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Do psychotherapists, doctors and leaders develop "emotional chainmail"? Two kinds of empathy.

I wrote yesterday about how, at the weekend, I was involved in an hour and a half's deep emotional conflict resolution with an old friend that was witnessed in a group by another eight people.  As pretty much always, in the feedback that emerged over the next twenty four hours, different people reported very different reactions to what they had seen.  I still (after forty years involvement in a wide cross section of psychotherapy groups) find it jaw-dropping the sheer variety of what different people feel & think when observing absolutely the same event.  However, it seemed that most of those who spoke were deeply moved and respectful of what we'd done and how well it had worked out ... and that was my experience too.  I know in these situations of long-term interpersonal hurt that I can become compassionate, understanding, forgiving and "wise" about my emotional distance from the other person ... but very often (not always) there's still a knot deep down inside, a holding, a doubt, a subtle maintained distrust of the other that faintly but distinctly colours my relationship with them.  It's like an old wound that has never fully been cleaned right down in its depths, despite the skilful stitching and clean bandages that make everything look all right.  I see the same in clients who come to me sufferering from more general traumas.  The evidence base is clear ... in this situation, trauma-processing is likely to be more helpful than all the meditation, compassion work and cool, rational understanding.  Sometimes the wound needs to be reopened for it to be cleaned and heal more completely.

And that's what we did for over an hour, with a little help from others.  Walking down into pain.  Teasing out anger and hurt.  Listening and feeling and expressing.  This walking in the emotional underworld isn't easy.  Travellers can get badly lost.  It's not usually OK just to dive into the strong feelings and let them wash you downstream.  I've written lots about this over the years - see for example "The jazz trio metaphor: reworking the core conditions, relational depth, compassion & two kinds of empathy", "Meeting at relational depth: a model", "Peer groups ... cathartic work from the inside" and "Different kinds of group, different kinds of friendship".  In my work as a therapist, I've sat in the room with people who tell me that they're now going to leave and kill themselves, or we've explored shocking pain, rape, abuse, murder, violence, or I've been attacked with snarling character assault, or worked with strong inappropriate sexual attraction, or walked beside clients as they faced the physical or emotional end of their world.  High winds, driving hailstorms of feeling.  And not just in others ... in myself too ... leaning back heels jammed into a steep snowslope for two hours wondering if the rescue helicopter would get to me before I slipped over the cliff below, or being with the death of my parents, or coping with back-ripping physical pain.  So at the height of the emotional processing with my friend, when I reached the most personally agonising section and my face & body fractured into sobs, I stayed sitting tall & open rather than collapsing.  And after we'd finished and my friend was gripped with a headache, I went into the kitchen to see what needed doing and a colleague said "How are you?  You can't be this strong, can you?"  And I can and that's a double-edged ability. 

Emotional and physical pain is all mixed up in a bundle often affecting the same nerve tissue - see, for example "The neural bases of social pain: Evidence for shared representations with physical pain."  And when we empathise with another's pain, we actually feel it; it may well literally hurt us too - see "Meta-analytic evidence for common and distinct neural networks associated with directly experienced pain and empathy for pain."  This is true for physical pain and it is also true for emotional pain.  As authors Singer & Lamm write in their paper "The social neuroscience of empathy" - "Consistent evidence shows that sharing the emotions of others is associated with activation in neural structures that are also active during the first-hand experience of that emotion."  And they go on to say " ... recent studies also show that empathy is a highly flexible phenomenon, and that vicarious responses are malleable with respect to a number of factors — such as contextual appraisal, the interpersonal relationship between empathizer and other, or the perspective adopted during observation of the other."  It seems useful to distinguish cognitive empathy (mentally understanding what the other person is experiencing) and emotional empathy (actually sharing what they're feeling).  This is well described in Walter's paper "Social cognitive neuroscience of empathy: Concepts, circuits, and genes".  We are more likely to feel emotional empathy when we have a sense that the other person is similar to us (see Preis & Kroener-Herwig's 2012 paper), so Meyer et al showed in their research - "Empathy for the social suffering of friends and strangers recruits distinct patterns of brain activation" - that observing a friend's (social) suffering "activated affective pain regions associated with the direct (i.e. firsthand) experience of exclusion ... 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']."  At worst, cognitive empathy involving only perspective taking (in contrast to the shared feelings of emotional empathy) can be used to help "read" another's mind and manipulate them for personal gain - see "Why it pays to get inside the head of your opponent: The differential effects of perspective taking and empathy in negotiations".

Empathy - probably particularly emotional empathy - is of very considerable importance for psychotherapists (Elliott et al, 2011), for doctors (Mercer et al, 2012) and for close relationships more generally (Canevello et al, 2011 & Sullivan et al, 2010).  Worryingly there is research suggesting that empathy actually declines over the course of medical training (Neumann et al, 2011) and may be declining as well in the general population (Konrath et al, 2011).  In tomorrow's blog post (the third & last in this sequence on "emotional chainmail") I'll look at ways that can help us "get the best of both worlds" - maintaining emotional stability while also staying empathically & emotionally connected with others.

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