Social Empathy: The Art of Understanding Others

WHILE I WOULD not say that empathy is a full-contact sport, it is also not a sedentary, in-your-head experience. Empathy starts in our body. We know that we are capable of picking up affective reactions when we see or imagine the behaviors of others. These perceptions trigger similar physical reactions in our own bodies, initially without our awareness. We have a physical sensation, and then our brain goes to work figuring out what that physical sensation might mean. Our mental awareness might kick in strongly enough for us to actually be aware that we are thinking about what other people are going through and how we might feel ourselves if we were in their shoes. Thus, empathy is both physical and mental.

A lot of the physical activity accompanying empathy goes on in our brains and requires a variety of nerve centers to connect and communicate. This means that if the full physical functioning of our brain activity is blocked or impaired, so too is our empathy. Because of this physiological connection to empathy, we need to consider what happens when there are competing demands on the same parts of our brain that are needed for us to engage empathically. To complete this examination, we need to go a bit deeper into the biological process of empathy in the brain. Once we have a good idea of the neural mechanics, we can consider whether common human experiences that involve similar parts of our brain, such as stress, depression, grief, or even intoxication, compete with our engagement in being empathic. In other words, can we experience empathy when we are stressed out, in a deep funk, grieving the death of a loved one, or overdoing it with cocktails at a party? Of course we humans can multitask, but these human experiences involve emotional and psychological demands that can be very powerful, so we need to ask if the intensity of other tasks closes off pathways that are used for empathic processing.

We have already talked about cognitive neuroscience, the study of our brain activity, and how we can read the brain activities that reflect empathy through advances in technology. This ability and study is relatively new. Back in the 1990s, researchers in Parma, Italy, were examining the brain activity of Macaque monkeys.1 The neurological monitoring they were doing involved electronic nodes attached to the monkeys that tracked all their brain activity. They were interested in identifying brain patterns that corresponded to physical activities such as grasping items, holding things, preparing food, and actually eating. One day, while they were taking a lunch break in the lab, they were surprised to see that the monkeys watching them had the same brain activity as if the monkeys themselves were eating, except they were only watching the action of eating. These Italian researchers had discovered mirror neurons, the nerve cells that transmit imagery into the feeling of action.² Their discovery paved the way for neurological research on empathy.

The proof of mirror neurons in humans is a bit controversial, in part because there is no one place in the brain that conclusively conducts mirroring.3 Because the mirroring process seems spread across numerous areas of the brain, it is often referred to as the mirror neuron system, suggesting a process conducted by groupings of neurons.⁴ Although there is debate as to whether there is an organized system that is responsible for mirroring, the action of mirroring is well accepted in empathy research. Although we still may not know exactly how it plays out neurologically, we do know that our brains trigger for actions we see, even if we are not doing the action ourselves. As discussed in chapter 1, there is no specific empathy center in our brains; instead a number of actions come together that can be traced to various neural regions. Thus, many different parts of our brains are involved in empathy.

There is a wonderful TV series, The Brain, on PBS that features the neuroscientist David Eagleman. I highly recommend his work because he makes a very complicated topic, the working of our brains, understandable and captivating. You can also read his book The Brain, which provides an even deeper look at our neurological functioning. To appreciate the complexity of our brain and the magnitude of its functions, it is worthwhile to consider the following facts: the human brain has about eighty-six billion neurons; a neuron is a cell that transmits messages between the brain and other parts of our bodies, including other areas of the brain; each neuron makes about ten thousand connections; if we could track each of these connections, it would be an incredible amount of data. “Reconstructing the full picture of all the connections in a human brain is such a daunting task, and one that we have no real hope of accomplishing anytime soon. The amount of data required is gargantuan: to store a high-resolution architecture of a single human brain would require a zettabyte of capacity. That’s the same size as all the digital content of the planet right now.”⁵ I learned that a zettabyte is a billion terabytes, and one terabyte is over a thousand gigabytes, which is to say that we have a lot going on in our brain! To me, this point makes it clear that the human brain is an incredible “computer” of its own, far beyond the ones we have built, and we have just begun to scratch the surface of mapping what happens with all the processes that go on in our brains.

