On a clear summer night in 2006, an ambulance is urgently dispatched to the family residence of Doctor Y, a well-respected senior military psychologist and the only credentialed mental health provider for a U.S. Marine base of 6000 military men.
Initial reports by Dr. Y’s frantic spouse indicate sudden paralysis, inability to speak, and unresponsiveness, suggesting possible seizure or stroke. When the emergency personnel are greeted at the door, the wife is panic-stricken and his two children are crying in desperation. But when they enter the room to find the high-ranking patient, he is sitting upright on a bed, conscious, and breathing on his own. Try as he may have done, Dr. Y could not reply to his wife’s frantic questioning nor the queries from the perplexed medical attendants.
As Dr. Y.’s listless body is loaded onto a gurney, medical staff learn of his gradually worsening insomnia, night sweats, and weight loss, in the context of 14-hours work days, 6–7 days a week. “My husband cares too much...it’s eating him alive, and now maybe it’s even killing him!” would declare Mrs. Y. A normally upbeat, fun-loving, and energetic personality, Dr. Y has steadily given way to a serious, easily frustrated, fatigued, preoccupied, and socially withdrawn persona.
Dr. Y remained immobilized, non-communicative, and holding a fixed gaze for a few days, but when whatever had caused his psychological arrest had eventually passed, the naval officer was walking and talking, and back to full-duty. Extensive medical and neurological examination revealed no identifiable cause, resulting in a vague, non descriptive diagnosis of “Idiopathic seizure”, a medically unexplained physical condition often associated with a spectrum of stress-related injuries.
Given an absent psychiatric or epileptic history, Dr. Y. finally agreed with his wife’s initial assessment. “I care too much, this is killing me!”.
But how exactly can “caring too much”, or giving empathy lead down this path of paralysis? Let’s look at what science can tell us about empathy, and why, at some point, your caring and empathising with others, is going to be something you should refrain from.
The history of terms pointing to the maladaptive effects of empathy begins with the term “shell shock by proxy”, introduced in Pat Barker’s acclaimed novel Regeneration in 1991. The term “shell shock” itself was a word that originated during World War I before PTSD was officially recognized, to describe the type of post-traumatic stress disorder that many soldiers experienced during the war. The term "shell shock by proxy" meant being vicariously affected by symptoms typical of shell shock. In his novel, Pat Barker depicts the true-life exploits of the legendary First World War Army neurologist and psychiatrist William Rivers and tells us that during his service at Craig Lock Heart hospital, Dr. Rivers had remarked that listening to individuals was fundamental to their recovery “The act of listening requires a willingness to be changed by what we hear” he would declare. But there was a real danger, he thought, that in the end the stories would become one story, the voices blend, into a single cry of pain. He had reached this conclusion because just like Dr. Y above, while at his hospital, Dr. Rivers began to unconsciously mimic the symptoms of his shell shocked patients. Disrupted sleep, severe speech impediment, excessive fatigue, irregular heartbeat, tremors, and even a disturbed gait, leading to the diagnosis of a Compassion Stress Injury as it was called in those days.
Other traces of maladaptive empathic responses is evident in the terms “old sergeant’s syndrome” and “burnt out” coined by U.S. Army psychiatrist Raymond Sobel during World War 2. These “old sergeants” were deeply concerned and committed to the welfare of their men, often serving as surrogate caregivers, while at the same time having to make impossible decisions leading to the deaths of those they cared for. Highly decorated, proven leaders, and demonstrating often an uncharacteristic tendency to be the first to get in the foxhole, and the last to leave, they succumbed to diverse constellations of psychiatric, somatic, and behavioral symptoms such as abnormal tremor, profuse sweating, excessive fear, speech deficit, severe fatigue, sleep disturbance, guilt, depression.
And if you thought this is normal and to be expected in the context of war, let it be known that such maladaptive empathy is not the backbone of only war, but the backbone of every deeply caring person, professional or non-professionals that they may be.
For instance, anecdotal descriptors of this phenomenon abound in talks about partners of veterans, the phenomenon falling under terms like “co-victimization”, “secondary survivor”, “rape-related family crisis”, and “proximity effects”. There are even recorded anecdotes of fathers displaying pregnancy symptoms. In fact, it is through this shared experience of stress, that the concept of Trans-generational trauma emerges after the Second World War. Danieli’s research on “generational trauma” within families of Jewish holocaust survivors reveals for instance the potential for unresolved Secondary Traumatic Stress to cross-generational boundaries, a topic I explored in detail in my blog Trauma Silently Walks in Time.
