In yesterday's post, I introduced the jazz trio metaphor ... head (observation/knowledge), heart (warmth/compassion) and gut (emotion/authenticity) ... and discussed both heart and, to some extent, head.  Continuing this exploration of head "observation & knowledge".  It's clear that cognitive empathy & perspective taking can be very helpful, but we need to be cautious about slipping into something quite cold-blooded and potentially manipulative. Recent research reported "Physicians down-regulate their pain empathy response: An event-related brain potential study" and we know the power differential between helper & helped can produce distance - "Power, distress, and compassion: turning a blind eye to the suffering of others". Yes, it's important that helpers don't drown in distress triggered by their responses to the suffering of those they're trying to help, however loss of compassion & emotional connection can be just as or more damaging - and this cuts both ways. So the classic Ambady et al study - "Surgeons' tone of voice: a clue to malpractice history" - where short recordings of doctor voices in routine consultations showed clear links between an uncaring, dominant tone and the chance of the doctor being sued. And also reduced empathy appears to be associated with an increased tendency to make medical errors & physically damage patients - "Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study".

So how does this all relate to the jazz trio metaphor? Well in the triad of head, heart and gut, head, for me, represents knowledge & research findings as well as perspective taking & cognitive empathy. It can be out of balance either dominating the picture - too cool, too manipulative - or not present enough as illustrated in the old saying "It's important to keep an open mind, but not so open that your brains fall out". The cerebral "head work", I feel, needs to be balanced by a connection that's much more emotional, more felt in my body. In a paper published earlier this year - "Social cognitive neuroscience of empathy: Concepts, circuits, and genes" - the author writes "This article reviews concepts of, as well as neurocognitive and genetic studies on, empathy. Whereas cognitive empathy can be equated with affective theory of mind, that is, with mentalizing the emotions of others, affective empathy is about sharing emotions with others. The neural circuits underlying different forms of empathy do overlap but also involve rather specific brain areas for cognitive (ventromedial prefrontal cortex) and affective (anterior insula, midcingulate cortex, and possibly inferior frontal gyrus) empathy."

I find this helpful, the notion that there is cognitive empathy and an overlapping but distinct affective empathy - in the jazz metaphor, I see affective empathy as "the gut". In another of this year's papers - "Empathy for the social suffering of friends and strangers recruits distinct patterns of brain activation" - this cognitive/affective distinction is enlarged on: "Humans observe various peoples' social suffering throughout their lives, but it is unknown whether the same brain mechanisms respond to people we are close to and strangers' social suffering. To address this question, we had participant's complete functional magnetic resonance imaging (fMRI) while observing a friend and stranger experience social exclusion. Observing a friend's exclusion activated affective pain regions associated with the direct (i.e. firsthand) experience of exclusion [dorsal anterior cingulate cortex (dACC) and insula], and this activation correlated with self-reported self-other overlap with the friend. Alternatively, observing a stranger's exclusion activated regions associated with thinking about the traits, mental states and intentions of others ['mentalizing'; dorsal medial prefrontal cortex (DMPFC), precuneus, and temporal pole]. Comparing activation from observing friend's vs stranger's exclusion showed increased activation in brain regions associated with the firsthand experience of exclusion (dACC and anterior insula) and with thinking about the self [medial prefrontal cortex (MPFC)]. Finally, functional connectivity analyses demonstrated that MPFC and affective pain regions activated in concert during empathy for friends, but not strangers. These results suggest empathy for friends' social suffering relies on emotion sharing and self-processing mechanisms, whereas empathy for strangers' social suffering may rely more heavily on mentalizing systems."

Emotion - such an important ingredient in psychotherapy - and in life. In the post "The importance of processing 'hot' cognitions & feelings" I said: In his paper "Emotional processes in psychotherapy: evidence across therapeutic modalities", Whelton wrote "At the present time there is an interest in emotion research in therapy that cuts across all therapeutic modalities. Emotional processing and depth of experiencing, two heavily-researched emotion process categories of the behaviourists and humanists respectively, have been shown to have a robust association with outcome. There is accumulating evidence that both the in-session activation of specific, relevant emotions and the cognitive exploration and elaboration of the significance and meaning of these emotions are important for therapeutic change".

Nearly twenty years ago, in his seminal paper "Emotion and two kinds of meaning: cognitive therapy and applied cognitive science", the great CBT researcher John Teasdale wrote "The clinical cognitive approach assumes that emotional reactions are mediated through the meanings given to events. Cognitive therapy aims to change emotion by changing meanings. It focuses on specific level meanings, evaluating the truth value of particular beliefs ... This focus on meaning at a specific level causes problems, e.g. the contrasts between 'intellectual' and 'emotional' belief, between 'cold' and 'hot' cognition, and between explicit and intuitive knowledge ... the Interacting Cognitive Subsystems (ICS) approach ... suggests a therapeutic focus on holistic rather than specific meanings, a role for 'non-evidential' interventions, such as guided imagery, and a rational basis for certain experiential therapies." There is a danger that cognitive therapists can find themselves all too easily working at the level of "cold" rather than "hot" cognitions. In their fascinating paper "Clients' emotional processing in psychotherapy: a comparison between cognitive-behavioral and process-experiential therapies", Jeanne Watson & Danielle Bedard wrote "The authors compared clients' emotional processing in good and bad outcome cases in cognitive behavioral therapy (CBT) and process-experiential therapy (PET) ... Twenty minutes from each of 3 sessions from 40 clients were rated on the Experiencing Scale. A 2 x 2 x 3 analysis of variance showed a significant difference between outcome and therapy groups, with clients in the good outcome and PET groups showing significantly higher levels of emotional processing than those in the poor outcome and CBT groups, respectively ... The results indicate that CBT clients are more distant and disengaged from their emotional experience than clients in PET." And I would emphasise, even just comparing clients in the CBT group, a deeper level of emotional processing - working more with "hot" cognitions - was associated with better clinical outcome. I find it valuable to keep a rough notion of what level we are on the "Experiencing scale" (PDF here) when I'm working with clients. And there's fascinating work suggesting that "the therapist's depth of experiential focus influences client's depth of experiencing, and this relates to outcome".

Gut stuff. Authentic gut stuff. As psychotherapists we can be surprisingly poor at navigating these internal emotional waters. This might be no surprise in cognitive-behaviourists, but my experience over the years is that it's not unusual for therapists of all persuasions to be daunted by moving deeply into feelings ... see, for example, "A quiet rant to group facilitators" and various posts discussing catharsis in peer group work. Much of the work on conflict is relevant here too as is "Is interpersonal group work better than sitting meditation for training mindfulness?"

The jazz trio. Head (observation/knowledge), heart (warmth/compassion) and gut (emotion/authenticity). I hope this exploration triggers off useful thoughts for you, the reader. What internal charts/reminders do you use ... especially when interpersonal interactions become more deeply emotional?