room.
Illumination of the face was 0.6 lux, measured by a digital photometer with a wide-angle
sensor (Pantec by Carlo Gavazzi, LM-20). In order to measure face illumination, the
photometer sensor was placed in contact with the observer‘s face and pointed towards the
mirror.
Procedure. Immediately after completing IRI, the participant received instructions for the
mirror-gazing task. Written instructions were the following: ―You should maintain a neutral
facial expression. Your task is to gaze at your face. You should fixate your eyes reflected in
the mirror. The session lasts 10 minutes. At the end of the session I will ask you to describe
what you have perceived with respect to your face.‖ The participant, after a few minutes of
light adaptation, performed a 10 minute session of mirror-gazing. At the end of the session,
participants were asked to give a description of their phenomenological experience (―What
did you see?‖); they were invited to compile a written list as detailed as possible. The
descriptions were classified according to categories found in previous studies (Caputo,
2010a). For each participant, the total number of different strange-faces was counted.
Statistical analyses. Kolmogorov-Smirnov test showed that IRI subscales (Z < .84, p >
.48) and number of different strange-face illusions (Z = .90, p = .39) were normally
distributed. Pearson correlation and Cronbach  were used for statistical analyses. Hereunder,
all data are expressed as means  SEM.
Results. Scores of IRI subscales were the followings: Fantasy 16.47 .97; Perspective
Taking 15.67  1.02; Empathic Concern 18.73  1.11; Personal Distress 12.33  1.27. Scores
were consistent with previously published norms for this measure (Davis, 1980). Correlations
between IRI subscales were non significant.
All participants perceived strange-face illusions. They reported to never had previously
experienced similar effects during mirror-gazing. The number of different strange-faces
ranged from 2–7 among participants. The mean total number of different strange-faces was
4.0  .38 per 10 minutes of mirror-gazing. Classification of phenomenological descriptions
showed that illusions were deformed facial traits (reported by 15 out of 15 participants), other
 Empathy and Mirror-Gazing 391

persons (8 out of 15), archetypes (7 out of 15), animals (2 of 15) and monstrous beings (6 out
of 15). None of the participants identified themselves with strange-faces.
Correlations between number of different strange-faces and IRI subscales were
significant for the Fantasy subscale (r = .66; p < .007;  = .62) and for the Empathic-concern
subscale (r = .62; p < .015;  = .55). The correlation between the number of different strange-
faces and the Personal-distress subscale was statistically not significant (r = .05; p = .86) nor
the correlation between the number of different strange-faces and the Perspective-taking
subscale (r = .23; p = .40).

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In: Psychology and Neurobiology of Empathy ISBN: 978-1-63484-446-8
Editors: Douglas F. Watt and Jaak Panksepp © 2016 Nova Science Publishers, Inc.

Chapter 15

COMPETING FACTOR STRUCTURES FOR

THE TORONTO EMPATHY QUESTIONNAIRE

Carlo Chiorri *

Department of Educational Sciences, Psychology Section,

University of Genova, Genova, Italy
Psyche-Dendron Association, Milano, Italy

ABSTRACT
The Toronto Empathy Questionnaire (TEQ, Spreng et al., 2009) has been proposed
as a short but comprehensive measure of empathy, with sound psychometric properties
such as internal consistency, test-retest reliability, construct validity and
unidimensionality. This chapter presents four studies that assessed the psychometric
properties of the Italian version of the TEQ. In general, results supported the reliability
(both as internal consistency and temporal stability) and construct validity of the scale, as
found in previous studies, but not its unidimensionality. Results from exploratory factor
analysis showed that a two-factor solution accounted for a substantially higher proportion
of variance and provided a neat simple structure (Study 1). The two factors clustered
straight and reverse items (Empathy and Callousness) and in Study 2 fifteen confirmatory
factor analysis models specifying either two substantively important trait factors, one trait
factor and ephemeral method artifacts associated with straight and reverse items or one
trait factor and stable response-style method factors associated with item wording were
tested. Results supported the findings of Study 1, since a model with two (moderately)
correlated factors defined by straight and reverse items had an excellent fit to observed
data. Results of Study 3 supported the discriminant validity of the two constructs, since
the Empathy score was significantly more associated than the Callousness score with a
measure of appraisal and perception of emotions (a facet of trait emotional intelligence
that includes empathy), whereas Study 4 provided evidence of test-retest reliability of
total and subscale scores. Taken together, the results presented in this chapter seem to
advise against the use of a single TEQ score and to suggest the computation of two

*
Contact details: Carlo Chiorri, PhD; Department of Educational Sciences, Psychology Section. University of
Genova; Corso A. Podestà, 2; 16128 Genova (Italy). e-mail: carlo.chiorri@unige.it; Tel. +3901020953726/
+3901020953726; Tel. direct +3901020953709; Fax +3901020953728.
400 Carlo Chiorri

subscale scores for the straight and the reverse items, although further research is needed
to investigate the replicability and generalizability of these findings in other cultural
contexts.

INTRODUCTION
Empathy is a key component of social cognition and contributes to the individual‘s
ability to understand and respond adaptively to others‘ emotions, succeed in emotional
communication, and promote prosocial behavior (e.g., Spreng, McKinnon, Mar, & Levine,
2009). The concept can be traced back to Aristotle (Rhetoric III.2.1411b), but the
psychological phenomena which it accounts for were observed and recorded in the eighteenth
century by several critics and philosophers in isolated passages (Thorpe, 1937). Apparently
(see Fogle, 1946), its first extended formulation was provided by Lotze (1858), to whom it
was a phenomenon which accounted for our knowledge of the external world. The German
term used by Lotze was Einfühlung, which literally means ―feeling into.‖ From a
psychological point of view, Lipps (1903) was one of the main contributors to the modern
definition of empathy, since he systematically organized the concept (Wispé, 1986). He
defined it as the tendency for the perceivers to project themselves into the objects of
perception and developed a mechanistic account of Einfühlung, in which the perception of an
emotional gesture in another directly activates the same emotion in the perceiver, without any
intervening labeling, associative, or cognitive perspective-taking processes. Titchener (1909)
translated the German term into English as ―empathy,‖ trying to preserve the idea of the self
projected into the perceived object by using a word that recalled the Greek empatheia, which
means ―passion, state of emotion,‖ from en (―in‖) and pathos (―feeling‖). As noted by Wispé
(1986), Titchener did not provide a neat definition of empathy, but he harbingered two
different concepts of empathy: a way of knowing another‘s affect and a kind of social-
cognitive bonding. Since then, the concept empathy has had a history of disagreement and
discrepancy (Preston & de Waal, 2002). In the last century research on empathy has
flourished in a number of different disciplines, including philosophy, theology,
developmental, social, clinical, counseling and personality psychology, ethology,
evolutionary science and medicine (for a review see Gerdes, Segal, & Lietz, 2010; Wispé,
1986, 1987), and lately the discovery of the so-called ―mirror neurons‖ (Di Pellegrino,
Fadiga, Fogassi, et al., 1992; Iacoboni, 2009) has triggered a new surge of interest. Despite
the remarkable consistency of empirical data across a wide range of species (see, e.g., Preston
& de Waal, 2002), the concept still suffers from a lack of consensus regarding its nature. As
reported by Preston and Hofelich (2012), the common terms in the empathy literature are:
Cognitive empathy (understanding the other by engaging one‘s own representations through
effortful top–down processes), Emotional contagion/Affective resonance (subjectively feeling
the same emotion or state as the other, usually for intense emotional states), Empathic
accuracy (correctly identifying and understanding the state of the other), Self-other overlap
(correspondence between observer and target. Neural-level overlap occurs when the observer
uses personal representations of experience to understand the target. Subjective overlap
occurs when these representations activate related feelings, which are then shared between
target and observer), Sympathy (Tender hearted feelings of compassionate concern, feeling
―sorry for‖ the other, but see Wispé, 1986), True empathy (a compassionate, other-oriented
 Competing Factor Structures for the Toronto Empathy Questionnaire 401

state that requires a distinction in the observer between self and other), with the very term
Empathy being what they called an ―umbrella‖ term for states of feeling ―with‖ or resonating
with the other, which can occur at any level, either neural phenomenological, conceptual or
affective.
Watt (2005, p. 187) pointed out that ―there has been endless hair-splitting in various
psychological literatures about the possible distinctions one might draw between the terms
compassion, sympathy, and empathy,‖ and argued that such finely nuanced distinctions were
of little usefulness from an empirical neuroscience point of view. Traditionally, the
definitions of empathy focused on either cognitive or affective issues. On the one side,
empathy is seen as dependent upon perspective taking, perception of affective states and
conscious imitation, i.e., emotion recognition, but this definition appears to be more
consistent with the concept of theory of mind (ToM), and it is rather a component of empathy,
not to be mistaken for empathy itself. For instance, psychopathy is usually identified by
characteristics such as a lack of empathy, but research has shown that individuals with
psychopathic traits not only can recognize emotional pain in others, but can be even more
able than most people in this regard (e.g., Fecteau, Pascual-Leone, & Théoret, 2008) and can
use this ability to manipulate others. From such an affective perspective, empathy is seen as
dependent upon the drive to respond with an appropriate emotion to someone else‘s mental
states. However, several studies have shown that affective empathy may be intact in
individuals, such as those with autism or Asperger syndrome, with difficulties in emotion
recognition (e.g., Rogers, Dziobek, Hassenstab, et al., 2007). Individuals with such deficit
struggle to understand others‘ motives, intentions and behaviour and tend to avoid
relationships, finding them confusing, but, differently from psychopaths, rarely hurt others.
Watt (2007) suggested that a more comprehensive definition of empathy should bring
together several processes of considerable complexity that bridge the domains of cognition
and emotion, i.e., a fundamentally positive and nurturing attitude toward another creature,
ToM and perspective-taking operations, contagion mechanisms that allow the individual to
―sample‖ the suffering of the other via a primitive induction mechanism that makes primary
emotions ―catchy‖ and affective regulation abilities such that the suffering of the other party
does not flood the individual. Watt (2005, 2007) concluded that human empathy probably
reflects variable admixtures of more primitive affective resonance mechanisms, melded with
developmentally later-arriving ToM and perspective taking. This integration of primitive with
more cognitive mechanisms occurs under the ―supervision‖ of a motivated valuing of another
sentient creature, a supervision that underlines intrinsic associations between empathy and
attachment processes.
Watt (2007) also cautioned not to confuse contagion and conscious imitation of emotion,
which are sometimes conflated in cognitive neuroscience literature (e.g., Carr, Iacoboni,
Dubeau, et al., 2003). While the former is automatic, ancient, and fast, and probably largely
subcortical, the latter is slow, effortful, requires cognitive development, cortex, and it is more
recent. Preston and de Waal (2002) consider contagion ‗on a border with empathy,‘ but
emotional empathy appears to depend on resonance inductions (contagion) and concern for
the other and their potential suffering (Watt, 2005). If one function of empathy is to promote
social interaction and motivate prosocial behavior (e.g., Batson, 1991; Davis, 1994), prosocial
aspects of empathy cannot be separated from this resonance induction as a mechanism for
understanding other persons‘ internal world and affective state. The state of suffering induced
by resonance is not supposed to flood the individual, but it can trigger a helpful or comforting
402 Carlo Chiorri

response, for which the empathizer‘s affective regulation and self-other differentiation must
be intact (e.g., Decety & Jackson, 2004). Moreover, there must be a fundamentally positive
affective stance towards the sufferer, in terms of the intrinsic motivation to somehow relieve
suffering. This does not mean that empathy requires only simple contagion, but basic
contagion may be considered as core component of empathy, melded with emotion
identification (Watt, 2005, 2007) and other later arriving functions including stable self-other
boundary and affective regulation.
The variety of definitions is inevitably reflected in the variety of existing measures of
empathy (self-report, observational, physiological, etc.), which have been recently reviewed
by Gerdes et al. (2010). Operational definitions of empathy have extended from a process-
oriented definition (Preston & de Waal, 2002) to a clear separation of the emotional form of
empathy from the cognitive form of mentalizing (Knafo, Zahn-Waxler, Van Hulle, et al.,
2008; Singer, 2006). As for self-report measures, the most widely used focus on both the
cognitive and affective components of empathy (e.g., the Interpersonal Reactivity Index,
Davis, 1983; the Empathy Quotient, Baron-Cohen, & Wheelwright, 2004; the Basic Empathy
Scale, Jolliffe & Farrington, 2006), although others only focus on only the cognitive (e.g., the
Empathy Scale, Hogan, 1969) or the affective component (e.g., the Questionnaire Measure of
Emotional Empathy, Mehrabian & Epstein, 1972). Grounding on existing self-report measure
of empathy, Spreng et al. (2009) sought to derive a unidimensional tool for empathy research
that could complement multifactorial approaches, the Toronto Empathy Questionnaire (TEQ).

DEVELOPMENT OF THE TEQ AND ADAPTATIONS

IN OTHER LANGUAGES

The TEQ was developed by selecting items from the (then) available measures related,
even tangentially, to the self-report of empathic processes or the assessment of deficits in
empathic ability. Several established self-report empathy measures were used, and the initial
pool included 142 items: 28 from the Interpersonal Reactivity Index (Davis, 1983), 15 from
the Hogan‘s Empathy Scale (Hogan, 1969), 9 from the Questionnaire Measure of Emotional
Empathy (Mehrabian & Epstein, 1972), 12 from the Balanced Emotional Empathy Scale
(Mehrabian, 2000), 4 from the Scale of Ethnocultural Empathy (Wang, Davidson, Yakushko,
et al., 2003), 6 from the Jefferson Scale of Physician Empathy (Hojat, Magione, Gonnella, et
al., 2001), 8 from the Nursing Empathy Scale (Reynolds, 2000), 10 from the Japanese
Adolescent Empathy Scale (10 items; Hashimoto & Shiomi, 2002), 3 from the Emotional
Intelligence Scale (Schutte, Malouff, Hall, et al., 1998), 4 from the Dysexecutive
Questionnaire (Burgess, Alderman, Evans, et al., 1996), 7 from a measure of emotion
comprehension (Hornak, Rolls & Wade, 1996) and 36 were newly developed on the basis of
the literature concerning individuals with altered empathic responding due to neurological or
psychiatric disease. Items were reworded to ensure consistency and assess frequency of
behavior rather than to pose general statements or tendencies, so that responses could be
provided on a 5-point, Likert-type frequency scale (i.e., never, rarely, sometimes, often,
always).
The items were administered to a sample of 200 undergraduate students and data were
analyzed through exploratory factor analysis forcing items to load onto a single factor. To be
 Competing Factor Structures for the Toronto Empathy Questionnaire 403

retained in the scale, items ought to have corrected item-total correlations higher than .30, to
improve internal consistency (as indexed by the alpha without the item statistic) and/or to
load substantively (>.40) on the single factor. As a result, 16 items were selected to form the
TEQ shown in Appendix along with its Italian translation (see below for the translation
procedure). Spreng et al. (2009) claimed that these items represent a wide variety of empathy-
related behaviors that have been described in relevant literature surrounding this process. The
attributes encompassed by the items are emotional contagion, emotion comprehension,
sympathetic physiological arousal, con-specific altruism, and engagement in higher order
empathic responding such as prosocial helping behaviors.
In their seminal work, Spreng et al. (2009) carried out three studies on undergraduate
students and found that TEQ scores correlated positively with some IRI subscales (Empathic
Concern, Perspective Taking, Fantasy), with behavioral measures of social comprehension
and interpersonal sensitivity and with the Empathy Quotient (Baron-Cohen & Wheelwright,
2004), and negatively with the Autism Quotient (Baron-Cohen, Wheelwright, Skinner, et al.,
2001). The TEQ always showed high (>.85) internal consistency, high (>.30) corrected item-
total correlations and high (>.40) factor loadings on the single factor. Dimensionality
analyses, carried out examining the scree plot and using parallel analysis (Horn, 1965) and
Velicer‘s minimum average partial correlation statistic (Velicer, 1976), suggested that the
TEQ comprised a single factor. Test-retest reliability was also adequate (r = .81, no
significant difference in scores of a second administration more than two months after the
first). Women scored significantly higher than men in two out of three studies.
It has been argued that the TEQ is mainly a measure of emotional empathy (Gerdes et al.,
2010), but Spreng et al. (2009) noted that while a focus on the emotional components of
empathic responding in the TEQ is consistent with the approach taken by other researchers in
developing self-report measures of empathy, the score correlated also with the IRI subscales
of Perspective Taking and Fantasy, which have been described as the cognitive components
of empathy (Davis, 1983).
So far, there have not been many studies that further investigated the psychometric
properties of the TEQ. It has been translated into Turkish (TEQ, Totan, Doğan & Sapmaz,
2012) and French (TEQ, Lelorain, Sultan, Zenasni, et al., 2013). The Turkish adaptation
enrolled 698 undergraduate students, and both item analysis and factor analysis found that
three items (1, 6 and 9) did not have an adequate (>.30) corrected item-total correlation, nor a
substantial (>.30) factor loading on the single factor. The authors decided to exclude them
and to perform validity and reliability studies of the TEQ on a 13-item measure. They fitted
both exploratory and confirmatory factor analysis models, and to reach what they reckoned an
adequate fit they had to free the correlation among the error variances of items 8 and 13.
Validity analyses showed positive correlations of TEQ with the total score and the cognitive
and affective subscores of the Basic Empathy Scale (BES, Jolliffe & Farrington, 2006) and
with the Empathic Tendency Scale (ETS, Dökmen, 1988). Adequate test-retest reliability (r =
.73, three-week interval) and higher scores in women were also found. The French study does
not report any translation procedure nor other psychometric properties of the scale, since it
aimed at investigating the unique contribution of physician practice-related variables (i.e.,
consultation length, clinical experience, etc.) to clinical empathy beyond the contribution of
empathic concern, which was assessed through the TEQ.
404 Carlo Chiorri

POSSIBLE WORDING DIRECTION EFFECTS IN THE TEQ?