I am not a neuroscientist, so my understanding of the brain is rather elementary. Even at my introductory level, I am struck by the power of our brains. Weighing in at a mere three pounds of neural tissue, the brain controls and guides all our actions—conscious and unconscious. We don’t have to think about our breathing, blood flowing, or heart beating. Our body hums along in ways that are unconscious to us, and then may or may not become conscious for us. The brain is our center for taking in information and making sense of it to help us negotiate our surroundings.

In general, the process starts with information taken in through our senses, such as sight, smell, or hearing. That information is processed through our internal systems to figure out what the information means for our bodies at that moment. Then the information gets routed to other parts of the brain for more advanced cognitive processing. For example, I am writing this while sitting at my computer during the summer with the air conditioning on. Because the air conditioning fluctuates, my body has to adjust to the slight temperature changes, cooling itself when the temperature is a bit high and readjusting when the air conditioning kicks on and I get a little blast of cool air. These are internal, unconscious adjustments. Sometimes, especially as the day gets warmer and the sun starts to hit the window in my study, I will all of a sudden become aware that I am hot and uncomfortable. I tune in mentally and realize that it is now afternoon; the sun is strong and facing my windows. I understand this process because I have learned over my lifetime about the power of the sun. I have also sat at my desk for many summers and learned specifically that my study gets hot in the afternoon. I also understand the working of the thermostat and that I can control the air conditioning. With all this processing of physical sensations, the science of the sun, and the knowledge of how air conditioning happens in my house, I get up and adjust the thermostat. Although empathy is complex and involves understanding the more abstract emotions and behaviors of other human beings, in a very simplistic way this example outlines the process we use to empathically experience sensations in our bodies and then process in our brains what those sensations mean.

Embedded in the center of our brains is a group of brain parts that we refer to together as our limbic system, which is the main processing center of the information from our senses. It includes the amygdala, hypothalamus, and hippocampus. Each part plays a crucial role in helping us to operate within our environment. The amygdala is the part that detects what we sense and then directs that information on for further processing. It is most concerned with detecting fear and anxiety, which are key to our most basic survival. The amygdala sends the information to the hippocampus, which draws on what we already know from our memory or stores new information in our memory and then sends the relevant information to the hypothalamus, which directs the body to do what it needs to do in response to all the information. All this is done unconsciously and is our basic survival mechanism. Once all this initial information is processed, it can be sent on to other regions of the brain for more advanced cognitive processing, basically what we might experience as the thinking part. For our purposes in understanding empathy and brain functioning, know that the brain takes two actions for empathy to occur. The unconscious reading of outside stimuli, typically processed through the limbic system, is first. Then the information is sent to the cognitive areas of our brain for us to figure out what it all means. When either action is blocked, the physical sensing or cognitive processing, we have difficulty in tapping in empathically.

I have tried to understand the various parts of the brain in order to teach about the neuroscience of empathy. To help myself place empathy within the workings of the brain, I developed table 5.1, which lists the activities related to empathy and the corresponding parts of the brain based on a review of dozens of neuroscience research studies.⁶ Because the field of cognitive neuroscience is expanding and tools for reading brain activity are advancing all the time, consider this listing dynamic and evolving. But hopefully it gives you a broad overview and demonstrates how neurologically varied and complex engaging in empathy can be.

I was in the process of developing this chart as preparation for a class I was teaching on empathy when it hit me: What if one or more of these brain parts did not work well? I started thinking about what happens to our ability to empathize if there is damage to the brain or underdevelopment of one or more of the many parts of the brain. There are a number of studies on brain damage and empathy. An overall review of almost thirty studies that looked at specific damage from a brain lesion and the ability to recognize, share, and understand the emotions of others does provide clinical research on the impact that brain damage can have on empathy.7 Indeed, the ability to read others and make meaning out of that information can be compromised with damage to parts of the brain. For example, in research on patients who had a stroke, particularly those with damage on the right side of the brain, there was impairment in their cognitive abilities, and they scored lower on empathy than did a comparison group of people who had not had a stroke.⁸ This deficit was also found in patients who had undergone surgery to remove slow-growing brain tumors. However, there was evidence that the brain can compensate under these circumstances and develop other ways to engage in cognitive processing, which we know is necessary for empathy.⁹