Finally in the context of my work as a therapist, Figley defines Compassion Stress as the left over of emotional energy from the empathic response we offer our clients. The on-going demand for relieving the suffering of the client leads us sometimes to be disturbed by persistent images or intrusive thoughts about the clients’ traumatic events. Such imagery can remain long after we have seen the client, and as a result, for some time, the therapist struggles with similar difficulties as the client, be that a crisis of faith, a sense of personal vulnerability, a fear of intimacy, or feelings of helplessness or hopelessness for instance. Thus the empathic involvement of the therapist with the client leaves the therapist vulnerable.
As a social animal, human beings possess a remarkable innate capacity to perceive, imagine, feel, understand, and respond to another’s emotional state, particularly distress and suffering. Sometimes we become so emotionally drained by caring so much that simply being a member of a family and caring deeply about its members, makes us emotionally vulnerable to the struggles that impact them. This is why for many of us, this natural emotional contagion is also often associated with avoidance behaviour. In fact, if it is true that there are people that have the tendency to empathise and go towards the sufferer, it is also true that in the face of suffering, many take a step backward, they become avoidant. I have seen personally the hostility that can emerge between these two tendencies, and I am sure you have too, but the the point is that both responses are evolutionary valid, and that the fact that some engage in avoidant, rather than approaching behaviour, does not mean that they are any less empathic. Both the approach and avoidant behaviour are ways of perceiving and managing the self-other distinction.
Nowadays, this hard-wired human capacity to synchronize with the pain experiences of others has been established by meta-analysis, confirmatory factor analysis, and systematic reviews, in other words, the very best that science can offer in research practices. The evidence behind the notion of empathic distress is pretty solid.
The pre-wired human empathic response is the result of a neurological reproduction of another’s experience in our brains. It occurs automatically by activating neural circuits involved in imitation, mimicry, and emotional contagion, all outside our conscious awareness or control.
The renowned and very much loved psychotherapist Carl Rogers, explained how this occurred in him: “Somehow there is a way in which the inner core of me relates to the inner core of the other person… I find myself responding to something in this other person that I didn’t know I was even aware of”.
Studies on the innate imitation ability of babies also help us understand how pre-conscious this ability is. A review on innate imitation by Meltzoff and Decety indicated that infants as young as forty-two minutes can accurately imitate facial expressions. These researcher’s seminal report of neonatal imitation has been substantially replicated, showing how innately hard-wired is the capacity for recognizing and duplicating the actions of others. Children, and adults, retain this uncanny natural ability as a powerful source of social learning, communication, and attachment.
But according to Klimecki and Singer, empathy can progress in two different ways. On the one hand, we have the pathway of compassion which operates on other-related emotions, not self-related emotions, such as loving kindness and positive motivations. On the other, we have the empathic distress pathway, which operates on self-related emotions, such as fear, poor health, and even burn out. Each of these reactions correspond to separate, but related neural pathways.
So in summary :
1. Empathy is rooted in our innate capacity to recognise and mimic the emotions of other people
2. Empathic Distress is an experience anyone can go through when helping others from a position of fear, poor health, or burn out.
2. Empathic Distress is an experience anyone can go through when helping others from a position of fear, poor health, or burn out.
Let’s look at some of the conditions that increase the likelihood of Empathic Distress. Ok so number one is a person’s empathetic ability. That is of course the individual’s specific capacity for noticing the pain of others, something that is naturally stronger in some rather than in others. The second factor is exposure. For instance face-to-face exposure evokes a stronger empathic response than say text or voice alone. Also, longer rather than shorter exposures, evoke more emotional content. The third factor is empathetic concern. This is the person’s drive to respond to those in need, and this is more the outcome of the person's upbringing than it is the outcome of a natural biological capacity, although the two are not completely separate. Finally empathetic response. This is the person’s degree of effort to alleviate the pain of others, again mostly an outcome of upbringing rather than biological factors.
So besides your natural empathic ability, there are three leverages you can operate to moderate the empathic distress you get when facing someone’s pain. These leverages are:
The last two of these three leverages are connected to your belief system, and many of your beliefs are models of behaviour you inherited unconsciously as a child. Thus the manner and intensity in which you respond to the needs of others is not that easy to change, and often requires learning new behaviours that could be in conflict with your family group, your friends, your culture, and your current interests. For instance, belonging to a collectivist or religious group, can make it a lot harder to change one’s attitude towards caring for others than belonging to a sports club.