The items excluded in the Turkish TEQ since they did not contribute to
unidimensionality and those whose error variances were allowed to correlate in the
confirmatory factor analysis model were all ―straight‖ items, i.e., items keyed in the same
direction of the construct intended to be measured  so that higher scores on the items
correspond to higher levels of the psychological variable (also referred to as positively
worded items or straight worded items)  as opposed to ―reverse‖ items, i.e., items keyed in
the opposite direction of the construct intended to be measured − so that higher scores on the
item correspond to lower levels of the psychological variable (also referred to as negatively
worded items or reverse worded items). The TEQ is composed of eight straight and eight
reverse items, with the latter supposed to reflect the frequency of situational indifference
toward another individual on the theoretical parameters of empathy (Spreng et al. 2009).
Handbooks of psychometrics (e.g., Nunnally & Bernstein, 1994, Coaley, 2010) usually
suggest to include both straight and reverse items in typical performance measures (i.e.,
measures of attitudes, beliefs, personality, psychopathology, etc.) to reduce or detect the
tendency for respondents to agree more than disagree (the so-called acquiescence bias), to
respond according to their general feeling about the subject rather than the specific content of
the items (the so-called response set bias) and, eventually, to identify careless responding
(Meade & Craig, 2012), and this strategy appears to be more effective when the scale consists
of an equal number of regular and reverse items (Baumgartner & Steenkamp 2001), as it is
the case of the TEQ. The rationale of the use of reverse items is that they should act as
cognitive ―speed bumps‖ (Podsakoff, MacKenzie, Lee, & Podsakoff, 2003, p. 884), making
respondents to engage in more controlled, as opposed to automatic, cognitive processing of
the item content, and they help in broadening the coverage of the content domain of the
construct and enhance the prediction of other constructs (Tourangeau, Rips, & Rasinski,
2000).
Some authors (e.g., Schriesheim & Eisenbach, 1995; Schriesheim, Eisenbach & Hill,
1991; Weijters & Baumgartner, 2012) pointed out distinctions among types of reverse items,
classifying them as ―polar opposites,‖ ―negated regular,‖ and ―negated polar opposites.‖ For
instance, item 7 of the TEQ is a polar opposite (―When a friend starts to talk about his/her
problems, I try to steer the conversation towards something else‖) along with 4, 11 and 15,
whereas item 14 is a negated regular (―When I see someone being treated unfairly, I do not
feel very much pity for them‖), along with 2, 10 and 12 (see Appendix). There are no negated
polar opposites in the TEQ  an example might be ―When a friend starts to talk about his/her
problems, I do not try to steer the conversation towards something else.‖
Naïvely, one may assume that reverse items are simply opposites of straight items, and
that their correlation, once disattenuated for measurement error, should approach 1.00, since
they can be thought to lie on the same continuum, representing opposite poles of it. However,
research has shown that is might not be the case, not only in psychometrics, but also in other
disciplines of cognitive psychology (see., e.g., Savardi, 2009). In fact, even when properly
designed, reverse items may produce artifactual response factors consisting exclusively of
negatively worded items that may disappear after the reverse-coded items are rewritten in a
positive keying (see, e.g., Nunnally & Bernstein, 1994). Schmitt and Stults (1986) argued that
the biasing effects of reverse items may occur because, once respondents establish a pattern
 Competing Factor Structures for the Toronto Empathy Questionnaire 405

of responding to a questionnaire, they may fail to attend to the positive-negative wording or

meaning of the items. This seems especially true for children (Benson & Hocevar, 1985),
preadolescents (Marsh, 1986), students (Barnette, 1996), and adults with lower educational
levels (Melnick & Gable, 1990). More detailed reviews on biases due to reverse items and the
psychological mechanisms underlying misreponse to reverse and negated items can be found
in Barnette (2000) and Weijters and Baumgartner (2012).
From a psychometric point a view, reverse items often have lower corrected item-total
correlations than regular items, and as a result, scales containing reverse items tend to have
lower reliability (e.g., Schriesheim et al., 1991). For instance, Chamberlain and Cummings
(1984) compared reliabilities for scores on two forms of a course evaluation instrument and
found that score reliability was higher when all positively worded items were used.
Schriesheim and Hill (1981) tested three alternative forms of a questionnaire (all straight
items, all reverse items, and mixed) in terms of internal consistency and mean scores and
found that reverse items, when mixed with reverse items, yielded significantly lower internal
consistency and mean scores. Also the functioning of response categories may depend on the
wording direction of the items (Rennie, 1982; Yamaguchi, 1997). Using a Rasch model
approach, Chiorri, Anselmi and Robusto (2009) found that in the Rosenberg‘s Self-Esteem
Scale (Rosenberg, 1965) straight and reverse items were different in affectivity and in the
functioning of rating scale categories. In other words, same scoring categories defined
amounts of the latent variable that differed between straight and reverse items, and therefore
they had a different probability of being observed.
In factor analyses reverse items may load on additional wording factors when as few as
10%-20% of the respondents fail to recognize that some items are reverse coded, thus
contributing to a poorer fit of a single-factor confirmatory model factor with reverse items (or
sometimes straight items) often exhibiting smaller factor loadings (Huang, Curran, Keeney,
Poposki, & DeShon, 2012; Schmitt & Stults, 1986; Woods, 2006). In some cases, reverse
items may even distort the factor structure and lead to the erroneous specification of multiple
substantive factors based on sets of items varying in their coding direction (e.g., Marsh 1996).
Benson (1987) and Pilotte and Gable (1990) found different response patterns and factor
structures for all-straight, all-reverse and mixed forms of their scales, which could result in
different score interpretations. Consistently, Knight, Chisholm, Marsh and Godfrey (1988)
reported that straight and reverse items loaded on separate factors on the revised UCLA
loneliness scale, and the same was found by Billiet and McClendon (2000) on a questionnaire
of ethnic prejudice, and by Rodebaugh, Woods and Heimberg (2007) on a measure of social
anxiety. Weijters, Geuens and Schillewaert (2009) manipulated the proximity and the nature
of the conceptual relationship between the items within a questionnaire and examined their
effects on the strength of the correlation between the items, and they found correlations
become weaker for straight items and stronger for reverse items the further items were
positioned from each other. Hence, even the distribution of straight and reverse items within
the scale appears to be able to affect the factor structure, since both internal consistency and
factor structure depend on correlations among item scores.
These findings lead some authors to argue against the use of reverse items in
measurement scales (e.g., DeVellis 2003), whereas others still support it, although with some
caution (see recommendations in Weijters & Baumgartner, 2012, p. 744). If turning down
reverse items can lead to a better reliability and a simpler factor structure, such results might
also be the outcome of a set of items that are minor and redundant variations of the same
406 Carlo Chiorri

basic question (Weijters et al., 2009), and therefore are all highly intercorrelated without
being a comprehensive and representative sample of the content domain of the construct they
are supposed to measure. Moreover, items that all share the same coding direction may give
rise to their own systematic method biases (e.g., responses may be biased in the direction in
which the items are worded), to the extent to method variance is completely confounded with
content variance and becomes undetectable. As shown above, items can be reversed in
various ways: Schriesheim et al. (1991) and Schriesheim and Eisenbach (1995) found that
there were differences between the types of reverse items, with negated polar opposite items
appearing to be the least valid. This is hardly surprising, since double negations in wording
are known to produce ambiguities in item understanding and handbooks suggest not to use
them (see, e.g., Janda, 1998).

AIMS OF THE RESEARCH PRESENTED IN THIS CHAPTER

The research presented in this chapter aimed at assessing, through a series of four studies,
the psychometric properties of the Italian version of the TEQ. Internal consistency, test-retest
reliability and construct validity were assessed, but the main focus was on TEQ factor
structure, and on whether measurement models specifying either two substantively important
trait factors (in this case, positive and negative empathy), one trait factor and ephemeral
method artifacts associated with straight or reverse items or one trait factor and stable
response-style method factors associated with item wording can provide an adequate
explanation of item responses. This case appears analogous to that of the Rosenberg Self-
Esteem Scale (Rosenberg, 1965), for which there is an ongoing and yet unresolved debate
about the factor structure underlying responses to its items (for reviews and recent results, see
Chiorri, et al., 2009, and Marsh, Scalas & Nagengast, 2010). In Study 1 the Italian TEQ has
been administered to a large online sample to investigate its factor structure, its reliability,
and the association of TEQ score with socio-demographical variables, an issue that could not
be adequately addressed by Spreng et al. (2009) and Totan et al. (2012), since their samples
were entirely composed of university students. In Study 2 the TEQ was administered to a
large community sample in its paper-and-pencil version to test alternative measurement
models that included trait factors, ephemeral method artifacts associated with straight and
reverse items and stable response-style method factors associated with item wording. In Study
3 the TEQ was administered in a battery including with well-established measures of
emotional intelligence, alexithymia, positive and negative affect, personality and social
desirability to test its construct validity and whether subscales defined by straight and reverse
items had a different patterns of correlations with such measures. In Study 4 the temporal
stability of TEQ scores was assessed by administering the scale twice at a 4-week interval.

Study 1

In Study 1 TEQ was administered to a large online sample to investigate its factor
structure, its reliability, and the association of TEQ score with socio-demographical variables.
According to previous studies, the total score should be higher in women (e.g., Spreng et al.,
 Competing Factor Structures for the Toronto Empathy Questionnaire 407

2009), have an inverse-U-shaped pattern across the adult life span (O‘Brien, Konrath, Grühn
& Hagen, 2013) and decrease with education (Kraus, Côté, & Keltner, 2010).

Participants
An online survey was developed through the Limesurvey (www.limesurvey.org) software
following the suggestions of Couper, Traugott and Lamias (2001). The author and his
assistants emailed the link to the survey their contacts, provided that they were at least 18
years old. Participants received an email invitation that included a short description of the
study and an access token randomly generated by the software. To gain access to the website,
they had to click their unique study identification link. To maintain anonymity, authors did
not know participants‘ identification links. Once logged in, participants were presented with a
detailed description of the procedure. To be allowed to answer the inventory, they had to
answer ―Yes‖ to a question asking whether they accepted participation in the study. The
website was visited by 1308 contacts between July 2009 and November 2010. Eighty-six
(6.6%) participants were excluded since did not provide any answer, failed to complete the
TEQ and/or reported that they had received a psychiatric diagnosis, while the remaining 1222
participants provided a complete set of valid answers to the socio-demographical schedule
and to TEQ items. Characteristics of the sample are shown in Table 1.

Table 1. Demographics of the samples used in the Italian validation of the Toronto
Empathy Questionnaire

Study 1 Study 2 Study 3 Study 4

(n = 1222) (n = 393) (n = 71) (n = 56)
Female (%) 68 42 72 55
Age (years) MDS 32.25+9.90 35.21+15.57 24.42+7.95 38.84+14.83
(range) (18-73) (18-93) (19-59) (18-64)
Education (years) 13.76+3.19 13.52+3.04 15.49+1.80 13.64+2.68
MDS (range) (5-21) (5-21) (13-22) (8-18)
Occupational status (%)
Occupied 70.6 38.4 19.7 62.5
Unoccupied 8.0 4.3 0.0 0.0
Student 18.8 43.8 80.3 32.1
Housewife 1.7 5.1 0.0 1.8
Retired 0.7 8.4 0.0 3.6
Marital Status (%)
Single 61.1 59.8 90.1 42.9
Married/Coliving 30.3 33.6 5.6 51.8
Separated/Divorced 8.3 4.3 2.8 3.6
Widow/er 0.2 2.3 1.4 1.8

Materials and Procedure

Participants had to fill in a socio-demographical schedule including questions on gender,
age, educational level, marital status, and occupation, and the TEQ. The Italian version of the
TEQ was developed through a mixed forward- and back-translation procedure (Behling &
Law, 2000). A lecturer of psychology and a psychology student fluent in English
408 Carlo Chiorri

independently translated the English version of the TEQ into Italian. After consensus among
translators was achieved, an Italian-English person, blind to the original version, translated
this preliminary version back into English. Discrepancies were discussed among the
translators and with the original authors (N. Spreng) until an agreement on a common version
was reached. The final Italian version of the TEQ is reported in the Appendix.
On the website, the socio-demographical schedule and the TEQ were presented on
separate full-page layouts such that participants could view each page of the questionnaire by
scrolling up or down. To avoid random responding, they were not required to answer all
items.