Because of the complexity of the brain and the fact that lesions and other forms of brain damage can vary greatly from patient to patient, we have a long way to go to be able to identify the exact relationship between damage to a specific part of the brain and its impact on empathy. Because empathy involves multiple tasks and numerous parts of the brain, injury in one part may have an impact but not necessarily a total blockage to empathy. For example, the parts of the brain that help with recognizing emotions in others might be damaged, but not the brain parts that help a person to take another’s perspective once the other person’s emotions are identified. In practice this might mean that if a person has a brain injury that impairs reading the emotions of others, telling that person how you are feeling can fill in for that deficit. The ability to read other people may be impaired but not the perspective-taking to understand what those feelings mean. I may not be able to feel that you are sad, but if you tell me that you are sad, I may then be able to think about what being sad means and comfort you. The complexity of empathy means that there can be disruptions in the brain to parts of but not the entire process. Although it may be challenging to zero in on which parts work and which don’t, in addition to compensating for what we can identify as problematic, the brain can recover or reroute processes. Learning and practicing alternative ways to take in and process information makes the return of empathy very possible, albeit possibly in a different way than before the injury.

The possibility of permanent or temporary brain changes or dysfunctions having an adverse effect on empathy intrigued and concerned me. What if no matter what we teach about empathy, the person we are working with has brain parts that are not working well? Asking someone to feel something for another person when the brain pathway to do that is impaired means empathy would be impossible. We would have to figure out a way to help people get rid of the conditions that impaired their brains or compensate and work around such brain issues. The question of whether there are barriers to empathy due to brain functioning led me to look at the extent that other neurological demands might affect the empathy brain parts. The first area that caught my attention was stress because I already suspected from my own life experience that when stress levels are high we are consumed by our worries and don’t think much about other people.

Robert Sapolsky, a biologist and neurologist, wrote a must-read book for anyone who wants to understand stress and the impact it has on our bodies.10 The book title Why Zebras Don’t Get Ulcers is the lead in to how stress differs for us as human beings than in animals. We are similar to animals in that our bodies are capable of recognizing threats to our survival and process that information in ways that help us to deal with the resulting stress. Sapolsky argues that our bodies have evolved to handle periods of stress, which is how we survived as a species. If you see a saber-toothed tiger prowling in the distance, your eyes feed that information through your limbic system, and in an instant your body processes that input to determine the level of threat. Your body is likely to immediately go into a different physical state—messages are sent to release stored energy and power up your body to react. We can feel that process in the quickening of our pulse and breathing. We often talk about a “rush of adrenalin.” The hormone that is secreted, epinephrine (the scientific name for what we call adrenalin), is the switch to turn up these functions. This process is unconscious, stimulating reactions that provide us with the resources to respond, giving us more oxygen, protein, and glucose, which altogether power us to run off or to fight.

Another hormone is released if the stress is not resolved quickly: cortisol. Cortisol is the hormone that continues the production of resources for energy but also shuts down body processes that are not needed in the immediacy of dealing with the stress. While running away from or staying to fight that saber-toothed tiger, we don’t need our body to work on growth, reproduction, regenerating our immune system, or high-level thinking. The hippocampus is activated, calling on our prior knowledge of saber-toothed tigers, either from previous personal experience or what we have learned from others. Cortisol plays a part in activating the hippocampus for retrieving those memories. Once the stress passes, presumably we have survived the saber-toothed tiger and are now catching our breath, returning to our calmer life. The body stops secreting hormones in response to stress, and we absorb those so the messages created to move the body into stress response mode stop. Epinephrine seems to be absorbed more quickly than cortisol. That is why after a particularly upsetting experience it takes some time for us to calm down, get our breathing and pulse back to normal, feel less on edge, and fall into a resting state.

