Always. (Another lemma)

One word. Said slowly. "Always."
If you are like me, you are now in floods of tears. (I'm sorry.) Two things can be said about someone who has this reaction to this single word:

1. They have read (and quite likely watched) too much Harry Potter. Apparently it is possible to read too much Harry Potter.
2. They have strong empathy.

I am in the middle of a series of blogs about Political Correctness, but I'm going to interrupt the flow briefly to discuss the concept of empathy. One reason is that empathy will be significant in the final essay of the series, where I will argue that Political Correctness, when it is not out of control, is simply the act of being considerate about others' feelings: something which we are urged to do by almost every religion including Christianity.
But the main reason for this discussion is that I just started taking courses on counselling at Old Dominion University, and one textbook (Ivey, Ivey, & Zalaquett, 2017) says that it will be teaching the skills necessary to respond to clients with empathy. This raises a question: can empathy be taught? This is the question we will consider here.
Apparently I am not the first person in my position to ask this question. "Such a question is often one of the first posed by students who are learning the art of counseling, and it is an issue consistently debated in faculty discussions on the training of graduate students in mental health professions." (Hatcher, et al., 1994, p. 961.)  It is an important question, because empathy is critical in many circumstances. In counselling, of course, empathy is vital because so much of the outcome depends on the building of a relationship between the client and the counsellor, a relationship based on empathy. There is increasing evidence that empathy of doctors and nurses plays a role in improving medical healing. Building empathy is one method being explored to reduce occurrences of rape on campuses (O'Donohue, Yeater, & Fanetti, 2003; Foubert & Newberry, 2006), at military academies, and in the military. Building empathy may also be a way to reduce prejudice (Monroe, 2006).
Although the question is important, it is not easy to answer. The first difficulty is determining what empathy is. For example, is it a state or a trait? or both? I am using the words here in a technical sense: a trait is a a characteristic of a person that is consistent and long-lasting, and thus may be difficult or impossible to alter; a state is a temporary condition of a person. Some aspects of personality can exist in both forms. For example, state anxiety is a response to  a current threat, while trait anxiety is a characteristic of an individual which describes a propensity towards feeling anxious.

What is empathy?

It's a word we use in everyday conversation, but like so many words we use it very sloppily. It is easily confused with related concepts such as sympathy, pity, and identification (Davis C. M., 1990). Brené Brown capably describes empathy in contrast with sympathy, but even she, I think, confuses sympathy with pity. All describe a relationship between two people (or a propensity for a relationship, if we think of them as traits): the difference is the relative positions of the two people involved. Carol M. Davis (1990) provides a good description of these processes, which I will summarize here.

Sympathy describes a sharing of feelings, but the two individuals remain separate. I may feel the same way you do about the World Cup, or the death of your grandmother, and thus have sympathy; this is stronger than simple agreement, but there is no sense of crossing over into your feelings. Thus sympathy is a side-by-side experience.

Pity is a form of sympathy, but in this case the person feeling pity is in a superior position. This is what we see in the antelope in the Brené Brown video. When I pity you, not only do I remain separate, but I look down on you.