Results
Item descriptive statistics showed a negative skewness for straight items (median =
.029, range 0.57-0.07) and a positive skewness for reverse items (median = 0.55, range
0.15-0.88). Kurtoses of all items ranged between 0.55 and 0.23, suggesting that the
departure from normality of item distributions was not substantial, i.e., both skewness and
kurtosis were in the [1, +1] range recommended by Muthén and Kaplan (1985).
The issue of determining the number of factors to extract in an exploratory factor analysis
was addressed by performing dimensionality analyses on the Pearson correlation matrix of
TEQ items through Scree-plot, Parallel Analysis (PA, Horn, 1965) and Minimum Average
Partial Correlation statistic (MAP; Velicer, 1976) and. On the basis of the recommendations
of Buja and Eyuboglu (1992), PA was performed on 1000 random correlation matrices
obtained through permutation of the raw data and following Longman, Cota, Holden, and
Fekken (1989) both the mean eigenvalues and the 95th percentile eigenvalues ere considered.
These analyses were performed with SPSS 13.0 using O‘Connor (2000)‘s syntaxes. The
Scree-plot suggested that eigenvalues began to level off after two factors, PA suggested to
extract 2 factors when both mean and 95th percentile were considered and MAP reached its
lowest value at two factors (Figure 1).
Exploratory factor analyses (EFAs) were performed using Principal Axis Factoring ,
setting to one and two (Promax rotation) the number of factors to extract. Results are shown
in Table 2.
The two models accounted for 21.7% and 35.3% of total variance, respectively. Although
the factor loadings in the 1-factor solution were consistent with previous research and
expectations (only three items with a factor loading smaller than |.30|), the 2-factor solution
provided a simple structure and, for some items, substantially higher communalities. The
correlation of factor scores in the 2-factor solution was .24.
Taken together, these results seemed to suggest that a two factor solution, in which
straight and reverse items loaded on different factors, should be preferred to a 1-factor
solution. The two factors will be now referred to as Empathy and Callousness. Empathy is
intended as inclination to think or feel alike someone else and the act or capacity of entering
into or sharing the feelings or interests of another, whereas Callousness as disregard for the
feelings and well being of others, tendency to despise other people, and cynism.
 Competing Factor Structures for the Toronto Empathy Questionnaire 409

Figure 1. Scree plot of the eigenvalues for Study 1 (n = 1222) exploratory factor analysis and randomly
permuted raw data. MAP = Minimum Average Partial correlation statistic (Velicer, 1976).

Table 2. Exploratory factor analysis on the online Toronto Empathy Questionnaire data
in Study 1 (n = 1222): factor loadings () and communalities (h2) for the 1- and 2-factor
solution. Factor loadings higher than |.30| are bolded for ease of interpretation

Model
TEQ item 1-factor 2-factor
 h2 1 2 h2
teq01 .27 .07 .47 .15 .19
teq03 .39 .15 .45 -.01 .20
teq05 .61 .37 .60 -.12 .43
teq06 .47 .22 .49 -.07 .26
teq08 .31 .09 .51 .15 .23
teq09 .43 .19 .56 .05 .30
teq13 .49 .24 .51 -.07 .29
teq16 .51 .26 .56 -.04 .34
teq02 -.42 .17 -.04 .50 .27
teq04 -.43 .18 -.06 .49 .26
teq07 -.34 .12 .01 .46 .21
teq10 -.27 .08 .10 .48 .21
teq11 -.29 .08 .12 .52 .25
teq12 -.42 .18 -.01 .55 .31
teq14 -.42 .18 -.04 .50 .27
teq15 -.31 .10 .02 .42 .18

Mean inter-item correlation was .16 (range -.11-.42) for the total scale, .27 (range .
18-.42) for Empathy and .24 (range .16-.34) for Callousness. Mean corrected item-total
correlation was .34 (range .20-.50) for the total scale, .44 (range .35-.54) for Empathy and .40
(range .35-.47) for Callousness. Cronbach‘s alphas (s) and mean scores are reported in
Table 3.
410 Carlo Chiorri

Table 3. Crobanch‟s alphas (s) (95% confidence intervals), correlations of Empathy

with Callouness raw scores (rEC), and scale score means, standard deviations and range
for the whole samples and gender subsamples (F = Female, M = Male) for the Toronto
Empathy Questionnaire

Study 1 Study 2 Study 3 Study 4 - Time 1 Study 4 -

(n = 1222) (n = 393) (n = 71) (n = 56) Time 2 (n = 56)
Total scale .75 (.72-.78) .77 (.74-.80) .80 (.73-.83) .75 (.65-.85) .77 (.68-.86)
Empathy .74 (.72-.76) .70 (.65-.75) .76 (.68-.84) .73 (.61-.81) .75 (.63-.87)
Callousness .71 (.68-.74) .77 (.73-.81) .77 (.70-.84) .68 (.55-.71) .71 (.58-.84)
rECc -.219*** -.296*** -.339** -.328* -.307*
Total scale 62.97++5.74 63.36+6.74 64.68+6.02 63.80+5.74 63.50+5.95
(43-77) (41-78) (51-78) (54-76) (49-76)
Empathy 30.60++3.62 30.39+3.66 32.21+2.82 31.54+3.16 31.13+3.46
(18-39) (16-38) (25-38) (25-37) (22-39)
Callousness 15.63++3.73 15.02+4.67 15.54+4.45 15.73+3.87 15.63+3.90
(8-28) (8-36) (8-24) (8-24) (8-26)
Total scale F
Total scale M 63.35++5.65 63.59+7.22 65.02+6.28 65.19+5.92 65.26+4.92
(43-77) (41-77) (51-78) (54-76) (56-76)
Empathy F 62.15++5.85 63.19+6.37 63.00+4.37 62.08+5.10 61.32+6.48
(45-77) (42-78) (56-71) (54-72) (49-76)
Empathy M 30.94+3.55 30.56+3.86 32.25+2.79 32.06+3.01 31.94+2.98
(18-39) (16-38) (25-38) (25-37) (24-39)
Callousness F 29.87+3.67 30.26+3.51 32.00+3.07 30.88+3.27 30.12+3.80
(20-38) (21-38) (27-36) (25-36) (22-39)
Callousness M 15.59+3.68 14.96+4.63 15.24+4.69 14.87+3.92 14.68+3.46
(8-28) (8-36) (8-24) (8-22) (8-21)
* = p < .05, ** = p < .01, *** = p < .001.

Although item analysis statistics for the total scale appear to be adequate, those of the two
subscales defined by straight and reverse items support the hypothesis of the existence of two
distinct scales. Moreover, the Spearman-Brown prophecy would predict a Cronbach‘s  for
the 8-item scales of .60, which is significantly lower than the observed s.
Association of TEQ scores with socio-demographical variables was investigated through
multiple regression models in which total, Empathy and Callousness scores were regressed on
gender, the quadratic and linear component of age and years of education. Significant effects
of gender1 (gender = .08, p = .007) and of the linear component of age (age = .09, p = .003)
were found for the total score (R2 = .01), but neither the quadratic component of age nor years
of education were significant (agesq = .04, p = .117, edu = .00, p = .897). Both gender and
years of education were significant predictors of the Empathy scores (R2 = .02, gender = .15,
p < .001, edu = .07, p = .024), but no significant effect of age was found (agesq = .00,
p = .886, age = .06, p = .075). For Callousness, the linear component of age and education
were significant (R2 = .02, age = .17, p < .001, edu = .07, p = .019) whereas gender and the
quadratic component of age were only marginally significant (gender = .05, p = .103,
agesq = .05, p = .076).

1
A negative coefficient for gender indicates higher scores in women, given that the gender variable was coded as
Females = 0 and Males = 1.
 Competing Factor Structures for the Toronto Empathy Questionnaire 411

Discussion
The results of this study are partially consistent with previous research. The Italian
version of the TEQ showed adequate internal consistency and corrected item-total
correlations as in Spreng et al. (2009) and Totan et al. (2012), and the total score was higher
in females and tended to decrease with age. However, the results of factor analysis did not
seem to support the unidimensionality of the TEQ. Although the test of the unidimensionality
of a scale should take into account also other indices (see, e.g., Slocum-Gori & Zumbo,
2010), the results of the dimensionality analyses, the substantially higher proportion of
variance accounted for and the neat simple structure of the 2-factor EFA solution suggested
that a 2-factor model might be a better measurement model for the TEQ items. The two
factors clustered the straight and the reverse items of the scale, and on the basis of their
content they were labelled as Empathy and Callousness. If Empathy and Callousness were
simple opposites, the empirical evidence should have shown that were strongly negatively
correlated, but the results of this study indicated that their correlation was only moderate.
These two factors also showed a different pattern of association with socio-demographical
variables: while the former was higher in females and decreased with years of education, the
latter decreased with age and increased with years of education.
One potential limitation of this study was the internet administration of the TEQ. In the
last decade the benefits of online psychological research have been acknowledged and it has
been shown that internet findings generalize across presentation formats, are not adversely
affected by nonserious or repeat responders, are consistent with findings from traditional
methods. (e.g., Gosling, Vazire, Srivastava, & John, 2004) and that online and paper-and-
pencil presentations are largely equivalent when an individual is faking responses in
psychological testing (Grieve & de Groot, 2011). On the other hand, issues about data quality,
representativeness of the samples, response rates, and, above all, lack of control on the
conditions in which the participants complete the survey are often raised (e.g., Bowling, 2005,
Lefever, Dal, & Matthíasdóttir, 2007). Although the general pattern of results of this study is
consistent with previous research on the TEQ, the results of factor analysis might have been
biased by an unknown proportion of careless responders, which, if higher than 10%, could
have contributed to the emerging of method factors (as, e.g., in Woods, 2006). Although none
of the participants showed a high (e.g., 10) number of identical consecutive responses or
provided seemingly inconsistent socio-demographical information (e.g., an 18-year-old that
reported having a PhD and being widow) (Meade & Craig, 2012), to test whether the results
of this study could have been due to the peculiar administration method, it was decided to
collect data on the paper-and-pencil version of the TEQ in a more controlled condition and to
test a set of measurement models as alternative structures to account for relationships among
the TEQ items that could or not include method effects.

Study 2

In Study 2 TEQ was administered to a large community sample in its paper-and-pencil

version to test alternative measurement models that included trait factors, ephemeral method
artifacts associated with straight and reverse items and stable response-style method factors
associated with item wording. Psychometric properties of the scale and association of scores
with socio-demographical variables were also assessed.
412 Carlo Chiorri

Participants and Procedure

The 393 participants of Study 2 lived in urban and suburban areas of a middle-sized city
in Northwestern Italy, and had responded to advertisements requesting potential volunteers
for psychological studies or were contacted by undergraduate students in partial fulfillment of
the requirements for the Bachelor‘s degree in psychology. To be included in the study, they
should be at least 18 years old, not report an educational level lower than primary school and
should not have received a psychiatric diagnosis. Their characteristics are reported in Table 1.
All participants volunteered to take part to the study after being presented with a detailed
description of the procedure, signed a written informed consent and were not paid for their
participation. They were tested confidentially, individually or in small groups, in a single
session on the premises of a psychology department, and were asked to complete the same
materials of Study 1. They received support from a trainee psychologist and were treated in
accordance with the Ethical Principles of Psychologists and Code of Conduct (American
Psychological Association, 2002). The entire procedure took approximately 10 minute to
complete.

Measurement Models for the TEQ

Fifteen measurement models could be specified and tested using confirmatory factor
analysis (CFA) grounding on the results of Study 1 and on the tradition of studies of method
effects, which generally used either the correlated item error variances(or uniquenesses, CUs)
strategy or the latent method factor (LMFs) strategy (Bagozzi, 1993; Marsh & Grayson,
1995). Both strategies are based on the logic of multitrait–multimethod (MTMM) paradigms
(for a review about strengths and weaknesses of both the LMF and CU approaches see, e.g.,
Horan, DiStefano & Motl, 2003). The former approach resolves the issue of method effects
by allowing correlations among the uniquenesses of straight items and/or among reverse
items (e.g., Marsh & Grayson, 1994), whereas the latter strategy specifies LMFs that capture
the variance between the items with the same method (Marsh et al., 2010). In either case,
method effects associated with one method (e.g., CUs among straight items or LMF for
straight items) are assumed to be uncorrelated with method effects associated with another
method (e.g., CUs among reverse items or LMF for reverse items) and with the trait factor.
Models that specify CUs have the advantage of often converging to a proper solution, but
they do not allow to easily summarize the size of the methods effects and relate them to other
variables (Marsh & Bailey, 1991). Contrarily, LMF models allow to directly estimate trait and
method effects and to separate method variance from error variance, but nonconvergence,
improper solutions (i.e., parameter estimates out of range such as negative variance estimates
or factor correlations greater than 1.0), and admissibility problems (due to empirical
underidentification) are possible, especially when the methods factors are correlated (Marsh
& Grayson, 1995). It is still debated whether one approach should be preferred over the other:
Lance, Noble and Scullen (2002) claimed that when convergent and admissible solutions are
found, the LMF approach should be preferred, but other authors supported the use of CUs
(e.g., Marsh, 1996).
Model 1 specified that all items loaded on a single, general factor, consistent with the
original design of the TEQ. Models 2 and 3 specified two latent factors defined by straight
and reverse items but purported to have a psychological meaning (Empathy and Callousness)
as suggested by Study 1, assuming that they were independent and correlated, respectively.
Note that these model imply that if method effects exist, they are confounded with the trait
 Competing Factor Structures for the Toronto Empathy Questionnaire 413

factors. Models 4-8 are based on the CU approach and posit one trait factor and separate sets
of CUs for only straight (Model 4), only reverse (Model 5), only negated regular and polar
opposite reverse (Model 6), both straight and reverse (model 7), and straight, negated regular
and polar opposite reverse (Model 8) items, respectively. Each set of method effects is
uncorrelated with the single trait factor and with the other method effects. Models 9-15 are
based on LMF approach and specified one trait factor and LMFs for only straight (Model 9),
only reverse (Model 10), only negated regular and polar opposite, both independent and
correlated (Model 11 and 12, respectively), both straight and reverse (Model 13), straight and
independent and correlated negated regular and polar opposite (Model 14 and 15,
respectively) items. In these models all trait and method factors are uncorrelated, except the
factors of different kinds of reverse items. (Figure 2).
Following Marsh, Hau and Wen (2004), they were used as fit indices the Tucker-Lewis
index (TLI), the comparative fit index (CFI), and the Root mean square error of
approximation (RMSEA). Parameter estimates were also considered. TLI and CFI values
greater than .90 and .95 were taken to reflect acceptable and excellent fits to the data,
respectively, and RMSEA values less than .06 were considered as reflecting a reasonable fit
(Marsh et al., 2004). Comparisons among nested models were performed considering the
difference in CFI and RMSEA, since the 2 test statistic is known to be sensitive to the
number of parameters in the model and to sample size. Supporting evidence for a more
parsimonious model required a change in CFI of less than .01 and a change in RMSEA of less
than .015 (Chen, 2007). Note that the comparison among the fit of models within the CU and
the LMF model groups allows to test the relative importance and substantive nature of the
method effects.
Given the known possibility of nonconvergence and instability of MTMM models, as in
Marsh et al. (2010) the robustness of the alternative models, i.e., their ability to consistently
converge to a fully proper solution in which parameter estimates provide reasonable
approximations to population parameters, was tested using simulated data in which the true
population parameters were assumed to be known. If a model were not able to provide
accurate estimates of known population parameters based on the matching population-
generating model, it would provide a dubious basis for estimating parameters from real data.
Using the Mplus 6.1 program (Muthén & Muthén, 1998–2010), a simulated population
according to each one of the fifteen models was generated, and the true model was tested with
500 replications of 393 cases each. The population parameters common to the models were as
follows: factor loadings = .5 (both for the trait and method factors), error variances = .2, latent
variances fixed at 1. For CU models, population correlations among uniquenesses within
straight and reverse items were .1. Population correlation among trait factors in Model 3 was
set at .3. Correlations among uniquenesses between straight and negatively worded items and
trait and method factors were fixed at zero, except for negated regular and polar opposite
method factors, whose population correlation was set at .5. The criterion to evaluate model
stability was the proportion of samples that converged to a proper solution, although other
indices can be considered (see, e.g., Marsh et al. 2010).
Figure 2. Fifteen measurement models for the Toronto Empathy Questionnaire (Study 2, n = 393). Model 1 = one factor; Model 2 = two trait (Empathy and Callousness)
independent factors; Model 3 = two trait (Empathy and Callousness) correlated factors; Model 4 = one factor with correlated uniqueness among straight items; Model 5
= one factor with correlated uniqueness among reverse items; Model 6 = one factor with correlated uniqueness among polar opposites and negated regular reverse items;
Model 7 = one factor with correlated uniqueness among straight and reverse items; Model 8 = one factor with correlated correlated uniqueness among straight and polar
opposites and negated regular reverse items; Model 9 = one factor plus straight latent method factor; Model 10 = one factor plus reverse latent method factor; Model 11
= one factor plus one factor plus polar opposites and negated regular reverse independent latent method factors; Model 12 = one factor plus one factor plus polar
opposites and negated regular reverse correlated latent method factors; Model 13 = one factor plus straight and reverse latent method factors. Model 14 = one factor plus
one factor plus straight and polar opposites and negated regular reverse independent latent method factors; Model 15 = one factor plus one factor plus straight and polar
opposites and negated regular reverse correlated latent method factors; Reverse items are shaded; e = error variance (uniqueness).
 Competing Factor Structures for the Toronto Empathy Questionnaire 415

Results
Item descriptive statistics showed a negative skewness for straight items
(median = 0.17, range 0.72 to 0.44) and a positive skewness for reverse items (median =
0.94, range 0.51-1.03). Kurtoses of all items ranged between 0.72 and 0.44. These results
suggested the use of a robust maximum likelihood estimator (MLR) in CFA analyses.
Results of the simulation analysis revealed all models resulted in fully proper solutions
for all 500 replications with the exception of Model 7 (297 completed replications), Model 13
(381) and Model 15 (379). These results questioned the usefulness of such models, which
might be affected by empirical underidentification due to overparameterization. In fact, when
the TEQ factor structure was tested with real data, Model 7 and 15 failed to converge to a
proper solution (see Table 4).