So our bodies are well equipped to handle periodic stressful events. The problem lies in that we are not well adapted to handle prolonged, chronic stress. Our ability as human beings to retain strong memories about the past and think about the future means that we can hold onto stress for long periods of time, including beyond its usefulness. For some people, their lives are in constant states of stress, such as not living in a safe place, not having enough to eat, working for a bullying boss, or being raised in a dangerous and unpredictable environment. Physiologically, the changes our bodies make for short-term stress are not good for us if maintained over long periods of time. Why Zebras Don’t Get Ulcers provides an extensive explanation of the biology of stress, which I do recommend reading if you want to understand the details. Perhaps one example can help to illuminate the downside of long-term stress. A lack of sleep can turn on our stress response, which in the short term may not be problematic, and it also makes sense—imagine being on alert for danger at night. Or in my case, that sleepless burst of energy is what helps me to meet a pressing deadline. But when there is a cycle of pressing deadlines, financial worries, or family problems that keep you awake night after night, your stress response stays activated, and you continue to toss and turn or sleep poorly. Lack of adequate and good sleep does not allow the body to recalibrate to its healthy, balanced state, leaving us open to illness, disease, and ultimately less sharpness in our mental functioning. Sapolsky sums it up well:

When too much cortisol remains in our body or continues to be produced, the neural messages for emergency operations stay on. Over time this is detrimental to our functioning. It is particularly problematic for children who need to develop and grow. According to the National Scientific Council on the Developing Child, when children experience frequent and prolonged stress, such as severe, chronic abuse, their cortisol levels stay elevated.12 This state of elevation in cortisol can change the functioning of the entire neural system, suppress immunity, and disrupt the actual structure of the brain. Such disruptions can have adverse effects on learning and developing memory. These are particularly harsh outcomes for children who will have a very difficult time later in life if their brain development is compromised by severe or prolonged stress at a young age.

If the process of long-term stress interrupts our ability to think clearly and operate at full health, does that bode poorly for our chances to be empathic while under stress? Many of the areas of the brain that we rely on for empathy are disrupted by long-term stress. We need the limbic system to experience affective response. For all the cognitive parts of empathy (mentalizing, self-other awareness, micro and macro perspective-taking, emotion regulation, and contextual understanding), we rely on various parts of the prefrontal cortex. This is the part of our brain where we perform sophisticated thinking. Unfortunately, it is also the part of the brain that is most sensitive to the negative effects of stress.¹³ For example, in one experiment, people who grew up in harsh families had different brain activities when viewing threatening faces than did those who grew up in nurturing families.¹⁴ The differences showed lower amygdala activity in those from harsh families. The researchers considered this response to reflect their ability to tune out or avoid the threatening stimulus. However, when both groups were asked to write about the picture, the opposite happened: those from harsh families had greater amygdala activity; they were overstimulated. On top of that, they also were not able to effectively activate their prefrontal cortex for emotion regulation. It is possible that once those with harsh family backgrounds engaged with the pictures, it triggered previous experiences that were stressful, hence their neural overreaction. This study gives us some important findings to think about in terms of prolonged early life stress and what that means for the brain parts crucial to empathy.

What about short-term stress, the kind that we all go through and that can even give us energy and motivation? Studies are mixed on that. There is some evidence that being exposed to a stressful event and then shown pictures depicting painful procedures (such as a needle being inserted into a hand) diminishes empathy, particularly because the prefrontal cortex shows impaired function.15 There may be a gender difference, with women responding to stress with stronger ability to engage in perspective-taking than men.¹⁶ Another possibility is that short-term stress improves our ability to affectively respond to stimuli, but not necessarily on the other parts of empathy.¹⁷

What the research suggests is that an acute or short-term incident of stress may heighten our attention to the actions of others but not have much of a positive effect on the cognitive parts of empathy. We can grab people’s attention through stress, but if it goes on for prolonged periods of time, that initial spike in awareness will become problematic and the hormonal releases activated will shut down the brain process necessary to tune in empathically. Does this mean a poor start to life sentences a person to living without empathy? Not necessarily, but it does require reworking one’s abilities with self-other awareness, perspective-taking, and emotion regulation. In fact, there is some research that suggests the key to overcoming the impairments from chronic stress turns out to be emotion regulation.¹⁸ Developing emotion regulation in children who have grown up in poverty with chronic stress can improve their prefrontal cortex functioning. And the prefrontal cortex is where so many of the components of empathy are processed, including emotion regulation. As we will discuss in chapter 8, the reworking of brain patterns can be done throughout life, giving us all a chance to overcome any early deficits and become fully engaged empathic people.

