CASE FOR MINDFULNESS-BASED APPROACHES IN THE CULTIVATION OF EMPATHY: DOES NONJUDGMENTAL, PRESENT-MOMENT AWARENESS INCREASE CAPACITY FOR PERSPECTIVE-TAKING AND EMPATHIC CONCERN?, THE
Block-Lerner, Jennifer
Empathic responding, most notably perspective-taking and empathic concern, has important implications for interpersonal functioning. While empathy training approaches have received some support for a variety of populations, few extant interventions have targeted empathic responding in couples. Mindfulness- and acceptance-based behavioral approaches, for couples as a unit and/or for individual family members/partners, are proposed as an adjunct to empathy training interventions. Preliminary findings suggest that the viability of these interventions for increasing empathic responding should be further investigated, and specific suggestions for this line of research are offered.
The case for mindfulness-based approaches in the cultivation of empathy: Does nonjudgmental, present-moment awareness increase capacity for perspective-taking and empathic concern?
Consider two scenarios. In the first, “Megan” returns home after a busy day at work. She has at least several hours of work to do to prepare for an important meeting the next day. She has also been fighting a bad cold and spent many hours the previous night worrying about a close family member’s health. Her husband, “Michael,” is already at home and, as soon as she walks through the door, Michael launches into a story about how stressful his day was and how inappreciative his boss is of the time and energy he has been putting into his projects. Megan immediately recoils, and as she is seemingly listening to the ins and outs of Michael’s complaints about his boss, she experiences an internal dialogue along the lines of, “I’ve heard this so many times. Doesn’t he get that I have my own stress to deal with? Besides all the work I have to do for the meeting tomorrow, I have three reports due Thursday and on top of that, I must call to make appointments for the boys to get physicals for spring sports. I wanted to stop at the supermarket to pick up some pasta to make with dinner, but I ran out of time. Oh well, dinner is not the most important thing. I really hope everything is okay with Mom. I am concerned that she hasn’t called.” The next thing Megan knows, she is staring at Michael talking animatedly about an unexpected encounter with a friend and she has no idea how he moved to that topic or about anything else he said during the past 5 min. She knows that when she questions him about some of the details, things will escalate into a fight and, as usual, they will both end up feeling hurt and not heard.
Scenario two: Megan returns home after the same busy day at work with the same stressors and concerns on her mind and Michael greets her with the same needs. However, as Megan begins to listen to Michael’s story, she first takes a moment to observe her current emotional and physical state. She notices that she is especially tired, and that she is having a somewhat typical thought process related to the fact that Michael’s greeting suggests that he does not understand that she has her own stressors to contend with. She brings awareness to these thoughts with an “oh, there I go again,” and, reminding herself of her values to really listen to those she is closest to and to share her own needs and concerns, she refocuses her attention on Michael’s story. Megan notes that Michael seems unusually wary and that his facial expressions and the tone of his voice indicate that something might really be upsetting him. She quickly considers several options and decides to say, “Honey, it sounds like this is really important. Would you give me a few minutes to go get changed and to decompress and then we can talk while we pull dinner together? I have a lot of work to do tonight, but I want to make sure that we get a chance to catch up for at least a few minutes. It sounds like you had a rough day and I would like to hear about it. I have some things on my mind I would like to share with you as well.”
We can easily imagine the probable differences in reactions on Michael’s part to the first and second scenarios. The tone of the whole evening would likely be different depending on whether Megan was able to bring nonjudgmental awareness to her emotional reactions in the face of her first-moment-through-the-door encounter with Michael. Whether Michael was able to respond in kind, perhaps noticing a bit of hurt at Megan’s request but also recognizing the fact that she too has been experiencing a lot of stress of late, with multiple work deadlines, illness, and family concerns, would likely further shape the trajectory of family interactions this evening.