Table 4. Fit indices for Toronto Empathy Questionnaire measurement models

(see also Figure 2) in Study 2 (n = 393)

Model 2 df CFI TLI RMSEA

Model 1 - 1 factor 380.6460 104 .700 .654 .082
Model 2 - 2 independent Empathy and Callousness 171.7740 104 .927 .915 .041
factors
Model 3 - 2 correlated Empathy and Callousness factors 137.8890 103 .962 .956 .029
Model 4 - 1 factor with CUs among straight items 78.7220 76 .997 .995 .010
Model 5 - 1 factor with CUs among reverse items 99.1050 76 .965 .960 .028
Model 6 - 1 factor with CUs among negated regular and 258.003 92 .820 .765 .068
polar opposite reverse items
Model 7 - 1 factor with CUs among straight and reverse DNC DNC DNC DNC DNC
items
Model 8 - 1 factor with CUs among straight and negated 57.729 64 1.000 1.013 .000
regular and polar opposite reverse items
Model 9- 1 factor with straight item latent method factor 134.2810 96 .959 .948 .032
Model 10- 1 factor with reverse item latent method 126.6200 96 .967 .959 .028
factor
Model 11 - 1 factor with negated regular and polar 261.145 56 .821 .776 .066
opposite reverse independent latent method factors
Model 12 - 1 factor with negated regular and polar 126.035 95 .966 .958 .029
opposite reverse correlated latent method factors
Model 13- 1 factor with straight and reverse item latent 118.1820 88 .967 .955 .030
method factors
Model 14 - 1 factor with straight and negated regular 116.174 88 .969 .958 .029
and polar opposite reverse independent latent method
factors
Model 15 - 1 factor with straight and negated regular DNC DNC DNC DNC DNC
and polar opposite reverse correlated latent method
factors
Note: .2 = chi-square test statistic; df = degrees of freedom; TLI = Tucker–Lewis index; CFI =
comparative fit index; RMSEA = root-mean-square error of approximation; CU = correlated
uniquenesses; DNC = did not converge to proper solution.
416 Carlo Chiorri

Table 4 shows that the single factor model cannot be accepted due to a poor fit and that,
according to the criteria stated above, the best fitting models were Model 8 and Model 4.
However, fit indices of the former seem to suggest an overfit and, besides, not all parameter
estimates of CUs among the groups of reverse items were significant. In Model 4, that
specified one single factor with CUs among straight items, straight items loaded significantly
on the empathy factor and all CUs were significant, except those of item 1 with item 16 and
item 9 with item 13. In general, models that specified ―general‖ reverse method factors for the
reverse items (i.e., 5 and 10) fitted substantially better than models that specified two
different reverse independent method factors (i.e., 6 and 11). Model 6 ha the same fit of
Model 12, that specified two different reverse correlated method factors, but the estimated
correlation among the negated regular and polar opposite method factors was .95, suggesting
that the two factors were indistinguishable. Model 3, that specified two correlated Empathy
and Callousness factors, had an excellent fit similarly to all the other models, while being
more parsimonious, i.e., estimated less parameters and had more degrees of freedom.
Cronbach‘s s, correlation among the subscale raw scores and TEQ mean scores are
reported in Table 3. Mean corrected item-total correlation was .37 (range .25-.47) for the total
scale, .39 (range .30-.50) for Empathy and .47 (range .34-.53) for Callousness. As in Study 1,
the association of TEQ scores with socio-demographical variables was investigated through
multiple regression models in which total, Empathy and Callousness scores were regressed on
gender, the quadratic and linear component of age and years of education. A significant effect
of gender and of both components of age was found for the total score (R2 = .11,
gender = .13, p = .008, agesq = .20, p = .002, age = .43, p < .001), while the effect of years
of education was not significant (edu = .05, p = .274). The same pattern of results was found
for Empathy (R2 = .11, gender = .14, p = .004, agesq = .21, p = .001, age = .44, p < .001,
edu = .02, p = .716), but not for Callousness, in which only the effect of the linear
component of age was significant (R2 = .05, gender = .08, p = .123, agesq = .12, p = .059,
age = .29, p < .001, edu = .06, p = .212).

Discussion
The results of this study replicated those of Study 1 in showing that the TEQ has
adequate internal consistency and corrected item-total correlations. The associations of TEQ
total scores with socio-demographical variables were more in line with expectations than
those of Study 1, since a gender difference and an inverse U-shaped association with age was
found. This might have been due to a larger number of older participants, and thus better data
to test age effects in this study, given that the third quartile of the age distribution was 47,
against 39 of Study 1, which included mostly young and middle-aged participants.
The findings of this study also suggested that a single factor might not be adequate to
account for the TEQ item intercorrelations. Models with CUs for the straight items (Model 4)
and for the straight and negated regular and polar opposite reverse items (Model 8) provided
the better fit to observed data, although not all estimated CUs were statistically significant.
The main issue about CUs is that any ex post facto decision about them could capitalize on
chance given the representativeness of the sample: since this study used a convenience
sample, it could not provide any evidence that those non significant CUs could actually be
ignored. If a model with a single factor and CUs were accepted, this would imply that in
applied research TEQ scale score could not be simply computed as an unweighted sum of
 Competing Factor Structures for the Toronto Empathy Questionnaire 417

item raw scores, but it should be derived by a CFA model that would refine the measurement
of empathy by allowing CUs among straight items. In most research and clinical contexts,
therefore, the computation of a total and two subscale scores appears to be much more
practical, as suggested by Model 3. In fact, consistently with results of Study 1, a two-
correlated-factor model provided an excellent fit, substantially similar to the fit of the other
models (except Models 4 and 8). Given the more controlled administration conditions of this
study, it appears unlikely that the best factor structure could be an artifact due to careless
responding of a substantial proportion of participants, as it has been argued for results of
Study 1. However, it must be noted that if trait factors exists for the TEQ, they are
confounded with method factors.
The correlation among the Empathy and Callousness factors estimated by the model
was .388, which is inconclusive with regard to the issue of whether the two factors are two
sides of the same coin or two distinct constructs, since a negative correlation is consistent
with the first hypothesis, but it is not enough strong to adequately support it  note that the
correlation estimated by the CFA model is a disattenuated correlation, since latent factor
scores are purged from measurement error. This result is consistent with results of Study 1
and with neurobiological research, that suggested that although empathy and callousness
share some common neurocircuitry involved in the shared representation of the emotions and
distress, in particular brain areas that integrate physiological input from the periphery and that
are less reactive in callous individuals, neurobiological impairments in individuals who
display little empathy are not necessarily due to a reduced ability to understand the emotions
of others (Shirtcliff, Vitacco, Graf, et al., 2009). Carmines and Zeller (1979) claimed that if
two factors were substantially meaningful, they should be differentially related to other
constructs or criteria. Hence, a construct validity study, in which Empathy and Callousness
scores were correlated with measures of other constructs theoretically related to empathy
(e.g., emotional intelligence and alexithymia), should provide evidence of whether they can
be considered as distinct or could be merged into a single empathy score. This has been done
in Study 3.

Study 3

The aim of this study was to test whether Empathy and Callousness scores had a different
patterns of correlations with well-established measures of emotional intelligence, alexithymia,
positive and negative affect, personality and social desirability. In its current definition
(Mayer & Salovey, 1997) emotional intelligence (EI) is defined as a cognitive ability
involving four hierarchical skills: perceiving, facilitating, understanding, and managing
emotion, but originally it consisted of ten facets, and empathy was one of them, defined as the
ability to understand others‘ emotions by relating them to one‘s own experiences (Salovey &
Mayer, 1990). However, when Mayer and Salovey (1997) revised the model targeting an
ability-based EI at the expense of a trait- or disposition-based EI (for a review, see, e.g.,
Mayer, Salovey & Caruso, 2000, 2008), empathy was not included because it did not fit the
ability framework. Despite the success of the ability model, a number of self-report measures
of EI have nonetheless been developed, and the Emotional Intelligence Scale (Schutte et al.,
1998) is arguably the most employed. It provides scores in three subscales: appraisal and
418 Carlo Chiorri

expression of emotion, regulation of emotion and utilization of emotions in solving problems.

An empathy score is expected to correlate positively with the first component, which, in the
original Salovey and Mayer (1990)‘s model, was divided into the subcomponents of verbal
and non-verbal when applied to the self and into the subcomponents of non-verbal perception
and empathy when applied to others. Alexithymia is commonly defined as a deficit in
experiencing and processing emotions (e.g., Taylor, Bagby, & Parker, 1997) and the 20-item
Toronto Alexithymia Scale (TAS-20, Bagby, Parker, & Taylor, 1994) is the most widely used
questionnaire to assess it. It is characterized by three factors, two related to emotional
awareness and expression (difficulties identifying feelings, difficulties describing feelings)
and one related to a specific tendency to deal with superficial themes and to avoid affective
thinking (externally-oriented thinking). An association between alexithymia and poor
empathic abilities has repeatedly been shown (see, e.g., Grynberg, Luminet, Corneille, et al.,
2010), hence negative correlations should be observed between an empathy measure and the
TAS. Positive and negative affect (PA and NA, respectively) are the most general dimensions
that describe affective experience, and almost all descriptors that refer to the ―basic‖ emotions
(Izard, 1977) fall within the PA and NA clusters. PA reflects pleasant engagement, the extent
to which a person feels enthusiastic, excited, active, and determined; while NA reflects a
general dimension of unpleasant engagement and subjective distress that subsumes a broad
range of aversive affects including fear, nervousness, guilt, and shame. Research has
suggested that positive affect is related to greater empathy (see, e.g., Volbrecht , Lemery-
Chalfant , Aksan et al., 2007). Empathy has also shown positive correlations with the Big
Five factors of personality (e.g., Jolliffe & Farrington, 2006), and especially with
Agreeableness (e.g., Caprara, Barbaranelli, Hann & Comrey, 2001). Finally, higher levels of
social desirability have been shown to be associated with higher levels of self-reported
empathy, especially in delinquent individuals (Kämpfe, Penzhorn, Schickora, et al., 2009).

Participants and Procedure

A group of 71 undergraduate students of psychology at a university in Northwestern Italy
participated for course credit in a personality assessment course. Their socio-demographic
characteristics are reported in Table 1. Participants were asked to complete the same socio-
demographic schedule of Study 1 and 2, and a battery of questionnaires including the TEQ
and the measures of emotional intelligence, alexithymia, positive and negative affect,
personality and social desirability described in the next subsection. The scales included in the
battery were administered in counterbalanced fashion to control for order and sequence
effects. The whole procedure took approximately 30 minutes to complete. Inclusion criteria
were the same of Study 2.

Measures
Toronto Empathy Questionnaire (TEQ, Spreng et al., 2009). As reported in the
Appendix.
Emotional Intelligence Scale (EIS, Schutte et al., 1998; Italian version in Di Fabio,
Giannini, & Palazzeschi, 2008). The EIS is a 33-item (22 in the Italian version) self-report
measure of emotional intelligence and its three components: appraisal and expression of
emotion (e.g., ―I can tell how people are feeling by listening to the tone of their voice‖),
regulation of emotion (e.g,. ―I have control over my emotions‖) and utilization of emotions in
 Competing Factor Structures for the Toronto Empathy Questionnaire 419

solving problems (e.g., ―When I am in a positive mood, I am able to come up with new
ideas‖). Participants are asked to rate each item on a 5-point Likert-type agreement scale.
Toronto Alexithymia Scale - 20-item version (TAS-20, Bagby, Parker & Taylor, 1994,
Italian version in Bressi, Taylor, Parker, et al., 1996). The TAS-20 is a self-report measure of
the three intercorrelated dimensions of alexithymia: difficulties identifying feelings (e.g.,
―have feelings that I cannot quite identify‖), difficulties describing feelings (―It is difficult for
me to find the right words for my feelings‖) and externally oriented thinking (―I prefer to
analyze problems rather than just describe them‖). Participants are asked to rate each item on
a 5-point Likert-type agreement scale.
Positive and Negative Affect Schedule (PANAS, Watson, Clark & Tellegen, 1988, Italian
version in Terracciano, McCrae & Costa, 2003). The PANAS is 20-item self-report adjective
checklist to measure positive and negative affect. Participants are asked to report the
frequency (from never to always) of their affect over an extended period of time, i.e., how
they felt ―in general‖ on a 5-point, Likert-type scale.
Ten Item Personality Inventory (TIPI, Gosling, Rentfrow, & Swann, 2003, Italian version
in Chiorri, Bracco, Piccinno & Fogli, 2012). The TIPI is a 10-item self-report measure of the
Big Five (Extraversion, Agreeableness, Conscientiousness, Neuroticism and Openness).
Participants are asked to indicate the degree to which each of 10 pairs of adjectives (e.g.,
―Extraverted, enthusiastic,‖ ―Disorganized, careless,‖ etc.) applies to their personality on a
7-point, Likert-type scale.
Marlowe-Crowne Social Desirability Scale - Short Form (MCSDS-SF, Crowne &
Marlowe, 1960, Manganelli-Rattazzi, Canova & Marcorin, 2000). MCSDS-SF is a 9-item
version of the original Crowne and Marlowe‘s self-report scale designed to measure social
desirability independent of psychopathology. Participants are asked to indicate whether
statements describing desirable but uncommon behaviors (e.g., admitting mistakes) or
undesirable but common behaviors (e.g., gossiping) are true or false for them.