One form of stress that has gained a lot of attention in recent years is posttraumatic stress disorder (PTSD). According to the National Institute of Mental Health, PTSD is an anxiety disorder that can develop after a person sees or lives through a threatening or harmful event.¹⁹ It is characterized by symptoms that last longer than a month and disrupt the person’s functioning in relationships and in life tasks such as holding a job. The symptoms can include reliving the trauma, avoiding feelings associated with the trauma, feeling tense and unable to sleep or relax, being easy to startle, having memory problems, engaging in negative thinking, and experiencing a loss of interest in enjoyable activities. While these are symptoms we would expect any person to have after a traumatic event, it is the ongoing duration and interference with day-to-day life that make such symptoms a disorder.

There is not a lot of research on empathy and PTSD. The research that we do have identifies an interesting difference in the neural processing of empathy for people with PTSD compared to people without PTSD. The researchers in two different studies found that for people with PTSD, the affective part of empathy, which includes mirroring, registers in their brains as less intense, but the cognitive parts that include perspective-taking are not different.20 This is similar to the research on stress in general. One possibility for the difference in affective response is that a lower reaction to emotional stimuli might be a good coping mechanism for people who have PTSD. Their state of being is likely on high alert because they may still be reliving the trauma or are on guard to protect themselves from another traumatic event. While they may be low on affective response, they are fully capable of engaging in the more deliberate thinking aspects of empathy, like perspective-taking and self-other awareness. This strikes me as a logical response to trauma. The body is still on high alert and the impact of the trauma still lingers, but that is exhausting. Tamping down the reaction to external stimuli can give the body a chance to rest and heal. However, outwardly that tamping down comes across as being distant, removed, and unconnected to others, which are some of the behaviors associated with PTSD.²¹

Knowing that people who suffer from PTSD are fully capable of cognitively processing the feelings of others but that getting there through affective response is more difficult means that engaging in empathy might take a different route than what is typical. One possibility is to help people increase their emotion regulation skills so the physical stimuli are not overwhelming. By taking in external stimuli in a calmer state with the help of greater emotion regulation, the cues can then be used to engage the cognitive components of empathy. Another possibility is relying more on the cognitive processing so that we engage empathy through discussions. For example, explaining what I am feeling, how I would like you to understand that feeling, and doing that by talking it through with you can bypass the shared physical affective response. This approach relies more on mental processing and less on physical sharing. Remember, empathy is a process, so how we get there and for how long can vary for each of us. Recognizing barriers to empathy, such as those that PTSD and other forms of stress may present, provides insight as to which component may need more attention and alternative ways to do that.

What impact might poverty make on empathy for those who grow up poor? We know that poverty is not good for physical health. Sapolsky’s work on stress includes a warning about the poor health outcomes from stress induced by poverty:

This is a public concern about the future of people’s health and well-being. To what extent does the physiological damage from poverty also impact people’s ability to tune into others? The research on brain development and poverty is limited, but what is out there is not optimistic. Comparisons of brain development between higher- and lower-income students found that the actual thickness of brain matter was greater for students from higher-income backgrounds, and greater brain matter was correlated with higher academic achievement.²⁴ More detailed research found that the picture may be more complicated. While some parts of the brain are less developed for lower-income children, other factors may be at play. In other studies, when a parent’s level of education was factored in, that was more important in explaining the difference.²⁵ It seems that parent education in situations with better income levels still was a strong predictor of a child’s brain development. The researchers suggest that a higher level of parent education may be a strong contributor to enhancing brain development for children. Thus, living with an educated parent, or one who can provide an intellectually stimulating environment, could override growing up in poverty.

If the key to brain development is creating intellectually stimulating environments for children, which in turn develops the neural abilities needed for empathy, we have an intervention to improve empathy: provide intellectual stimulation for all children so they develop healthy brains! While there may be a moral imperative to provide stimulating learning for poor children or those with parents of low education as does exist for children of higher economic and social classes, there is also the benefit of better brain development. And better brain development can improve health and cognitive functioning, which also allows for the development of empathy.