Research on empathy suggests that comprehending and being able to convey accurate and compassionate understanding of another’s emotional experience often lead to a deepening sense of intimacy and greater satisfaction among any two (or more) individuals (Davis & Oathout, 1987; Long & Andrews, 1990; Long, Angera, Carter, Nakamoto, & Kalso, 1999). The above examples speak to the role that mindfulness (i.e., “nonjudgmental, present-moment awareness”; Kabat-Zinn, 1994, p. 4) might play in the fostering of such empathic responding. The purpose of this article is to further explore the relation between facets of mindfulness and aspects of empathic responding. The case will be built for consideration of mindfulness- and acceptance-based behavioral therapeutic interventions as an adjunct to existing approaches designed to increase individuals’ capacities for empathy. Additionally, shedding light on the relation between these two constructs may help us to appreciate broader relational and societal effects of mindfulness-based therapeutic interventions. We begin with a discussion of the construct of empathy.
The term “empathy” comes from the German “Einfühlung,” meaning humans’ projection of feeling into the things and people they perceive (Duan & Hill, 1996). It has been distinguished, by Wispé (1986), from sympathy (i.e., “heightened awareness of the suffering of another person as something to be alleviated”; p. 318), although affective elements of empathic responding are related to sympathy, and defined as “the attempt by one self-aware self to comprehend nonjudgmentally the positive and negative experiences of another self” (Wispé, 1986, p. 318). Inherent in Wispé’s definition is a degree of self-awareness, which, as we will discuss later, is also a crucial component of the process of mindfulness.
The construct of empathy has perhaps received the most attention in the counseling literature, specifically within the domain of humanistic therapeutic approaches such as Rogers’s client-centered therapy. Rogers (1992) considered empathy to be one of several “necessary and sufficient conditions” of psychotherapeutic change and defined it thus: “to sense the client’s private world as if it were your own, but without ever losing the ‘as if’ quality” (p. 829). Greenberg, Watson, Elliott, and Bohart (2001), citing Barrett-Lennard’s (1981) classification, point to the importance of considering empathy within the therapeutic relationship from three different perspectives: the experience of the therapist, the view of an observer, and the experience of the client.
Duan and Hill (1996) argued that conflicting definitions and conceptualizations of empathy may account for contradictory findings in the literature about the value of empathic responding. They highlight the importance of distinguishing between empathy as a personality trait or stable ability, as a “situation-specific cognitive-affective state” (p. 262), and as an experiential process with multiple phases that must be considered on a moment-to-moment basis. These authors also encourage explicit differentiation of the cognitive and affective components of empathy (which are not mutually exclusive), which they deem “intellectual empathy” and “empathic emotions,” respectively.
While many researchers have, consistent with Duan and Hill’s (1996) suggestion, highlighted the cognitive and affective components of empathy, some believe that these two aspects are still too broad and suggest that empathy should be viewed in terms of the more specific ways we react to others. Davis (1983) identified four distinguishable elements of empathy which give rise to one’s overall reactivity to another. Perspective-Taking (PT) is the cognitive ability to take on the psychological perspective of another; Empathetic Concern (EC) is experiencing “other oriented” feelings of sympathy and concern for others’ misfortune; Personal Distress (PD) involves one’s own feelings of discomfort and anxiety in emotional social situations; and Fantasy (FS) is the tendency for one to transpose him- or herself into the thoughts and feelings of fictitious characters in books, plays, and movies.
Davis’s (1983) view of empathy, as operationalized by the Interpersonal Reactivity Index (IRI), is generally consistent with Duan and Hill’s (1996) “dispositional empathy.” While we do find Davis’s components of empathy useful to consider and we report findings based on the IRI, our conceptualization of empathy and related empirical findings is actually most consonant with Duan and Hill’s empathic process. Specifically, rather than being a trait that individuals have high or low levels of, we view empathy as reflected in specific behaviors (both overt and covert) that may be assessed, from various perspectives, on a moment-to-moment basis.
IMPLICATIONS OF EMPATHIC RESPONDING
Empathy has long been of interest to therapists of all orientations, given its reputed positive effect on the therapeutic relationship (e.g., Greenberg et al., 2001). Research has shown, for instance, that empathy strongly predicted clinical improvements among depressed patients receiving cognitive-behavioral therapy (Burns & Nolen-Hoeksema, 1992). In fact, empathy is thought to be a necessary, though not sufficient condition, for therapeutic change and growth (Hubble, Duncan, & Miller, 1999).