Results
Cronbach‘s s, correlation among the subscale raw scores and mean scores for the TEQ
are reported in Table 3. Cronbach‘s s and correlations of TEQ scores with scores on the
other measures employed in this study are reported in Table 5 along with the significance of
the Zcontrast test (Westen & Rosenthal, 2003).
The Zcontrast test allows to test whether the correlation coefficients of two variables with a
third are statistically different in a sample of participants by taking into account the
correlation between the first two. In this case absolute values of correlation coefficients of
Empathy and Callousness with the third variable were used, since substantial correlations of
the same size but opposite sign would be likely result statistically different, but they would
suggest the same predictive ability, and thus no substantial difference.
The TEQ total score showed significant positive correlations with EIS total score,
Appraisal and expression of emotions, Utilization of emotions in solving problems,
Agreeableness and Social Desirability and negative correlations with TAS total score,
Difficulty describing feelings and Externally-oriented thinking. Despite some differences in
the significance of the coefficients, Empathy scores showed a similar pattern of associations:
the correlations with Appraisal and expression of emotions and Utilization of emotions in
solving problems were the highest in size, and a significant correlation with Conscien-
420 Carlo Chiorri

tiousness was observed. Callousness scores showed significant negative correlations with
Utilization of emotions in solving problems and social desirability and positive correlations
with TAS Difficulty describing feelings and Externally-oriented thinking. Zcontrast tests
revealed that the correlations of Empathy and Callousness with EIS total score and Appraisal
and expression of emotions were statistically different. However, since 16 comparisons were
made, an adjustment of the comparisonwise significance level was needed in order to limit
the inflation of the Type I error rate, i.e., finding a significant result for chance alone. The
widely used Bonferroni correction is known to be overly conservative (i.e., it inflates the
Type II error rate), so the two-stage Benjamini-Hochberg step-up false discovery rate
controlling procedure (Benjamini, Krieger, & Yekutieli, 2006) was used. The difference
among correlations of Empathy and Callousness with Appraisal and expression of emotions
remained statistically significant also after this correction.

Table 5. Internal consistency () of measures employed in Study 3

(n = 71), Pearson correlations of Toronto Empathy Questionnaire (TEQ) scores with
scores on the other measures and significance (p(Zcontrast) of the comparisons between the
absolute value of correlations of Empathy and Callousness with each measure

TEQ scales
Measure  Total Empathy Callousness p(Zcontrast)
EIS - Total score .86 .32** .43*** -.16 .043
EIS - Appraisal and expression of .77 .29* .46*** -.11 .006
emotions
EIS - Utilization of emotions in .76 .46*** .47*** -.32** .214
solving problems
EIS - Regulation of emotions .74 .00 .03 .02 .747
TAS - Total score .85. -.23* -.17 .20 .866
TAS - Difficulty identifying feelings .75 .07 .03 -.08 .730
TAS - Difficulty describing feelings .77 -.24* -.14 .23* .480
TAS - Externally-oriented thinking .70 -.42*** -.34** .35** .938
PANAS - Positive affect .79 .10 .20 -.02 .193
PANAS - Negative affect .88 .03 -.09 -.09 .194
TIPI - Extraversion .78 -.07 -.12 .02 .445
TIPI - Agreeableness .34 .23* .19 -.19 .982
TIPI - Conscientiousness .68 .22 .29* -.11 .194
TIPI - Neuroticism .46 .11 -.04 -.17 .121
TIPI - Openness .48 .01 .08 .04 .392
MCSDS-SF - Total Score .68 .32** .21 -.31** .443
Note: EIS = Emotional Intelligence Scale; TAS = Toronto Alexithymia Scale; PANAS = Positive and
Negative Affect Schedule; TIPI = Ten Item Personality Inventory; MCDSD-SF = Marlowe-
Crowne Social Desirability Scale - Short Form; * = p < .05, ** = p < .01, *** = p < .001.

Discussion
The aim of this study was to test whether Empathy and Callousness were differentially
related to other constructs, and the results showed that this occurred when their correlation
with a measure of appraisal and expression of emotions of the EIS was considered. As
reported above, this facet of emotional intelligence is the one that, in the original formulation
 Competing Factor Structures for the Toronto Empathy Questionnaire 421

of Salovey and Mayer (1990)‘s model, included empathy. Although the sizes of correlations
of the two subscales with the other measures were not significantly different (consistently
with the neurobiological hypothesis of common neurocircuitry, Shirtcliff et al., 2009), the fact
that the only difference occurred in the theoretically most relevant measure seems to support
the hypothesis that Empathy and Callousness measure two substantially different constructs,
though further research is needed to replicate and extend these findings. It must be noted that
the initial item pool of the TEQ included three items from the EIS, but none of these was
selected for the final version (see Spreng et al., 2009, Table 2, p. 65).
In general, the results of this study provided evidence of the construct validity of the TEQ
and its subscales. As expected, the total score correlated positively with a measure of
emotional intelligence and with two out of its three subscales assessing the appraisal and
expression of emotions and the utilization of emotions in solving problems, and negatively
with a measure of alexithymia and its subscales assessing difficulty describing feeling and
externally-oriented thinking. A significant, though small-sized, correlation was observed with
agreeableness, which is the Big Five factors associated to the a tendency to be altruistic,
sympathetic to others and concerned with social harmony and other‘s well-being.
Consistently with the literature, a positive association with social desirability was also found,
which might suggest a possible bias in the direction of social desirable responding. However,
the MCSDS-SF employed in this study is mainly a measure of impression management (i.e., a
deliberate response distortion in situations were it is desirable to present oneself in a positive
light, Paulhus, 1984) and not of self-deceptive enhancement (i.e., a stable view of oneself in
positive terms, Paulhus, 1984), and it has been suggested that the ability to self-enhance may
be considered an indicator of social competence and a predictor of successful interactions
with others (e.g., Ones & Viswesvaran, 1998), which are outcomes expected from the
empathic individual  not surprisingly, the Callousness score was negatively correlated with
the MCSDS-SF. However, this issue needs to be addressed by future research.

Study 4

The aim of this study was to assess the test-retest reliability of the Italian TEQ.

Participants and Procedure

A group of 56 participants completed the TEQ twice within a 4-week time interval.
Recruitment, inclusion criteria and procedure were the same of Study 2. Socio-demographic
characteristics of the participants are reported in Table 1.

Results
Table 3 reports Cronbach‘s s, correlation among the subscale raw scores and mean
scores for the TEQ for both administrations. No substantial differences were found in internal
consistency, correlation among Empathy and Callousness and total and subscale scores across
the two administrations. Test-retest reliability was also adequate. Intraclass correlation
coefficients (two-way mixed model with participants as a random effect and time as a fixed
effect, single measure; McGraw & Wong, 1996) were .79 (95% confidence interval: .66-.87)
for total score, .77 (.63-.86) for Empathy and .75 (.61-.85) for Callousness.
422 Carlo Chiorri

Discussion
The findings of this study suggest that TEQ scale and subscales internal consistency,
correlation among Empathy and Callousness and scores are fairly stable over a 1-month
interval and, therefore, relatively insensitive to contamination by short-term state changes.
These results replicate those of Spreng et al. (2009) and Total et al. (2012), that found test-
retest reliability coefficients for the total score of .81 and .73, respectively. No difference in
temporal stability was found in Empathy and Callousness, either. Since the two scales had
also similar internal consistencies across all studies (see Table 3), it can be concluded that
they do not differ in their reliability.

CONCLUSION
Empathy is an evolved response of approach and concern for others, beginning with an
emotional resonance between the potential empathizer and another, followed by the
empathizer‘s perspective taking on the other‘s situation. It is the perspective taking that
enables the empathizer, under certain circumstances, to provide a helping or care-taking
gesture (de Waal, 2009). Being able to understand and respond adaptively to others‘
emotions, and succeed in emotional communication is therefore crucial for the development
of prosocial behavior and empathy appears as a key trait for a successful adaptation to our
social environment. On the other hand, callousness, i.e., the disregard and disdain for the
feelings and well-being of others, has been found to be associated with delinquency (Byrd,
Loeber, & Pardini, 2012), with disruption of intrapersonal coordination among moral identity,
moral judgment, and moral behavior (Cameron & Payne, 2012) and it is considered a basic
dimension of personality disorders and a clinically relevant personality trait in a dimensional
approach to personality pathology (Livesley & Jackson, 2009). Hence, both constructs should
play a central role in personality assessment. A number of measures of empathy have been
developed, and the Toronto Empathy Questionnaire (TEQ, Spreng et al., 2009) has been
proposed as unidimensional tool that could complement multifactorial approaches while
being quick to administer and to score and thus useful in research settings and in all those
situations where brevity is a priority, such as clinical contexts with limited time for
assessment or batteries of questionnaires to be used in large-scale surveys. Although sound
psychometric properties were found in its seminal paper (Spreng et al., 2009), results
appeared to be of limited generalization since data were collected on a presumably highly
homogeneous sample of university students. The Turkish adaptation of the TEQ was also
tested on university students, and results did not seem to support a unidimensional structure,
since three items had to be dropped from the scale and a correlation between two item error
variances had to be freed to reach an acceptable fit of a single factor model. The research
presented in this chapter investigated the psychometric properties of the Italian adaptation of
the TEQ using diverse groups of participants such as an online sample (Study 1), community
samples (Study 2 and 4) and an undergraduate student sample (Study 3), and found support
for the reliability (both as internal consistency and temporal stability) and construct validity
of the scale. However, a unidimensional measurement model failed to adequately fit the data
in both exploratory and confirmatory factor analyses. A two-factor structure emerged as a
better, more parsimonious and theoretically relevant measurement model. In the exploratory
 Competing Factor Structures for the Toronto Empathy Questionnaire 423

analyses (Study 1), the two factors clustered the straight and reverse items of the scale, thus
suggesting two trait factors (labelled as Empathy and Callousness) confused with method
factors. Using a confirmatory factor analysis approach, Study 2 tested fifteen alternative
measurement models that included trait factors, ephemeral method artifacts associated with
straight and reverse items and stable response-style method factors associated with item
wording. The model with correlated uniquenesses among the straight items was the best
fitting one, suggesting that the lack of fit the unidimensional model, both here and (possibly)
in the Turkish study, was mainly due to a substantial proportion of straight item covariance
that could not be explained by the single factor. However, a simpler two-correlated-trait-
factor model also had an excellent fit to data and implied a much simpler scoring procedure
for the TEQ, since the raw scores of straight and reverse items can be summed up to produce
Empathy and Callousness scores. The moderate negative correlation between the two factors
(in the .30s) suggested that the constructs they measured were similar but not enough to be
considered as two faces of the same coin. Hence, in Study 3 it was investigated whether they
were differentially related to other constructs in the same nomological net of empathy, such
as emotional intelligence, alexithymia, positive and negative affect and personality. In
general, the size of the correlations of the two scales with the other measures did not
significantly differ (although it differed in the significance of the single correlation
coefficients), but the correlation with the Empathy of a key construct, the appraisal and
expression of emotions, which is the facet of (trait) emotional intelligence that includes
empathy, was stronger than the one with Callousness score. This result is consistent with
neurobiological research, that found that, although empathy and callousness share some
common neurocircuitry involved in the shared representation of the emotions and distress,
displaying little empathy does not appear to be necessarily due to a reduced ability to
understand the emotions of others (Shirtcliff et al., 2009). Taken together, these results seem
to advise against the use of a single TEQ score and to suggest the computation of two
subscale scores for the straight and the reverse items. However, further research is needed to
further investigate the construct validity of the two subscales and, perhaps more importantly,
their association with behavioral outcomes (e.g., delinquency).
Some limitations of the studies presented in this chapter have to be pointed out. The
groups of participants were all convenience samples, thus limiting the generalizability of the
results. However, the results of Study 1 and 2 were consistent although the two samples
differed in their socio-demographical background (see Table 1) and administration method.
Besides, the reliability of the scale and of the subscales did not substantially varied across the
general population and student samples. The results about the association of TEQ scores with
age, gender and education appear inconclusive, since they did not replicate across the first
two studies, although women uniformly tended to obtain higher empathy scores than men,
consistently with previous research and some recent fMRI research (Schiffer, Pawliczek,
Müller, et al., 2013). The method effects could also have been the result of the specific
wording of the Italian translation, but much care had been put in keeping the translation as
much literal as possible while maintaining semantic and conceptual equivalence (see
Appendix). Rather, cultural differences might explain these results. It has been claimed
(Hollan, 2012) that more ethnographic studies of empathy in context, as it manifests itself in
the flow of naturally occurring behavior, are required to better identify and analyze the
variety of cultural frameworks, social situations, and political economic conditions than tend
to either suppress and inhibit basic empathy or amplify it into a frequent and reliable means of
424 Carlo Chiorri

social knowing. This issue could be addressed by adaptation studies of the TEQ in other
cultural contexts.

ACKNOWLEDGMENTS
The author thanks Maria Paola Civano for the help in translating the TEQ into Italian and
in collecting data in Study 1 and 2; Gerardina Galella for the back-translation of the TEQ;
Cinzia Airaldi, Massimiliano Cosmelli and Simona De Pietri for the help in data collection in
Study 2; Valeria Battini for the help in data collection in Study 3; Giulia Alberti for the help
in data collection in Study 4.

APPENDIX
Italian version of the Toronto Empathy Questionnaire

Item English Italian

Below is a list of statements. Please read each
Troverai qui di seguito una serie di
statement carefully and rate how frequently affermazioni. Per favore, leggi ogni
you feel or act in the manner described. Circle
affermazione attentamente e indica con quale
your answer on the response form (never, frequenza ti senti o agisci nel modo descritto.
rarely, sometimes, often, always). There are no
Per rispondere, poni una X sul numero che
right or wrong answers or trick questions. meglio rappresenta la tua risposta nella scala
Please answer each question as honestly as presentata accanto ad ogni affermazione,
you can. ricordando che 1 = Mai, 2 = Raramente, 3 =
Talvolta, 4 = Spesso, 5 = Sempre. Non ci sono
risposte giuste o sbagliate, né domande a
trabocchetto. Per favore, rispondi ad ogni
affermazione il più sinceramente possibile.
teq01 When someone else is feeling excited, I tend Quando qualcun altro si sente euforico, tendo a
to get excited too diventare euforico anch‘io
teq02RN Other people‘s misfortunes do not disturb me a Le disgrazie altrui non mi turbano
great deal particolarmente
teq03 It upsets me to see someone being treated Mi addolora vedere che qualcuno viene trattato
disrespectfully con disprezzo
teq04RP I remain unaffected when someone close to me Rimango indifferente quando qualcuno a me
is happy caro è felice
teq05 I enjoy making other people feel better Mi piace far sentire meglio le altre persone
teq06 I have tender, concerned feelings for people Provo sentimenti di tenerezza e di
less fortunate than me preoccupazione per le persone meno fortunate
di me
teq07RP When a friend starts to talk about his/her Quando un amico inizia a parlare dei propri
problems, I try to steer the conversation problemi, cerco di spostare la conversazione
towards something else verso un altro argomento
teq08 I can tell when others are sad even when they Riesco a capire quando gli altri sono tristi
do not say anything anche se non lo dicono esplicitamente
teq09 I find that I am ―in tune‖ with other people‘s Mi accorgo di essere ―in sintonia‖ con gli stati
moods d‘animo altrui
 Competing Factor Structures for the Toronto Empathy Questionnaire 425

Item English Italian

teq10RN I do not feel sympathy for people who cause Non provo solidarietà per le persone che sono
their own serious illnesses la causa dei propri gravi problemi di salute
teq11RP I become irritated when someone cries Mi irrita vedere qualcuno piangere
teq12RN I am not really interested in how other people Non sono realmente interessato a come si
feel sentono le altre persone
teq13 I get a strong urge to help when I see someone Sento un forte impulso ad aiutare quando vedo
who is upset qualcuno che sta male
teq14RN When I see someone being treated unfairly, I Quando vedo qualcuno che viene trattato
do not feel very much pity for them ingiustamente, non provo molta compassione
per lui/lei
teq15RP I find it silly for people to cry out of happiness Trovo che sia sciocco che le persone piangano
di felicità
teq16 When I see someone being taken advantage of, Quando vedo qualcuno subire un sopruso o
I feel kind of protective towards him/her un‘ingiustizia, mi sento piuttosto protettivo nei
suoi confronti
Note: RN = reverse item negated regular; RP = reverse item polar opposite.