As noted earlier, when looking at class background and empathy, research finds that those from lower-income backgrounds show higher levels of correctly judging the emotions of others compared to people from higher-income backgrounds.²⁸ So ironically, poverty may not be a barrier to empathy if the physiology of the brain is not compromised because those who grow up as part of lower social and economic classes have greater interest in context and social interactions. Being from a lower socioeconomic group means it is more likely to be outside the circle of power, which, as discussed previously, means it is more important to understand context and watch the behaviors of others. That interest may provide more opportunities to develop the skills of contextual understanding and perspective-taking, making empathy, particularly social empathy, actually more developed among those from lower-class backgrounds than among those from higher classes. Of course, the foundation for this is a healthy brain. If we can support the physiological development of healthy brains for all children, then empathic development can follow.

In 2016, more than four million allegations of child maltreatment were investigated by professionals with child protective services agencies across the United States.29 This was more than a 10 percent increase over the previous four years. And of these millions of cases, almost seven hundred thousand children were confirmed to have been victimized, three-fourths of whom were neglected and one-fourth physically or sexually abused. Each year more children are added to the list of those we know have experienced stressful and threatening events at the hands of adults who either did not protect them or were abusive. Based on what we know about child development and empathy, it should worry us that every year millions of children are at risk of maltreatment that compromises their emotional attachment and brain development. Abuse threatens to create a negative starting point for empathy.

We know that stress in childhood has adverse effects on engaging the parts of the brain needed for empathy. For some children, constant stress is part of a traumatic childhood. It may be impossible to separate stress that emanates from a childhood of neglect and abuse from the impact of other harsh childhood experiences. But given the extent of the abuse and neglect of children in this country, it is important for us to consider how that start to life may impact the ability of people to fully engage empathically. Numerous studies have found that childhood maltreatment is associated with structural brain changes. Those changes include abnormalities in the prefrontal cortex, as well as the amygdala and hippocampus.³⁰ We know that these regions of the brain are critical to empathy. It also seems that these are the same parts negatively impacted by stress. It is likely that the experience of maltreatment evokes the same bodily responses as chronic stress. This is not surprising. Maltreatment is extremely stressful and can stretch over long periods of time. Although the majority of cases of child maltreatment involve neglect, which may sound less severe, the impact is significant and can set the stage for problems later in life. Children raised in families with chronic neglect are at greater risk for severe cognitive impairments that contribute to emotional, behavioral, and interpersonal relationship difficulties later in life.³¹

In terms of empathy, emotional damage from maltreatment early in life compromises a child’s ability to develop empathy, with the biggest deficit in emotion regulation.³² Maltreated children live through situations that are unpredictable and frightening without emotional support. Living in such an environment requires that a child constantly be vigilant and watchful for warnings of mistreatment. Their lives are lived on edge. That level of stress produces all the negatives we discussed earlier, especially compromising the neurobiological ability to regulate emotional responses to stressful stimuli.³³

Even if we did not have evidence of neurological differences in children who have experienced maltreatment compared to children who have not had such trauma, we know enough about empathy to worry that their empathic abilities would be compromised. The state of overarousal and constant vigilance with unpredictable emotional support would make developing self-other awareness, perspective-taking, and emotional regulation difficult. That is not to say that children who have experienced neglect and abuse are not empathic or capable of developing empathy. What child maltreatment does is make that pathway more challenging. Developing empathy after a harsh childhood requires the unlearning of behaviors that were protective while being maltreated but are not helpful in becoming empathic. In fact, there may be evidence that even a stressful early life, such as being institutionalized, can be overcome with predictability and support that come with adoption and a stable home.34 One of the most encouraging things to know about our biology is that our brains are malleable; we can unlearn things that are not helpful to our well-being. It’s not easy, but it is possible, and we will talk more about that in chapter 8.

