Developing Empathy: Lessons for Therapy with Children & Families

Developing Empathy: Lessons for Therapy with Children & Families Katharina Manassis, MD, FRCPC Professor Emerita, University of Toronto

Disclaimer Conflicts • I get book royalties from Routledge, Guilford, and Barron’s Educational Series; my book “Developing Empathy” with Routledge is the most relevant • I have done unrestricted talks for Shire & Janssen

“The moment when someone can participate in another’s lived story, a different kind of human contact is created.” –Daniel Stern“Grant that I may never seek so much to be understood as to understand.” –St. Francis of Assisi

Why must we seek something that is supposedly ‘hard-wired’? • Mirror neurons & mimicry in mammals • Oxytocin & emotional (sometimes in-group) empathy • Dopamine, vasopressin, and cognitive empathy • Serotonin and other regulators of intense/fight or flight emotions • Humans are social animals, and empathy stabilizes groups/communities • Golden Rule crosses spiritual/religious traditions • Renewed interest in empathy & mental health with Positive Psychology

Lessons (Overview) • Empathy is more than perspective-taking • Demonstrating empathy is the best way to teach it • It is hard to be empathetic when physically or mentally distressed • It is hard to be empathetic when you have a history of insecure attachment • It is hard to be empathetic when certain beliefs/ideologies encourage the opposite • Empathy facilitates therapeutic change • Empathetic parenting is not easy, and needs community support • Empathy benefits physical, mental, and community health • Empathy has the potential to change the world • It’s never too late

1. Empathy and Perspective-Taking • Tip-sheets for parents/educators tend to focus on perspective-taking, and have little evidence • Somewhat more evidence for experiential approaches like “Roots of Empathy” • Sociopaths are very good at understanding others’ perspectives: that’s how they con you! • Autistic individuals are very bad at understanding others’ perspectives, but they can still pick up on others’ emotions sometimes

Other Elements in Empathy • Empathy has both cognitive and emotional elements, as well as other components • Boundaries: over-identifying with the other person is not always empathetic (e.g., Sienna) • Preoccupation with personal distress or daily events can prevent focusing on others • Communicating empathetically may need practice

The Process of Empathy Attention to the Other Person Self-Transcendence Taking the Other’s Perspective (cognitive, emotional, boundaries) Communicating Empathy

2. Teaching Empathy • “Imagine how that makes your brother feel!” (mother shouts at a boy who broke his brother’s toy after his brother wrecked his science project) • Translation: “I understand exactly how your brother feels. You, on the other hand, are completely incomprehensible to me, and you should be ashamed of your actions.” • What would have been a better way to turn this into a lesson in empathy?

Consider: • Actions speak louder than words: demonstrate rather than preaching • Helping him regulate his upset feelings first would improve the chances of understanding his brother’s perspective in time • Blaming one side or the other is rarely helpful • Mom may need some support too

3. Distress Increases Self-Focus Psychological Mental illness (most typical in depression, e.g., Juanita) Fight or Flight (anxiety, anger) Personality Disorder Addictions Daily Hassles Empathy is possible when these are acknowledged, effectively treated, and strengths are developed Biological • Discomfort • Neglect of Health Habits (low self-compassion, low activity) • Illness Symptoms • Illness Coping Strategies • Disability • Empathy is still possible with a conscious, mindful approach to these challenges

Focusing on Others • Prioritizing the person over other commitments, e.g., Marvin • Implies every person deserves our attention and respect as a unique and uniquely valuable human being • Implies rules are made for people rather than the other way around (so should not be applied indiscriminately) • Implies conversations with people should never be treated as tasks to be crossed off the to-do list • Implies an “I-Thou” inter-subjective relationship, rather than “I-It” where the other person is objectified (using Martin Buber’s terms)

4. When the Past Interferes • It is hard to be empathetic when you have a history of insecure attachment: physiologically impairs emotion regulation, creates distorted mental models of relationships, predisposes to patterns of insensitive behavior that affect the next generation —e.g., Aloofa • Parental trauma, loss, and mental illness result in the most disorganized and damaging attachments • It may be difficult to empathize with people who remind us of a negative aspect of our past (transference)—e.g., Danny & Arjun • Mistrust or resentment due to past hurts can be a particular obstacle to empathy e.g., bullied child; Selena • Recognition of these issues and relevant change are hard, but freeing: try to remember your mentors more than your tormentors