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EPILOGUE
In: Psychology and Neurobiology of Empathy ISBN: 978-1-63484-446-8
Editors: Douglas F. Watt and Jaak Panksepp © 2016 Nova Science Publishers, Inc.

Chapter 16

CLOSING NEUROSCIENTIFIC REFLECTIONS

AND CULTURAL/PHILOSOPHICAL IMPLICATIONS
OF EMPATHY RESEARCH

Douglas F. Watt1 and Jaak Panksepp2

1
Cambridge Health Alliance, Harvard Medical School, Boston, MA, US
Clinic for Cognitive Disorders, Quincy Medical Center, Quincy, MA, US
2
Baily Endowed Chair for Animal, Well-Being Science,
Department of Integrative Physiology and Neuroscience,
Washington State University, Pullman, WA, US

Empathy remains a challenging and confusing concept in terms of current

neuropsychological investigation and theorizing. However, increasing evidence suggests that
a proto-empathy, constituted by highly resonant socio-emotional feelings, must be a
fundamental foundation for more complex forms of human empathy, and is shared across
most mammalian species but is not a primarily a cognitive function organized by human
neocortex. Indeed, this subcortical locus of control for affective urges is true for all the primal
emotional systems of the brain, albeit mature empathic urges in humans surely reflect
contributions from higher neurocognitive processes as well. Still, we argue that the
fundamental mammalian core of empathy is founded on a process of basic emotional
contagion, and although contagion is surely modified by cognitive development and affective
regulation, it remains a fundamental mechanism upon which human empathy is built.
Although most of the relevant animal work has been done with FEAR (Panksepp and
Panksepp, 2013), which is not usually thought of as a prosocial emotion, the most
fundamental mammalian prototype affective system with the greatest relevance for more
complex and cognized human empathy is the system for mammalian maternal CARE (as
outlined in Panksepp, 1998). This prototype emotional system for maternal devotion
constitutes a distinguishing but still poorly mapped feature of the mammalian genome. A
second prototype system with special relevance for empathy (and with close ties to this
system for maternal CARE) is the system driving infant separation calls (primal PANIC
responses) which directly mobilize maternal care and help focus maternal attention towards
436 Douglas F. Watt and Jaak Panksepp

infants that are lost, injured or otherwise distressed. A final consideration is that maternal
attachment to offspring is surely energized in part by the mother‘s own separation distress
circuitry. Thus, a proto-empathy capacity as a basic mammalian endowment may emerge
from the concerted functioning of several of these primary affective systems.
Maternal care is surely complex but appears aimed at several interrelated goals: 1)
maintenance of infant homeostasis; 2) the termination of infant distress – as most
prototypically signaled by cessation of separation cries and other distress vocalizations, 3) the
maintenance of proximity to a vulnerable infant who may be in need of ongoing if not
virtually continuous physical protection. Attachment has been framed traditionally in terms of
a basic proximity maintenance system (Bowlby, 1969; 1971) and such proximity of course
helps to both delimit separation distress and also makes it possible for the maternal caregiver
to minimize other forms of infant distress as well. More recent work on attachment has added
to these classical notions a newer emphasis on the importance of a mutuality of smiling and
play responses (Trevarthen, 2009; Panksepp and Biven, 2012) – clarifying that good
maternal/paternal care is not simply about regulating and delimiting negative emotions but
also about sustaining positive ones as well, with the positive social responses of smiling and
play also being highly contagious. All of these conjoined operations make the restoration and
maintenance of a positive affective state in the vulnerable infant much more likely, and such a
state appears critical to promoting stress resilience, optimal development and eventual
reproductive competence (Panksepp, 1998; Meaney, 2001). Although research remains in
early stages, emerging preliminary evidence encourages our working hypothesis that a
fundamental capacity for affective contagion likely energizes these several behavioral
components of mammalian maternal CARE; distress signals in the infant engender PANIC
type distress in the (typically maternal) caretaker and thereby drive the intrinsic motivation to
protect and comfort offspring, while a positive mutuality of play and smiling responses also
appears to highly dependent on contagion effects as well (although this question has been
significantly less studied). The potential evolutionary selection mechanisms here seem self-
evident – minimizing loss to predation and other dangers, and thus significantly protecting
and increasing reproductive success not only in caretakers but also simultaneously protecting
those same future opportunities in offspring.
Our core argument is that this capacity for contagion may also index how highly social an
individual brain might be; our working hypothesis is that brains and minds that exhibit ‗high
emotional contagion‘ are likely to be more social brains and minds as well. In general, the
possibility that basic contagion mechanisms are essential to the construction of a highly ‗pro-
social‘ brain is only beginning to be empirically considered in both affective neuroscience as
well as in more social and cognitive neuroscience models, but in general this working
hypothesis (of a fundamental relationship between susceptibility to contagion and pro-social
behavior and functioning) has so far been insufficiently probed. This hypothesis seems a
reasonably heuristic starting point. Such a core contagion mechanism – presumably
somehow built into sensory processes that guide and inform the heavily subcortical
machinery for prototype affective systems – allows pro-social brains to have rapid real-time
sampling of the affective states of other creatures in the immediate environment. Such a
sampling mechanism clearly would have adaptive advantages in terms of rapidly molding
individual‘s response to social contingencies, affective pressures and the intentions of others
in the immediate social space. This would increase the likelihood of social brains achieving a
better integration of needs with opportunities, both in relationship to organism defense
 Closing Neuroscientific Reflections and Cultural/Philosophical Implications … 437

(rapidly recruiting FEAR and RAGE systems as needed in situations of potential threat), and
in relationship to more pro-social affective systems (PLAY, LUST and of course
prototypically maternal CARE, with this latter system perhaps being at least partially
constructed from a proto-empathy capacity). More obviously, and commonly appreciated,
such a basic contagion mechanism for sampling and sharing the affective states of others also
could potentially foster small group cohesion, a process which may have been heavily
selected in hominid lines and which may have contributed to the adaptive success of early
human tribal groups (Spoor and Kelly, 2004). We believe the central and foundational role
that contagion mechanisms may play in the overall architecture, scaffolding and development
of a prosocial brain has been potentially underappreciated, perhaps because of a tendency to
conceptualize contagion as a primitive antecedent mechanism (putatively lacking boundary
awareness and affective regulation) that a more ‗refined‘ and cognized human empathy
somehow replaces in both phylogenetic and ontogenetic development (see for example
Decety & Lamm, 2006; de Vignemont & Singer, 2006 for these views of contagion). Our
emphasis on the other hand – that contagion both indexes a ‗proto-empathy‘ capacity and that
contagion is built into the architecture for the prototype affective states, as outlined in
Panksepp, 1998) – highlights an emerging, and perhaps somewhat more affective and less
cognitive picture of empathy, informed in part by emerging animal models (see more detailed
coverage of animal models in Chapter 1 and in Chapter 2). This is also consistent with a soft
emerging consensus (outlined in the review by Cuff et al., 2015) that the term empathy
requires more than cognition about affect, and must involve some degree of shared affect –
even if questions of personal boundary, intensity, and degree of isomorphism still remain
poorly defined, and refractory to any easy or quick consensus.
Although this possibility has also been minimally probed, we believe that contagion may
have provided an evolutionary foundation for later arriving mammalian social-cognitive
functions, as precursors for cognitive theory of mind processes, by not only permitting
humans to think about the emotional dynamics of others but providing a primary motivation
to do so. In other words, we suspect that capacities for contagion may form a
neurodevelopmental foundation for later developing theory of mind and perspective taking, as
emotional contagion makes the internal operations of another mind an intrinsically salient
subject for initially an affective, and then later through development, a more cognitive
understanding. Abundant evidence already exists that core affects emerge directly from
subcortical emotional action systems (Panksepp, 1998; Panksepp and Biven, 2012) – that
affect is the signature of several ancient ‗emotional command systems‘ that jointly code
prototype action responses to prototype survival situations. Contagion ensures that affects
experienced in other minds alter our own affective states accordingly, providing a rich, albeit
surely not exclusive, motivational foundation for developmentally later emerging attempts to
understand other minds in more cognitive terms. How theory of mind might emerge from
more primitive contagion mechanisms is unclear, although a required precursor and necessary
component may be simply a primary and sustained interest in the affective experiences and
states of others, something which basic contagion helps ensure. Shared affect in other words
may motivate and inform attention to those other minds, with whom one appears to share so
much.
An additional neglected and still unanswered question is how much contagion might be
related to an attitude of positive concern and supportive attitudes towards others. In other
words, do positive affects about another amplify contagion effects and do negative affects
438 Douglas F. Watt and Jaak Panksepp

inhibit contagion, particularly in relationship to suffering and negative states witnessed in the
other? An earlier version of our basic model (Watt, 2007), emphasizing the idea that empathy
was highly ‗gated‘ or modulated and not simply a steady-state phenomenon based on a
relatively static representational process, posited that positive emotion might amplify
empathy while negative emotions towards the other might inhibit it. There is still a large
implicit assumption in the burgeoning empathy literature that contagion or affective
resonance might be something functionally separate from a posture of affective concern or
caring for others, but there is actually no direct evidence for such an assumption and some
evidence against it (e.g. Singer et al., 2006, who found that irritation and a perception of
unfair play deteriorated empathy for those judged negatively).
We believe that attitudes of caring and generalized capacities for social-affective concern
(Decety and Svetlova, 2012) may ‗open one up‘ to contagion processes, creating large shared
affective spaces, for the greater social good. Of course, evidence also suggests that there is
likely to be a ‗gradient‘ here of affective concern, with the experience of those we are mostly
strongly attached to and value most mattering highly, which is of course is totally consistent
with a familial, and small social-group attachment ‗biasing‘ of empathy (Decety and
Svetlova, 2012). On the other hand, a more antisocial or even just asocial attitude – that other
people‘s affective experience is of no particular or genuine importance – may close contagion
down, or may simply be a developmental correlate of this antisocial attitude (with the neuro-
genetic basis of impaired contagion in sociopathy still not elucidated). Evidence for these
relationships is seen in studies of conduct disordered youth and adult antisocial personality
disorders (Blair, 1999; 2005), where individuals often show little affective contagion, and
hence little affective empathy (and hence, minimal concern for the welfare of others). All of
this supports a basic hypothesis – albeit the systematic/formal evidence base remains modest
– that the capacity for primal affective contagion may be an essential building block for
higher social brain maturation and social development. Such capacities directly support the
long-term creation and stability of local social bonds and help promote a broader social
solidarity. However we readily concede that this question about affective concern and its
relationship to capacities for contagion and affective resonance remains both befuddled by
continuing terminological confusion (see Chapter 1 for more extended treatment and
discussion) and where there has been minimal probing of our default hypothesis of an
intrinsic relationship (that concern and positive affect about the other open us up to contagion
effects making a shared affect more likely, while negative affect towards the other party, or
utilitarian attitudes, do the reverse).
From the standpoint of studies of empathy in humans, many functional imaging studies
have allowed us to make a much clearer distinctions between complex distributed networks
supporting empathy, versus those supporting both theory of mind and the mirroring of action,
contradicting early widespread assumptions that mirror neurons were foundationally critical
for empathy (Kennedy and Adolphs, 2012). Thus, while empathy for sadness or pain or other
negative emotions, mirroring of action and the creation of theory of mind may all be
functionally related, in terms of indexing adaptive linkages between the sensory and
executive sides of the brain (‗perception-action loops‘ as emphasized by Preston and DeWaal,
2002), the ‗objects‘ of that imitation or ‗mirroring‘ are all quite different. Thus, the ability to
discern what someone is thinking, to have a genuine resonance with their sad affective state,
or to imitate their motor output in terms of a spatiotemporal pattern of movement, call on
different distributed networks. Although a dozen years ago this distinction was still debated
 Closing Neuroscientific Reflections and Cultural/Philosophical Implications … 439

(that neocortical action mirroring networks may not be the neural substrate for more affective
empathy), the evidence for differentiation between affective empathy networks, theory of
mind networks, and mirror neuron networks has become quite compelling (see Kennedy and
Adolphs, 2012 for summary overview and graphical brain maps).
Supporting this set of concepts, emphasizing that affective foundations for empathy
reliably and consistently activate more paleocortical regions critical for higher-order affective
consciousness, are findings implicating the dorsal/mid anterior cingulate and the anterior
insula in affective forms of empathy (Fan et al., 2010). The fact that these regions are also
reliably activated in relationship to many other experimental probes that activate affect
underscores that empathy (at least as we are defining it here and in this volume generally) is a
primary affective as opposed to a more tertiary cognitive process. This may be true despite
the fact that empathy in its fully developed and more cognized forms presumably requires
developmentally later-arriving cognitive capacities for affective regulation and self-other
boundary (Jackson and Decety, 2004). Such considerations may help explain why it is that a
huge variety of emotional probes, including many if not most empathic paradigms, show
consistent activation of anterior cingulate and anterior insula (see Lamm, Decety, and Singer,
2011 for meta-analysis). These two paleocortical regions have among the richest connections
to PAG, the ventral striatum and other core and deeply subcortical affective systems central to
prototype emotions, as outlined in affective neuroscience (Panksepp, 1998). Paralimbic
systems in insula and anterior cingulate may thus form a neural bridge between the sensory
and cognitive portions of the brain and more ancient prototype affective regions (see Watt,
2000 for discussion of PAG connectivities and functions). The anterior insula and cingulate
may create basic connectivities that link higher corticocentric cognitive processes in
heteromodal and other neocortical regions to the core subcortical ―emotion executive‖ regions
in PAG, hypothalamus, mesodiencephalon, basal forebrain and limbic basal ganglia (Watt,
2007; Panksepp, 1998).
Empathy also appears to have some fundamental limits and inhibitory controls placed on
it as well – and certainly the basic ‗gating‘ model of empathy proposed in the first chapter of
this book (with increasing empirical research actually directed to the critical in-group/out-
group ‗gate‘) suggests another still somewhat neglected set of dimensions in relationship to
empathy, namely its opponent processes. Opponent processes that directly inhibit and oppose
empathy would centrally include a disinhibited dominance and the lust for power – and where
again selection mechanisms are obvious, as dominance has a substantial impact on
reproductive opportunities. Although we do not believe that dominance is the result of any
true prototype emotional system itself (see discussion in Panksepp, 1998, but see also van der
Westhuizen and Solms, 2015), it is clearly a virtually universal emergent property of all social
groups, in which individuals have to compete for limited environmental resources, social
rewards and of course paradigmatically for reproductive opportunities. The relationship
however between a disinhibited or hypertrophied dominance drive and severe empathy failure
– although discussed in many places in the psychoanalytic literature (see Kernberg, 1975) –
has received minimal empirical neuroscience attention, although it has received attention in
the work of Blair (2013), in relationship to sociopathy. This represents an important gap in
the empathy literature, given highly consistent anecdotal evidence that an overriding interest
in dominance is generally (although perhaps not always) associated with narcissistic and even
antisocial attitudes and personality types, and where a basic developmental failure of empathy
has been extensively documented and researched, at least in relationship to antisocial
440 Douglas F. Watt and Jaak Panksepp