The quantity and intensity of exposure is, on the other hand, in the short term, perhaps the easiest leverage we can operate to moderate our empathic distress. Reducing contact or exposure, and switching to text based interactions rather than face to face or video calls, would be an example of leveraging. Of course, done without reason, these tactics may leave the sufferer in even more suffering, thus triggering a backlash on us later on. These tactics need to be negotiated and communicated properly.
However, there are also a few other more subtle mechanisms that we can engage with to modulate empathic distress. Contemporary neuroscientific models of empathy posit that altruistic behavior is moderated by the manner in which we are aware of the boundary between Self and Other.
In human development, the emergence of a self-representation is vital for the empathic process. Conversely, sharing emotion without self-awareness corresponds to the phenomenon of emotional contagion, which takes the form of “total identification without discrimination between one’s feelings and those of the other”. As I have mentioned before, this is typically observed in babies who cry as a response to hearing other babies crying. Therefore, self-oriented awareness provides the critical capacity to differentiate self and other, and allows a person to detach and moderate the bottom-up instinctual empathic response. In short, the more self-aware you are, the more able you are not to melt into a single cry of pain mentioned by Dr. Rivers.
There is also Emotion Reappraisal, which is the ability to deliberately, and cognitively, re-evaluate ambiguous or negative emotions of others in a more positive manner. Think of your favourite comedian, and their ability to reframe their own suffering and that of others in ways that expresses a greater degree of detachment from the pain experienced by themselves and others. This is a case of reappraisal, and it has been shown in neuroimaging studies to help people leverage the automatic emotional synchrony with distressed others, by decreasing activity in the brain’s emotional processing regions, while increasing activation in regions essential for memory, cognitive control, and self-monitoring.
In fact, humour, the foundation of comedy, is all about top-down processes like perspective-taking, which activate neural pathways that stop automatic emotional reproduction of another’s behavior, as well as amplify cognitive appraisal of the self.
So mature empathy is the ability to recognize that the other person is like ourselves, while maintaining an appropriate self-other boundary. Self-regulation represent an essential component to maintain self-other distinction during an emphatic reaction, and the ability to shift between self-and other-perspectives, even though it has no impact on your automatic simulation of the other person’s emotions, it regulates the controlled aspects of empathy in a manner that makes Empathic Distress less likely.
In this respect it might be worth knowing that the cost of not moving in this more healthy direction, is rather severe. Besides physical symptoms, which I will speak more clearly in a minute, McCann and Pearlman identified seven major alterations of our thinking that occur when we are held captive by our tendencies to help. These are:
Now let’s look at the range of symptoms appearing when someone is under Empathic Distress because the diverse range of symptoms and signs associated with compassion stress are as severe as those attributed to “acute stress reactions” and “combat/operational stress reactions”. This is serious guys.
Here is a great table, extracted from an academic paper by Mark Russell and Matt Brickell 2015, showing how the stress response, activated in empathic distress fatigue, can manifest in physical, cognitive, emotional, and behavioural ways.
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On the left hand side of this table we have a list of common physical symptoms associated with the empathic distress response. It includes chills, difficulty breathing, dizziness, grinding teeth, headaches, nausea, profuse sweating, twitches, fatigue and weakness, and even fainting. These physical symptoms can be accompanied by feeling blameful, being confused, nightmares, poor concentration, increased alertness, or its opposite, decreased awareness of your surrounding and memory problems.
Emotionally, empathic distress also manifests in several ways. Agitation and anxiety, as well as depression and grief are the more common responses, but data also suggests guilt, denial, fear, loss of emotional control, and irritability and anger as being possible responses to empathic distress.
So how do these symptoms translate into behaviour? We have changes in communication and speech patterns as we saw with Dr. Rivers, changes in sexual arousal and appetite, we become more suspicious as we have seen with MacCann and Pearlman’s research, we find it difficult to rest as we saw with Dr. Y at the beginning, we begin to have unexpected emotional outbursts, we might withdraw socially, or increase our consumption of numbing drugs such as alcohol or marjuana, and finally we might find ourselves behaving anti-socially.
Empathy, if not managed, can paradoxically lead us far astray from its original intention.
The main lesson here being that empathy is a door to the sensitive capacity of every human to feel the other, but also a capacity that if not respected and managed, particularly in the hyper-sensitive persons like myself, can lead to pretty disastrous consequences.
So stop giving empathy away without a conscious understanding of how this impacts you, ask those who expect you to be empathetic towards you to be aware of how their sharing and asking might affect you negatively in the long run, and invest in self-awareness, your perspective-taking skills, and your ability to make jokes out of seemingly painful situations.
Thank you for reading, and as always, look after your heart,
Your Shrink In Bansko
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