The literature on empathy and grief is concerned with having empathic feelings for those going through the difficulties of grief and bereavement. Needless to say, that is important. But when I was thinking about physical states that might block our ability to be empathic, I was wondering whether grief has physical demands that might interfere with our ability to be empathic. To my knowledge, this is an unanswered question. I did find some research that compared cognitive performance and brain matter volume across three groups: people with no grief, people with normal grief such as bereavement for a loved one, and people with persistent and prolonged grief that is categorized as complicated grief.35 Although the differences were not great, those with prolonged and complicated grief performed poorly on cognitive tests and had a smaller amount of brain matter than those in the other groups. This suggests that there could be neural effects of grief that might diminish our cognitive processing, which we need for the full array of empathy to occur. I am reminded of my colleague Cynthia Lietz’s work on resilience that I mentioned in chapter 2. People who have come through very difficult events, which includes grieving a loss, have found ways to make meaning through their understanding of what others have gone through. They show resilience over time by engaging in empathy. So it is possible that the immediacy of grief might create a kind of brain drain that initially affects empathic abilities, but that empathy may be a part of working through our grief. Mind you, this is a theory, but it would make sense that one tool to deal with grief is to connect with others who have gone through a similar circumstance and to share emotions and insights. Such actions would involve the components of empathy.

There is a lot of research that looks at the impact of alcohol and drugs on our brains and neural systems. Of course, a review of such research is far beyond the scope of this discussion and my expertise. One helpful way to get a sense of this much research is to consult work by experts in the field who review many studies, often referred to as a meta analysis, which is a comparison of multiple studies. In a review of 140 studies that used brain imaging to track the effect of alcohol on the brain, the overall finding was that heavy alcohol use does adversely affect our brains, both in the physical structure and in the abilities to carry out mental functions.³⁶ It is possible that the brain changes found in heavy alcohol users are in part a consequence of time, that is, using alcohol for years and years. To address the question of whether it is a matter of long-term use, another review of multiple studies focused on younger people.³⁷ These researchers wondered if heavy alcohol use in younger people whose brains were still developing and were not exposed to alcohol use for many years showed abnormal brain changes. These studies also showed diminished brain structure, particularly in the prefrontal cortex. Overall, there was evidence that brain development for adolescents may be affected adversely by heavy alcohol use.

A very small study did examine the parts of the brain related to cognitive and affective processing in people with alcohol use disorder compared to people without the disorder.38 Indeed, they did find a reduction in brain matter (cortical thickness) in the areas of the brain that are used for processing empathy in those with alcohol use disorder compared to healthy participants. They even divided the healthy participants into two groups, those with a family predisposition to alcohol use disorder and those without, to be sure that it was not a genetic or inherited difference. The only participants to have the reduced brain matter were in the group with alcohol use disorder.

Although we do not have large-scale research that tracks alcohol use and empathy, we should worry that the damage to the brain that can come from heavy alcohol use affects a key region for cognitive processing: the prefrontal cortex. This means that we should at least be aware that changing the structure and ability to function of the brain due to alcohol could negatively impact one’s ability to use those brain regions to engage empathically.

Like with alcohol, there is scant research on drug use and empathy. However, we can assume that if drugs impact our brain, neural actions related to empathy will be affected too. Of course, we would likely think that such interference in empathy would be as a result of using serious drugs, ones that really alter our brain chemistry. That relationship has yet to be studied closely. But there is one recent study that did look at empathy and the use of a common, over the counter drug, the painkiller acetaminophen (which can be found in brands such as Tylenol, Excedrin, Nyquil, Sudafed, and Dristan).39 Given that acetaminophen is a legal and easily bought medication, the fact that it might alter our empathic abilities is rather surprising. Acetaminophen is a relatively common, low-level painkiller and is often included in mixtures for other drugs such as cold medicines. We would not expect a dramatic impact on our brain activities. However, the researchers confirmed that acetaminophen works to suppress physical pain, but that in that process, it also reduced the extent to which people felt others’ pain. These findings might reinforce the physical actions of mirroring. What if painkillers can lessen both the actual physical sensation of our own pain and the body’s sensation of pain triggered by viewing or imagining someone else’s pain? We might have proof that the mirroring of pain is a real physical sensation. In other words, feeling someone else’s pain is not just in our heads, we really do feel it. While these findings may confirm the power of mirroring, might they also raise the risk of lowering our empathy for others because we use medications to lower our own physical reactions? Or is it that only our mirroring for pain is impeded and we can still fully engage in perspective-taking, self-other awareness, emotion regulation, and assessment of context? That is, we may not be unconsciously triggered by the sharing of pain, but if we have learned how to think about what happens to others and what that means, we will move into cognitive empathic processing. One limitation of this study was that it used healthy, pain-free participants. What about people who really are in pain and use acetaminophen to alleviate it? Maybe in those cases, if their pain is eased, they can focus on others and go from a state of less empathy to more.⁴⁰ This recent research raises these questions and opens a very large area of study that needs to be considered in the future.