personality (Blair, 2005). In this sense, high social dominance and utilitarian attitudes towards
others may be seen as core opponent processes to empathy.
There may be other opponent processes inhibiting empathy besides the drive for social
dominance and the all too common human lust for power, such as fear and shame, but there is
little literature on how those might impact empathy. However, there is some work on the role
of in-group/out-group boundaries, reviewed in the first chapter in this volume. A fundamental
tribalism and perhaps a primal potential for harsh in-group out-group distinctions may be
built into the human genome through a simple bias for ‗like‘ others and against ‗unlike‘
others, biases visible from early infancy (see Hamlin et al, 2013). These biases would
predispose us to chronic empathic failures for other tribes and other individuals viewed as
fundamentally different from us – an obvious mechanism underpinning most common forms
of prejudice. While this may have been heavily selected at earlier points in our evolution,
possibly to promote the adaptive function of better group cohesion, such a biasing may be
counterproductive now, at a time when humanity dearly needs more inclusive images of
itself, and where global, non-sectarian perspectives on every aspect of the human condition
are badly needed. Indeed, an interesting question that has no clear answer yet is how
evolution might have selected for such ‗sectarianism‘ and tribalism, but one obvious
possibility is simply that small group cohesion was heavily promoted in our early hominid
evolution, as small groups may have been an optimal functional ‗unit‘ of hunter-gatherer
social systems. As early Homo sapiens hunter gatherer organization was gradually replaced
by larger organized societies, a transition perhaps enabled by agriculture, loyalty to and
identification with the larger group may have become a critical social cement. The simple
enhancement of within group affective solidarity conjoined with inhibition of empathy
between potentially competing hunter-gatherer and later and larger ethnic and city-state
groups may have promoted group cohesion and survival, perhaps at a potentially severe cost
to more generalized capacities for ‗social fairness‘ (which might require less bias for the in-
group and less bias against the out-group). Under the impact of such mechanisms, one can
readily imagine how more cohesive groups might have easily outcompeted or even
extinguished less cohesive groups. In other words, evolution may have actually selected
against a certain kind of evenhandedness so to speak, by prioritizing loyalty to tribe, family,
as well as the larger forms of ‗tribal home base,‘ such as emergent city-states in our early
recorded history. Although our tribalism is no ‗big news‘ so to speak, especially for anyone
observing our enormous range of sporting competitions, the negative impact on empathy by
selection effects creating a relatively harsh ingroup/outgroup boundary may still be
underappreciated, while its energizing of many forms of prejudice seems undeniable and
obvious.
Affective empathy surely works best when we can actually see suffering ―up close and
personal‖, and appears to be fundamentally less reliable and less powerfully elicited when
stories take the place of directly witnessing the affective states in others. Primal or proto-
empathy, requiring affective resonance, thus appears to be a rather ‗short-range‘, proximal
and immediate mechanism in relationship to suffering, also suggesting (consistent with the
above issues) that empathy is more intrinsically related to small groups, families, and intimate
attachments and not ―naturally‖ (or at least not evenly) extended to strangers. Thus, we are
willing to sacrifice ties to more anonymous and less visible others, particularly others in any
version of a perceived or culturally designated ‗out-group tribe‘ (see Xu, et. al, 2009 for
 Closing Neuroscientific Reflections and Cultural/Philosophical Implications … 441

neural correlates of empathy failure across racial lines), especially when there is competition
for limited resources.
All of those immediate and ‗embedded‘ social contexts appear to strongly amplify basic
empathic responding, presumably because the preservation of those social ties and the well-
being of such a ‗tribal home base‘ has been – historically anyway – far more important to our
survival than more abstract concerns with a larger humanity. One could speculate here that
evolution may have tuned an exquisite balance between the promotion of empathy within
tribal and cultural groups conjoined with a relative inhibition of empathy between groups.
Group cohesion of course would be significantly strengthened by empathy among group
members, without such feelings being extended to rival groups. Hamlin et al (2013), Mahajan
and Wynn (2012) and other developmental researchers have offered new perspective on our
‗Us vs Them‘ tribal nature by showing that even preverbal infants treat ‗like others‘ more
positively than ‗unlike others‘, albeit neither the genes nor relevant neural networks
supporting these biasing processes have been elucidated. Since in-group empathy is a short-
range and evolved ‗proximal‘ mechanism, it may not drive us to respond as vigorously to
more global human suffering at a distance, especially for those other tribes who may seem so
different from us. However this is where cognitive extensions to these more proximal and
ancient mechanisms – particularly theory of mind and affective theory of mind may help
mobilize us to reduce suffering.
In any case, our current global environment begins to expose the obvious and even severe
limitations of our predisposition to highly provincial/tribal and local perspectives, suggesting
a possible evolutionary mismatch between this endowment for tribalism and many of our
current global challenges. This ‗evolutionary mismatch‘ may become particularly worrisome
in the context of climate change, declining resources, and potential competitive
confrontations between nations with highly destructive technological arsenals. Only our vast
social learning and cognitive abilities can help promote the kinds of cultural practices that
may have more beneficent outcomes in terms of improved ‗intertribal‘ relations (Hein and
Singer, 2008; Rifkin, 2009). Indeed, an increasing acceptance and promotion of concepts of
universal human rights, and a steady (and ongoing) pushback against social prejudice in all its
many protean forms has provided a potent and even inspirational historical moderation of our
predisposition towards ‗Us versus Them‘ social dynamics. Such concepts of universal human
rights may indeed be impossible to achieve without a basic capacity for real affective
empathy, and can be said to reflect perhaps one of empathy‘s most important tertiary-
cognitive extensions.
We believe that these considerations should focus more research attention both on
empathy and also on its various ‗opponent processes‘ such as greed, lust for power, and other
forms of narcissistic self-aggrandizement. Productive topics for future research can also be
found in the potential relationship vs. disjunction between affective resonance/contagion on
the one hand, and affective concern for others and motivation to relieve suffering on the other
hand. In the first chapter in this volume, we noted that there is still divided opinion on the
extent to which these are necessarily conjoined in affective forms of empathy, vs. whether
basic motivation to relieve suffering is an ‗add-on‘, or perhaps part of something distinct,
such as ‗sympathy‘ or ‗compassion‘. We would suggest a default hypothesis that affective
concern for others amplifies the potential for contagion, and that contagion, concern for
others and motivation to relieve suffering may amplify each other as related prosocial
affective functions. At the same time we must acknowledge that the evidence for much of our
442 Douglas F. Watt and Jaak Panksepp

argument here is still mostly anecdotal, and the question of an intrinsic relationship between
openness to contagion effects and concern for suffering (implying a clear motivation to
reduce it) merits much more empirical evaluation and systematic probing.
We also believe that some critical variables impacting empathy on the positive side (such
as abundant early play and social education) have been less probed than variables on the
negative affective side (such as the ingroup/outgroup boundary which has received increasing
empirical attention recently). Additional variables on the positive (empathy-promoting) side
may centrally include the degree of ‗cuteness‘ and felt vulnerability in the suffering party,
which at face value seem obvious amplifiers of empathic responding, an amplification effect
underscoring the intrinsic evolutionary link of empathy to the affective prototype of maternal
CARE (Panksepp, 1998). One obvious manipulation to test these putative empathy
modulators would be to examine empathy responses to affectively stressful or painful stimuli
as experienced by powerful alpha males versus cute and relatively helpless infant mammals
and/or infant humans. Surprisingly this relatively simple paradigm for probing empathy
modulators with high face value has yet to be empirically evaluated. However, the obvious
prediction would be a differential amplification of both contagion effects (shared affect) and
also of motivation to relieve suffering by exposure to those judged ‗cute‘ or vulnerable vs. in
relationship to alpha males. Both contagion and motivation to relieve suffering would be
predicted to be much higher when observing relatively helpless infants and much lower when
observing powerful alpha males, perhaps also with gender differences in observers as another
important variable – one might readily predict that female observers would show even larger
differential responses to suffering in alpha males vs. helpless infants. Another domain
meriting further study might be the neural differences as well as similarities between proto-
empathy in humans and other mammals, esp. proto-empathic responses (e.g., emotional
contagion) in infants and young children, where the massive cognitive overlays on subcortical
emotional systems have yet to fully develop.
The natural affective resonances between mother and child are very well described
behaviorally (Reddy, 2008; Trevarthen, 2009). Within the empathy literature, such
phenomena are typically subsumed under the concept of emotional contagion, and from the
brain perspective, mirror-neurons and similar theory of mind networks presumably provide
necessary neural substrates and impetus the development of more cognitive forms of action
mirroring and cognitive empathy respectively (Gallese, 2001; Kennedy and Adolphs, 2012).
Of course this type of ‗mirroring‘ is especially evident with emotional states, a phenomena
that has been documented in the context of studies of disgust and pain, and the
―infectiousness‖ of such states, with neural resonances in the same brain regions (especially
anterior cingulate and insular cortices) in individuals experiencing the affective states of
others (Wicker et al., 2003: Jackson, Meltzoff, and Decety, 2005; Singer et al., 2004). Indeed,
such neural resonances in somatosensory cortex have been found to occur between
individuals simply observing others touching themselves (Blakemore, et al., 2005; Keysers et
al., 2004). Of course, such seemingly intrinsic contagion processes are very susceptible to
learning effects, and hence abundant cross-cultural variations that are especially evident in
display rules for emotions. One example is the lower expression of anger and fear among
Japanese, perhaps because they have more formalized rules governing dominance and
submission in relationships, yielding display rules that down-regulate negative affective
expressions such as anger (Hess, et al., 2000). Such work has yielded some interesting cross-
 Closing Neuroscientific Reflections and Cultural/Philosophical Implications … 443

cultural differences in brain responses to emotional stimuli (Murata, et al., 2013), making it
challenging, and at times very difficult, to generalize findings across cultures.
Consistent with the evolutionary conception of the brain as a conglomeration of nested
hierarchies (See figure 4, in Watt and Panksepp lead chapter of this book) linking more
ancient affective and more recently evolved cognitive abilities, our highest neurocognitive
capacities may potentially service and amplify capacities for empathic responding.
Psychological perspectives and cognitive insight into our affective nature may enhance
appreciation for our deep mutual interdependence as a species, and how the quality of our
social bonds and attachments has a determining influence on whether any individual life
trajectory is felt to be successful and affectively positive, or not. In the same vein, those
cognitive capacities have brought us a deeper appreciation for our equally fundamental
interdependence with many other life forms. In that sense, the current ongoing mass
extinction of other species, which shows every indication of deepening and worsening in the
context of climate change and habitat erosion, might profitably be a target for such cognitive
extensions of empathy. We also need greater empathic work on the exquisitely vulnerable
stages of human development (especially infancy and early childhood as well as the high-risk
periods of adolescence). We need to ensure that the ‗better angels‘ of our prosocial selves
receive sustained nurturance and optimal maturation, especially during those critical
neurodevelopmental windows of childhood. Our survival as a species may depend on our
empathy and our other more prosocial capacities trumping and inhibiting the traditional
seductions of power, territory and dominance.

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EDITORS’ CONTACT INFORMATION

Dr. Douglas F. Watt,

Cambridge Health Alliance
Harvard Medical School
Clinic for Cognitive Disorders
Quincy Medical Center
Boston University School of Medicine
Fax 617-376-5410
Email: drdougwatt@gmail.com

Dr. Jaak Panksepp,

Baily Endowed Chair for Animal
Well-Being Science
Department of Integrative Physiology and Neuroscience
Washington State University
Pullman, WA. 99164-6520 USA
Email: jpanksepp@vetmed.wsu.edu
 INDEX

A B

acceptance and commitment therapy, 309 balanced emotional empathy scale, 239, 255, 263,
accurate empathy, 304, 305, 306, 307, 308, 309, 310, 265, 271, 279, 280, 292, 402, 429
311 body dysmorphic disorder, 381, 385, 393, 394, 395,
affective ability, 231 397, 398
affective dimension of pain, 269, 270 brain structure, 223, 260, 266, 268, 287, 391
affective empathy, xii, 7, 25, 27, 29, 112, 122, 124, burnout, 74, 75, 88, 92, 93, 94, 95, 97, 98, 99, 101,
130, 131, 132, 134, 172, 173, 176, 204, 212, 213, 105, 233, 248, 257, 274, 275, 282, 284, 286, 288,
214, 215, 218, 219, 220, 222, 239, 260, 266, 273, 300, 303, 304, 305, 308, 309, 311, 312, 313, 314,
323, 325, 326, 328, 333, 334, 335, 337, 345, 353, 316, 319
389, 401, 438, 440
affective regulation, viii, xiv, 4, 10, 19, 71, 124, 153,
205, 278, 302, 305, 401, 402, 435, 438 C
affective resonance, vii, xii, 3, 4, 6, 7, 8, 9, 11, 16,
caring behavior, 273
20, 63, 65, 72, 76, 113, 120, 125, 134, 150, 172,
cognitive ability, ix, 38, 118, 150, 172, 188, 231,
212, 260, 303, 305, 324, 325, 326, 355, 378, 401,
328, 417
440, 441
cognitive empathy, x, xii, 34, 38, 66, 69, 73, 94, 112,
affective state, xi, 6, 11, 16, 18, 19, 22, 27, 28, 47,
117, 122, 124, 130, 132, 134, 135, 146, 156, 172,
53, 111, 112, 113, 114, 115, 119, 121, 122, 127,
174, 188, 189, 192, 211, 212, 213, 214, 215, 219,
152, 163, 212, 232, 259, 260, 261, 262, 268, 270,
222, 239, 245, 260, 261, 264, 323, 325, 326, 327,
327, 329, 350, 351, 352, 359, 360, 369, 401, 436,
328, 330, 333, 334, 335, 336, 339, 341, 345, 346,
437, 438, 440, 441
352, 378, 379, 389, 392, 396, 441
aging, x, 34, 36, 97, 101, 211, 212, 213, 214, 215,
compassion, 5, 6, 8, 9, 27, 33, 69, 70, 74, 75, 81, 87,
216, 217, 218, 219, 220, 221, 222, 223, 224, 225,
88, 91, 93, 94, 95, 96, 97, 99, 101, 102, 105, 106,
226, 247, 258
113, 143, 172, 232, 275, 298, 300, 301, 304, 305,
alienation, 298
308, 309, 311, 312, 314, 315, 318, 325, 386, 395,
arts and humanities, 248
397, 401, 426, 441
attachment, vii, ix, xiv, 4, 7, 10, 11, 13, 14, 16, 21,
compassion fatigue, 74, 75, 87, 88, 94, 99, 101, 106,
27, 28, 30, 33, 55, 67, 80, 83, 95, 96, 97, 117,
300, 304, 305, 308, 311, 314, 318
126, 136, 137, 142, 143, 147, 149, 153, 157, 166,
compassion satisfaction, 95, 105, 298
168, 169, 175, 176, 182, 184, 185, 260, 262, 265,
conduct disorder, vii, xii, 94, 129, 132, 133, 134,
267, 284, 288, 293, 301, 318, 328, 339, 378, 380,
142, 145, 146, 323, 325, 330, 331, 336, 338, 339,
401, 436, 438, 442
340, 341, 342, 344, 345, 346, 438
autism spectrum disorders, xii, 69, 90, 133, 209, 323,
consultation and relational empathy, 235, 255
324, 327, 338, 342, 343, 347, 371
contagion, viii, xii, xiii, xiv, 4, 5, 6, 7, 9, 11, 12, 16,
17, 18, 19, 20, 21, 22, 23, 26, 27, 29, 30, 38, 53,
450 Index