Identification occurs when I decide I want to be like a person or a group. It involves my adopting the values of the group. We see it currently in political affiliation: so many of us hold certain values simply because those are the values of the political party with which we identify. Identification happens more often when one struggles with one's own identity, which is one reason we find the counter-intuitive examples of gay men becoming evangelical Christians (Wolkomir, 2006) and the incidence of transgender individuals in the military being twice as high as in the general population (Gates & Herman, 2014).
Empathy is more difficult to explain. Carol M. Davis (1990) draws on the work of Edith Stein (later known as St. Teresa Benedicta of the Cross) for her description of empathy. She describes the act of empathy as something that happens, rather than as something that one does, and one doesn't know that it has happened except in retrospect. In this sense, it closely resembles falling in love. She describes it as a three-stage process, each stage of which is one of the phenomena often confused with empathy. When I experience empathy for you, I start with self-transposal, which is thinking myself into your situation. In the second stage, I find myself identifying with you so strongly that I "cross over" and our feelings become bound together. Often the person experiencing this feels an irresistible urge to reach out and touch the other person; I have often felt that myself. This could be an attempt to make physical the affective (i.e. emotional) connection which has happened, or it could be an attempt to re-establish my own identity as separate from yours. This leads to the third stage, where I regain my own separate identity and settle into what is effectively sympathy. It is the crossing-over, the connection to the point of losing my own identity in your emotion, that distinguishes empathy. And since this is something that happens, not something that one does, C. M. Davis is clear that it cannot be taught. What can be taught, however, are skills of active listening and taking the perspective of the interviewee, which establish conditions that enable empathy to happen.
Teresa Wiseman (1996) examined the concept of empathy as understood by nurses in training, and as expressed in the literature. She noted that confusion occurs in the literature because of confusion about the definition, and in particular the state/trait dichotomy. There has also been (and continues to be) confusion over whether empathy is a cognitive or an affective process. Wiseman (1996, p. 1164) noted that Carl Rogers "described empathy as having three components: affective (sensitivity), cognitive (observation and mental processing), and communicative (helper's response)." In her own study, she found that there are four defining attributes of empathy (which Brené Brown describes in her video). These are:

1. See the world as others see it
2. Non-judgmental
3. Understanding another's feelings
4. Communicate the understanding

Mark H. Davis (1980) also identified multiple dimensions to empathy, which form the four subscales of the Interpersonal Reactive Index (IRI) he developed:

1. Perspective-taking. The tendency to spontaneously adopt the psychological point of view of others.
2. Fantasy. Tendency to transpose oneself imaginatively into the feelings and actions of fictitious characters in books, movies, and plays. [This is the reason there are some movies my wife won't let me watch in a cinema; the intense sobbing disturbs the other viewers.]
3. Empathic concern. Feelings of sympathy and concern for unfortunate others.
4. Personal distress. Feelings of personal anxiety and unease in tense interpersonal settings.

Davis found significant differences between males and females for each of the four subscales. In all four cases, women had a higher average score than men, which is consistent with earlier results, and with the general impression that women tend to have higher empathy than men.

Can empathy be taught?

The IRI is a useful measure for detecting whether or not empathy can be taught, because success can be assessed in each of the subscales, although there are other measures which have been used. In one such study, Hatcher and her associates (Hatcher, et al., 1994) used Rogerian methods to teach empathy to both high school students and college students. They found that college students showed more improvement with the training than did high school students, especially in Empathic Concern and Perspective Taking. (The control group showed no improvement.) Although college females started with higher scores than their male counterparts, the amount of change resulting from the training was the same for both genders. To me, this suggests both a trait component to empathy (which is at least partially associated with gender), and a state component (which can be enhanced by training).
The ability to teach empathy has recently been debated in the medical profession, in a pair of contributions by Jeffrey and Downie (2016). Underlying their debate is the continuing question of whether or not doctors should be taught empathy. Downie, like others with whom I have spoken, worries that it will affect the physician's ability to be dispassionate. He writes, "Feelings require to be damped down or they may get in the way of sound clinical judgment and treatment" (Jeffrey & Downie, 2016, p. 111). He fears that all those feelings will contribute to faster burnout of doctors. I get the impression that Downie fears vulnerability. And yet it is vulnerability, Brené Brown argues in her famous TED talk, which makes us resilient.
In contrast, Jeffrey argues from the stance that empathy enhances the clinical outcome. He appears more grounded in the view that the physician is treating the patient, not the disease (Armbruster, 1981). [And if you're curious, yes that is my mother.] He argues that we can teach both the behavioural dimensions of empathy and the affective dimensions, and that "empathy is neither detachment nor immersion but an iterative relational process of emotional resonance, reciprocity and curiosity about the meaning of the clinical situation for the patient" (Jeffrey & Downie, 2016, p. 111).
Teding van Berkhout and Malouff (2016) conducted a rigorous meta-analysis of empathy training, using only studies that employed randomized controlled trials (RCTs). They found that training did improve measures of empathy across the 18 studies included in their research, although improvement was seen only in objective measures of empathy, not in self-report measures. They also found that the improvement in empathy was higher for some populations compared to others. Specifically, results were better with medical professionals and college students than with others (mostly younger subjects), which they considered consistent with requiring a certain level of neurological development in order adequately to display empathy. Training was improved by using all four components of behavioural skills training (instruction, modelling, practice, and feedback). There was also some improvement in effectiveness (although not reaching the level of statistical significance) in studies that targeted training behavioural empathy. They suggest that this "may be because cognitive empathy is considered to involve processes that can be consciously acquired, whereas affective empathy is considered to be more autonomic" (Teding van Berkhout & Malouff, 2016, p. 38).