New emerging research on the neurochemical aspects of empathy has begun to look at the natural hormone oxytocin. Our bodies produce oxytocin, and it seems to be present when we are engaged in prosocial actions. There is evidence that oxytocin is linked to prosocial human behaviors, including empathy, social cooperation, group participation, and trust.⁴¹ Although we know our bodies produce oxytocin and it is linked to prosocial behaviors, we do not know biologically how it works.⁴² It may act as a messenger of empathy that already exists or enhance the building of empathy. At this point, all we really know is that when it is active in the body, so too are prosocial actions like empathy, cooperation, and sociality. Can we administer medically manufactured forms of oxytocin to help stimulate empathy and prosocial behaviors? So far there is minimal research on this. There is one study that administered oxytocin (through nasal sprays) to both patients with PTSD and healthy controls and found no significant changes in their empathic abilities.⁴³ More research is needed, but it does raise an interesting possibility for intervention. Can we alter neurochemical hormones to encourage empathy? I confess to being skeptical that we can take a pill and, voila, have empathy. But if there are neurochemical transmitters that help the brain to better engage in learned empathic processing, it certainly would be worth pursuing.

Several brain differences have been found in people with psychopathy, particularly the processing of the amygdala and part of the prefrontal cortex (specifically the ventromedial region).⁴⁶ The differences are characterized by a reduced response by the amygdala to stimuli followed by less discrimination of what those stimuli might mean. It is unclear if both areas are dysfunctional or if the amygdala takes in less input, leaving the prefrontal cortex with insufficient information to process. The result of these deficiencies plays out in poor learning of what behaviors are good and what behaviors are harmful.⁴⁷ Perhaps most important is research that finds that people with psychopathic personalities can identify others’ emotions but do not feel others’ emotions.⁴⁸ This is not empathy. This is a skill at reading other people, which can be dangerous without empathy. Reading other people can make it possible to identify their motives, desires, and fears but not take their perspective, and instead take advantage of them or treat them with disregard. This is why people with psychopathic personalities often act in ways that are callous, dominating, and lacking in empathy.

Empathy Component	Corresponding Parts of the Brain
Affective response	Amygdala
	Hypothalamus
	Hippocampus
	Mirror neurons, which seem to be located in the part of the brain that handles our motor abilities
Affective mentalizing	At least four different parts of our brain, two in the front, the ventromedial prefrontal cortex and dorso medial prefrontal cortex, and two in the back, the temporo-parietal junction and the bilateral superior temporal sulcus
Self-other awareness	Some of the same regions as for mentalizing, including the ventromedial prefrontal cortex and the temporo-parietal junction, another part of the front of the brain, the medial prefrontal cortex, and the right supramarginal gyrus, which is found at the junction of three lobes in the center of the brain
Perspective-taking	Uses the regions found under affective mentalizing as well as the perigenual anterior cingulate cortex, which spans sections in the middle of the brain
Emotion regulation	Shares the anterior cingulate cortex used by the mirror neuron system, the medial prefrontal cortex used in self-other awareness, and the ventromedial prefrontal cortex used in mentalizing
Contextual understanding	All of the regions above, with greater emphasis on the actions of the prefrontal cortex to process the multiple sources of input
Macro perspective-taking	Uses the regions found under affective mentalizing as well as the perigenual anterior cingulate cortex, which spans sections in the middle of the brain with attention to the parts of the brain activated with self-other awareness