65, 67, 71, 73, 75, 76, 102, 113, 115, 116, 117, emotional detachment, 275
118, 119, 120, 125, 130, 131, 132, 134, 135, 153, emotional empathy, xii, 56, 58, 73, 77, 105, 113,
154, 155, 159, 160, 162, 163, 184, 192, 203, 219, 116, 133, 146, 152, 167, 185, 192, 212, 213, 219,
245,260, 261, 262, 264, 267, 268, 275, 282, 287, 226, 235, 239, 240, 245, 254, 255, 260, 261, 263,
303, 304, 307, 325, 326, 329, 335, 342, 345, 361, 267, 278, 280, 292, 294, 317, 340, 346, 347, 359,
377, 378, 379, 380, 385, 389, 400, 401, 435, 436, 360, 374, 378, 380, 397, 401, 402, 403, 429
437, 438, 441, 442 emotional empathy scale, 235, 263
cue-based paradigm, 270 emotional exhaustion, 282, 300, 315, 319
cultural awareness, 308 emotional intelligence, x, xiv, 187, 188, 189, 190,
cultural differences, xi, 229, 236, 237, 423, 442 191, 193, 194, 195, 196, 198, 201, 203, 204, 205,
cynicism, 74, 275, 300 208, 212, 224, 302, 305, 306, 310, 313, 315, 318,
399, 402, 406, 417, 418, 420, 421, 423, 427, 429,
431
D emotional labour, 284, 292, 293, 299, 300, 311
emotional literacy, xii, 297
deep acting, 299, 300, 302
emotional regulation, 153, 158, 160, 161, 274, 299,
defense mechanisms/attitudes, 279, 281
305, 307, 308, 310, 311, 329
depersonalisation, 300, 305
emotional regulation skills, 274, 305, 307, 310, 311
development of empathy, x, 111, 119, 121, 126, 147,
empathic accuracy, 66, 67, 92, 99, 179, 180, 184,
152, 157, 160, 162, 163, 167, 169, 170, 176, 211,
186, 205, 208, 238, 257, 262, 265, 273, 291, 295,
246, 260, 289, 293, 391, 430
339, 398, 428
dissociation, 34, 72, 73, 132, 146, 226, 256, 288,
empathic communication, 247, 257, 277, 294
319, 334, 335, 339, 340, 346, 375, 380, 383, 384,
empathic personality trait, 265, 385, 386, 388, 389
385, 389, 392, 394, 396
empathic presence, 277
doctor-patient relationship, xi, 229, 233, 248, 251
empathic process, xi, 12, 15, 23, 239, 259, 260, 261,
dyads, 174, 179, 294, 384, 385, 392
262, 266, 267, 268, 271, 282, 286, 395, 402
empathic response, 11, 17, 20, 22, 23, 25, 26, 39, 77,
E 78, 80, 82, 83, 87, 88, 102, 115, 117, 120, 121,
130, 231, 261, 262, 267, 269, 272, 273, 274, 275,
economic game, 78, 267 278, 285, 290, 293, 295, 299, 303, 340, 441
effective communication, 278 empathic responsiveness, 12, 15, 29, 231, 235, 266,
Einfühlung, xiii, 6, 111, 167, 377, 385, 386, 400, 428 268, 274
Eisenberg, xi, 8, 38, 56, 64, 68, 80, 92, 97, 101, 112, empathic tendency, 173, 262, 263, 264, 265, 266,
113, 120, 121, 122, 124, 125, 126, 130, 132, 136, 273, 274, 279, 280, 281, 282, 283, 285, 403
137, 139, 140, 141, 142, 146, 148, 156, 157, 158, empathic understanding of interpersonal processes
161, 164, 165, 168, 169, 174, 175, 181, 183, 184, scale, 235
188, 205, 207, 208, 212, 223, 230, 231, 253, 259, empathy construct rating scale, 235, 263
260, 261,263, 264, 265, 280, 282, 289, 292, 294, empathy skills, 180, 253, 285, 318
325, 326, 340, 386, 393, 432 empathy test, 185, 235, 263, 340
emotion recognition, xiii, 113, 128, 133, 138, 144, experiential learning, 249, 307, 308, 310, 311
206, 219, 220, 221, 225, 237, 245, 261, 268, 324,
329, 330, 333, 335, 339, 341, 342, 346, 347, 350,
F
352, 355, 356, 357, 359, 362, 368, 370, 372, 373,
375, 376, 401
facial expressiveness, 264, 368
emotional boundaries, xii, 297, 299
fantasy, xiii, 158, 173, 192, 193, 194, 195, 196, 201,
emotional contagion, viii, ix, xii, xiii, xiv, 4, 10, 11,
204, 304, 377, 385, 386, 388, 389, 390, 391, 395,
18, 19, 20, 21, 22, 38, 59, 63, 90, 112, 114, 115,
403
116, 135, 150, 151, 155, 162, 172, 189, 230, 245,
Freud, 32, 114, 115, 140, 230
260, 261, 274, 281, 282, 294, 297, 299, 300, 302,
303, 304, 324, 329, 342, 360, 361, 372, 377, 378,
394, 403, 435, 436, 437, 441
emotional contagion/affective resonance, 189, 299,
300
 Index 451

G M

gender, x, xi, 22, 77, 78, 97, 98, 102, 121, 122, 135, medical education, vii, xi, 229, 232, 233, 234, 236,
137, 157, 158, 163, 164, 165, 168, 169, 177, 179, 238, 239, 246, 247, 248, 250, 252, 253, 254, 255,
184, 185, 187, 188, 190, 191, 193, 198, 203, 204, 256, 257, 258, 311, 312, 314, 315, 317, 428
205, 206, 207, 208, 209, 214, 215, 229, 240, 241, medical humanities, 249, 250, 251, 286
242, 243, 244, 250, 251, 252, 254, 255, 257, 263, medical professionals, xi, 74, 229, 233, 250
264,266, 291, 292, 294, 295, 315, 338, 339, 407, medicine, 3, 67, 99, 101, 103, 104, 105, 138, 164,
410, 416, 423, 441, 443 229, 232, 233, 234, 237, 238, 243, 244, 248, 251,
gender differences, xi, 78, 121, 122, 177, 179, 206, 252, 253, 254, 255, 256, 257, 277, 279, 301, 309,
229, 240, 295, 338, 441 312, 313, 314, 315, 318, 319, 340, 344, 400, 428,
genuine empathy, 250, 299 445
global rating of empathy, 237 mentalization, 245
mimicry, xiii, 21, 105, 113, 118, 146, 159, 264, 294,
324, 326, 329, 333, 335, 344, 349, 360, 361, 362,
H 363, 366, 367, 369, 370, 372, 377, 378, 379, 380,
384, 385, 389, 392, 395, 397
helping behaviour, 265, 282
mindfulness, 308, 309, 311, 312, 314, 315, 318, 319
Hogan empathy scale, 166, 235, 263, 303
mindfulness based stress reduction, 309
humanism and professionalism, 248
mirror, xiii, 21, 23, 51, 122, 125, 136, 137, 141, 151,
hypnosis, 381, 391
152, 153, 166, 209, 245, 256, 257, 271, 342, 344,
352, 353, 368, 371, 373, 375, 377, 379, 380, 381,
I 382, 383, 384, 385, 386, 389, 390, 391, 392, 393,
395, 396, 397, 398, 400, 427, 428, 438, 441, 443
instruments, 191, 235, 262, 279, 425 mirror neuron system, 125, 245, 342, 427
interpersonal reactivity index (IRI), xiii, 158, 184, mirrored-self misidentification, 381, 391
192, 234, 377, 386, 388, 390 mirror-gazing, xiii, 377, 380, 382, 383, 384, 385,
386, 389, 390, 392
mirror-neuron, 375, 379, 382, 441
J multiple-selves, 386

Jefferson Scale of Patient Perceptions of Physician

Empathy, 237 N
Jefferson Scale of Physician Empathy, 235, 241,
243, 250, 253, 257, 258, 263, 303, 314, 402 nociceptive stimulus, 269
JSPE-HP, 235, 243, 244
JSPPPE, 237
O
Jung, 256, 385, 386, 394
oxytocinergic system, 245
K
P
Kohut, 230, 255
Korea, xi, 229, 236, 241, 243, 244
pain, 8, 16, 17, 18, 19, 23, 25, 27, 32, 33, 36, 40, 41,
43, 50, 51, 52, 53, 55, 57, 58, 59, 60, 61, 65, 77,
L 80, 93, 102, 103, 107, 124, 125, 128, 131, 136,
152, 154, 165, 224, 235, 245, 247, 252, 267, 268,
Lipps, 111, 142, 150, 167, 360, 374, 385, 386, 395, 269, 270, 271, 272, 273, 274, 275, 276, 279, 282,
400, 428, 431 284, 286, 287, 288, 289, 291, 292, 293, 294, 295,
literature and humanities, 248 298, 315, 329, 333, 336, 344, 350, 351, 352, 354,
loving kindness meditation, 309 359, 373, 374, 375, 391, 393, 394, 395, 396, 397,
398, 401, 438, 441, 443, 444
pain matrix, 19, 25, 245, 269, 270, 271
452 Index

Panksepp, xi, 5, 7, 8, 9, 10, 11, 13, 15, 16, 17, 18, 19, Rogers, 73, 84, 97, 104, 225, 230, 256, 278, 293,
20, 21, 23, 24, 28, 31, 33, 34, 35, 38, 40, 43, 44, 304, 318, 329, 334, 340, 344, 345, 401, 430
45, 53, 55, 57, 59, 63, 69, 74, 80, 83, 84, 85, 86,
87, 88, 102, 117, 118, 121, 125, 151, 152, 153,
177, 186, 188, 190, 208, 230, 232, 245, 256, 259, S
260, 262, 264, 266, 267, 293, 298, 325, 350, 352,
schizophrenia, 5, 189, 208, 223, 346, 384, 391, 392,
354, 374, 384, 397, 435, 436, 437, 438, 439, 441,
393, 396
442, 443, 445
secondary trauma, 92, 94, 95, 97, 102, 105, 301, 304,
parallel sharing empathy, 260
316
patient-nurse relationship, 277
self and others, 79, 118, 158, 209, 249, 270, 272,
people-oriented, 244
327, 350, 352
personal accomplishment, 298, 300
self other differentiation, 331, 334
personality, 5, 28, 31, 32, 58, 59, 66, 69, 70, 90, 91,
self/other, 8, 134, 379, 380, 381, 382, 384, 385, 386
92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 104,
self/other boundary, 380, 381, 382, 385, 386
105, 106, 133, 134, 137, 139, 144, 145, 146, 163,
self-boundary, 381, 389
164, 165, 167, 168, 182, 183, 184, 185, 186, 198,
self-compassion, 308, 317
204, 205, 207, 208, 209, 212, 223, 224, 225, 226,
self-recognition, xiii, 38, 122, 136, 377, 380, 382,
246, 251,252, 253, 254, 255, 257, 265, 287, 288,
383, 386, 394, 397
289, 291, 292, 293, 294, 313, 317, 318, 319, 331,
sensory dimension of pain, 269, 270
335, 338, 339, 340, 341, 342, 344, 345, 355, 370,
shame-prone, 231
373, 381, 382, 385, 386, 389, 390, 391, 392, 393,
sharing, ix, xi, xiii, 9, 22, 26, 32, 41, 53, 64, 77, 112,
395, 400, 404, 406, 417, 418, 419, 420, 422, 425,
117, 121, 131, 132, 137, 144, 150, 154, 159, 162,
426, 427, 428, 429, 430, 431, 432, 438, 439, 444
218, 219, 230, 232, 259, 260, 265, 267, 268, 269,
perspective taking, ix, xi, xiii, 4, 6, 9, 11, 13, 30, 38,
271, 273, 281, 283, 286, 288, 303, 304, 311, 326,
63, 66, 70, 73, 79, 85, 97, 106, 112, 113, 115,
335, 339, 349, 350, 351, 353, 354, 356, 359, 361,
120, 123, 129, 131, 133, 147, 150, 157, 165, 172,
367,368, 369, 378, 408, 437
173, 174, 175, 176, 177, 178, 179, 181, 182, 184,
similarity, 26, 28, 29, 68, 80, 93, 117, 208, 265, 267,
186, 212, 213, 214, 216, 225, 259, 261, 282, 303,
272, 287
305, 306, 312, 324, 326, 331, 334, 335, 336, 338,
simulationist models, 379, 382
340, 342, 345, 347, 378, 390, 401, 403, 422, 430,
social competence, x, xii, 10, 121, 129, 136, 168,
437
171, 176, 180, 181, 185, 188, 289, 297, 310, 311,
physician-patient interpersonal relationship, 234
421
physicians in society, 248
social functioning, xiii, 69, 100, 135, 139, 148, 164,
picture-based paradigm, 270
173, 189, 222, 284, 303, 313, 323, 324, 325, 337
positive unconditional acceptance, 278
SP, 247
professional helping relationship, 277
specialty preference, 236, 240, 244, 245
projection, xiii, 377, 384, 385, 386, 389, 392, 398
state empathy, 262
prosocial personality orientation, 265
strange-face illusions, xiii, 377, 383, 384, 385, 386,
388, 389, 390
R suffering, vii, xi, 3, 4, 8, 9, 10, 11, 23, 27, 28, 29, 30,
43, 52, 64, 65, 70, 71, 72, 74, 75, 81, 83, 88, 105,
reading the mind in the eyes test, 191, 192, 205, 223 113, 117, 128, 133, 152, 153, 205, 249, 259, 262,
reflection, 233, 249, 252, 278, 305, 311, 312, 318, 267, 269, 270, 271, 273, 274, 275, 278, 279, 280,
326, 328 281, 282, 283, 285, 286, 299, 303, 308, 309, 311,
reflective ability, xii, 297, 305, 306, 308, 310 325, 326, 328, 335, 395, 401, 437, 440, 441
reflective supervision, 308, 309, 310 surface acting, 300, 302
regulation, ix, 16, 19, 26, 29, 36, 70, 78, 100, 104, synchronization, 16, 378, 384, 385
114, 118, 120, 124, 126, 139, 142, 143, 150, 151,
156, 159, 160, 161, 163, 164, 165, 166, 167, 169,
182, 185, 193, 224, 265, 275, 277, 283, 284, 289, T
290, 292, 294, 301, 305, 309, 315, 316, 324, 328,
technology-oriented, 244
333, 336, 351, 376, 379, 381, 402, 418, 420, 431,
444
 Index 453

theory of mind, viii, x, xi, 4, 6, 7, 9, 11, 13, 29, 30,

32, 34, 59, 63, 66, 69, 73, 79, 94, 101, 105, 113,
V
115, 123, 128, 131, 132, 134, 136, 138, 140, 143,
virtual patients, 247
144, 146, 147, 151, 154, 158, 162, 163, 172, 188,
189, 190, 191, 192, 194, 195, 196, 198, 201, 203,
204, 205, 206, 207, 208, 209, 211, 212, 215, 216, W
217, 218, 219, 223, 224, 225, 226, 245, 255, 259,
262, 270, 273, 282, 304, 326, 337, 338, 341, 342, watt, xi, xii, 5, 8, 10, 14, 23, 27, 28, 35, 36, 53, 63,
343, 344, 346, 352, 372, 373, 375, 377, 378, 379, 65, 69, 71, 74, 80, 81, 83, 84, 85, 86, 87, 106,
394, 396, 401, 437, 438, 441 112, 113, 117, 118, 121, 125, 136, 147, 151, 152,
training, ix, 45, 46, 54, 67, 74, 75, 77, 80, 92, 97, 99, 153, 169, 181, 186, 230, 235, 245, 255, 258, 259,
103, 111, 134, 136, 138, 145, 147, 208, 234, 235, 260, 261, 262, 263, 265, 266, 267, 268, 269, 271,
236, 238, 239, 246, 247, 248, 249, 250, 251, 252, 273, 274, 276, 282, 290, 295, 297, 298, 299, 301,
253, 276, 285, 286, 287, 292, 302, 307, 308, 309, 303, 319, 325, 326, 347, 350, 361, 376, 378, 379,
311, 312, 313, 315, 316, 317, 318, 339, 369, 395 380, 384, 397, 401, 432, 437, 438, 439, 442, 444,
trait empathy, 68, 78, 80, 82, 212, 262, 266, 386 445

uncontrolled empathy, 300