5. Ideals that Promote Empathy • You can’t tell people what to believe • A focus on future reward accessible only to a few deserving individuals typically reduces empathy (empathy requires a present-moment focus; empathy acknowledges interdependence and therefore the value of all) • Tribalism is empathy only toward kin; that’s why we need more than oxytocin to be empathetic! • When patients don’t share our ideals, it can be difficult to show empathy: until we see how their potential and their enjoyment of life are limited by their ideals; when we focus on helping them develop a fuller life, ideals sometimes no longer take centre stage

6. Empathy and Therapeutic Change “You’re wonderful just as you are…so change!” --when we feel understood and validated, we no longer feel so threatened by new experiences “Empathy is in itself a healing agent…it brings even the most frightened client into the human race. If a person is understood, he or she belongs." --Carl Rogers

Empathy in Therapy • Empathetic assessment includes respecting the right not to talk about certain issues, and time for calming down and constructive comments at the end, so it’s a therapeutic (not traumatic) event • Empathetic treatment considers the impact of the treatment on those around the patient (e.g., Jason’s anxiety; ask family effects) • When “burned out”, take a vacation rather than being a therapist who offers only “canned empathy” • Try to learn from “empathetic disconnect” with patients: counter-transference, different world views, defensiveness, resistance to change/wrong treatment

Empathy in Therapy (2) • Supplement therapy with calming, centering activities that promote an outward focus (e.g., exercise, mindfulness, artistic pursuits, altruism, positive sensory experiences, full concentration activities) • Attend to spiritual and meaning-focused questions/themes, especially when people are facing difficult life events, e.g., focusing less on big existential meaning & more on the meaning found in responding well, as the situation calls for (Frankl’s chess analogy) • Advocate for better mental health services/systems (e.g., funding for psychological/developmental therapies; multiplier effect of training people in remote areas in evidence-based care)

7. Empathetic Parenting • Secure attachment is a good place to start, because feeling cared for motivates caring about others; parental trauma, loss, or illness (physical or mental) can make this difficult • Parental support from other adults is often needed (practical and emotional), including flexible workplace policies • Parents can model empathy as well as good self-care, healthy coping with stress, inclusive attitudes, and cooperation and fun (not just “winning”)

Empathetic Parenting (2) • Parents can encourage children to put themselves in others’ shoes (e.g., storybook villains as in Maleficent) • Parents can limit exposure to violent, dehumanizing media or at least talk about it in terms of real human beings and relationships • Parents can set limits kindly and consistently, with the child’s best interest in mind • Children with differences/special needs can pose particular challenges to parental empathy (see “Far from the Tree”)

8. Benefits to Individuals and Communities • “The forest is mankind, and the hill is the world… Trees of different names stand side by side. The trees fall and die and help the young grow. Even the crooked sticks help to build the world. And all the nations have to build that forest.” --Chief Walking Buffalo • Individual benefits include lower vulnerability to anxiety, depression, and aggressive behavior; increased resilience; better school and work adjustment; greater cooperation and community involvement • Community benefits are myriad (see table), e.g., Mrs. Finney

Empathetic Communities Unhealthy Organization Empathetic Community

9. Changing the World “In the end, it is the reality of personal relationship that saves everything.” –Thomas Merton • Big problems are inter-related (e.g., poor people struggle to survive regardless of the environment, and are desperate enough to wage war; wars devastate the environment and use up money that could help the poor; global warming disproportionately affects poor countries, and resource shortages fuel wars), and overcoming them requires empathetic leadership • Empathetic leadership is more likely when those leaders and their parents grow up without trauma, loss, or deprivation • The Butterfly Effect: the world is interconnected and interdependent so small actions can make a huge difference, especially if those actions are based on empathy e.g., the barrista, Junior

Empathy and the World Prosperity for All Empathetic Leadership Environmental Sustainability Peace

10. It’s Never Too Late • There are often second chances for people from harsh family backgrounds e.g., Ashley’s choir teacher, Benny’s coach, my grandmother • Even people who are insensitive and cruel when stressed can become humane and empathetic when circumstances improve (i.e., empathy may be more of a state than a trait) • Random acts of kindness may not be so random…and we all become more aware of our shared humanity as they multiply • All that we do to improve out patients’ physical and mental health, and that of their parents, will support empathy now and in future generations

Questions?

Developing Empathy: Lessons for Therapy with Children & Families