A neurological connection

Recent research has begun to identify neurological components associated with empathy (Loggia, Mogil, & Bushnell, 2008; Iacoboni, 2009). This is particularly exciting, because it will allow us to examine whether training on empathy is reflected in neurological changes, or only in behavioural changes.

Conclusion

My conclusions are that empathy is important, both in many professions (even policing: see Thompson & Jenkins, 2013) and in everyday life, that there are both trait and state components to empathy, that empathy involves both cognitive and emotional (affective) components, and that there can be some improvement in empathy through training communication skills.

References

• Armbruster, G. (1981). A holistic approach for gifted children and their families. In D. Bitan, N. Butler-Por, A. Evyatar, & E. Landau (Eds.), Gifted children: Challenging their potential new perspectives & alternatives (pp. 222-236). New York: Trillium Press.
• Davis, C. M. (1990). What is empathy, and can empathy be taught? Physical therapy, 70, 707-711.
• Davis, M. H. (1980). A multidimensional approach to individual differences in empathy. Catalog of selected documents in psychology, 10(4), 1-17.
• Foubert, J. D., & Newberry, J. T. (2006). Effects of two versions of an empathy-based rape prevention program on fraternity men's survivor empathy, attitudes, and behavi. Journal of college student development, 47(2), 133-148.
• Gates, G. J., & Herman, J. (2014). Transgender military service in the United States. The Williams Institute.
• Hatcher, S. L., Nadeau, M. S., Walsh, L. K., Reynolds, M., Galea, J., & Marz, K. (1994). The teaching of empathy for high school and college students: testing Rogerian methods with the Interpersonal Reactivity Index. Adolescence, 29(116), 961-974.
• Iacoboni, M. (2009). Imitation, empathy, and mirror neurons. Annual review of psychology, 60, 653-670.
• Ivey, A. E., Ivey, M. B., & Zalaquett, C. P. (2017). Intentional interviewing and counseling: facilitating client development in a multicultural society. Boston, MA: Cengage Learning.
• Jeffrey, D., & Downie, R. (2016). Empathy – can it be taught? Journal of the Royal College of Physicians of Edinburgh., 46(2), 107-112.
• Loggia, M. L., Mogil, J. S., & Bushnell, M. C. (2008). Empathy hurts: Compassion for another increases both sensory and affective components of pain perception. Pain, 136(1), 168-176.
• Monroe, K. R. (2006). Can empathy be taught? Academe: bulletin of the AAUP, 92(4), 58-63.
• O'Donohue, W., Yeater, E. A., & Fanetti, M. (2003). Rape prevention with college males: The roles of rape myth acceptance, victim empathy, and outcome expectancies. Journal of Interpersonal Violence, 18(5), 513-531.
• Teding van Berkhout, E., & Malouff, J. M. (2016). The efficacy of empathy training: A meta-analysis of randomized controlled trials. Journal of counseling psychology, 63, 32-41.
• Thompson, G. J., & Jenkins, J. B. (2013). Verbal judo: the gentle art of persuasion. New York: William Morrow & Co.
• Wiseman, T. (1996). A concept analysis of empathy. Journal of advanced nursing, 23, 1162-1167.
• Wolkomir, M. (2006). "Be not deceived": the sacred and sexual struggles of gay and ex-gay Christian men. New Brunswick, N.J.: Rutgers University Press.