Beyond its benefits in the therapeutic context, studies have additionally demonstrated that empathy may impact other types of close relationships in important ways (e.g., Kilpatrick, Bissonnette, & Rusbult, 2002; Worthen, 2000). For example, research suggests that adolescents who demonstrate higher levels of empathy evidence higher interpersonal competence, lower aggressiveness, and less discordant friendships relative to adolescents with lower levels of empathy (Worthen, 2000). Empathy has also been linked to altruism and other forms of helping behavior (e.g., Batson, 1997; Dovidio, Allen, & Schroeder, 1990). Finally, couples able to accurately infer the specific content of their partners’ thoughts and feelings (termed “empathic accuracy”) are more likely to engage in relationship-enhancing behavior, such as accommodation (Kilpatrick et al., 2002). Overall, research has identified empathy as an important predictor of marital adjustment and predilection for divorce in married couples (Long & Andrews, 1990).
DEVELOPMENT OF EMPATHY
Given its implications for positive and healthy relationships, it is important to consider how the capacity for empathic responding develops. To some extent, aspects of empathic responding are a natural outgrowth of both the separation/individuation process (i.e., Mahler, 1974) and the decline in egocentrism (i.e., Piaget, 1932) that comes with increasing age through childhood. Hoffman (2000) posits that empathy develops in three stages. Initially, infants do not experience themselves as separate from others; they seek comfort for themselves when, for example, they hear another child cry. Toddlers are able to experience themselves as different from others, but do not yet recognize that others have different mental states than they do. This is exhibited by a tendency to respond to another individual’s distress in a way that they would find comforting themselves. As children become less egocentric (approximately between 2 and 3 years of age), their ability to take another person’s perspective advances and they come to realize that other people may have feelings that are different from their own. It is at this point that empathic behaviors (e.g., attempting to console a crying friend) become more appropriate to others’ needs and circumstances. The capacity to empathize with whole categories of people (e.g., the homeless, victims of terrorist attacks), however, comes about in later childhood and adolescence as more sophisticated cognitive abilities (e.g., perspective-taking, abstract thinking) develop.
While much of this process is thought to occur spontaneously as the child interacts with the world, there are, however, ways that differential capacities for empathic responding are shaped. For example, theorists and researchers have emphasized the role that interaction with peers (e.g., Kruger & Tomasello, 1986; Piaget, 1932) and siblings (e.g., Jiao, Ji, & Jing, 1986) plays in the decline of egocentrism. Additionally, parenting practices that make use of inductive techniques, which encourage children to think about the effect of their actions on others, as opposed to power-assertive techniques, are thought to aid in the development of empathy (Hoffman, 1994). In the face of a child stealing candy from a store, for instance, a parent using an inductive approach might ask her child, “How do you think the store owner feels?” or “How would you feel if you were the store owner?”
The above-mentioned practices (i.e., engagement with peers, inductive parenting techniques) may be seen as fostering the development of perspective-taking abilities. More generally, sensitive and responsive parenting, known to contribute to a secure attachment (i.e., Type B) style (Ainsworth, 1993; Richter, 2004), has been linked to the development of empathy (e.g., Mikulincer, Gillath, & Halevy, 2001), and relatedly, compassionate and altruistic responding toward others (e.g., Mikulincer & Shaver, 2005).
Empathy Training Approaches
Children without a stable and supportive caregiver, or, even more so, those who are abused, may not fully develop their capacity to feel empathy for others. While sensitive and responsive care is best, those who do not receive it may still be able to develop their empathic capacity in other ways, as empathy may be viewed as a malleable characteristic (i.e., individuals can actually learn how to become more empathie). Indeed “empathy training” has been utilized for a variety of populations (e.g., high school and college students, Hatcher, Nadeau, & Walsh, 1994; graduate students, Patore, 1995; nursing staff, Herbek & Yammarino, 1990; parents, Brems, Baldwin, & Baxter, 1993; and criminals, Wormith & Hanson, 1992). Existing training approaches are typically tailored for the population of interest and their specific goals for increasing empathy. For example, in Herbek and Yammarino’s empathy training intervention with nurses, participants were trained to substitute “higher-level” (i.e., conveying higher levels of empathic understanding) responses for “lower-level” ones to make better use of limited time with patients in a busy hospital environment.
While empathy training approaches have garnered some empirical support, an overall paucity of research in this area suggests that evaluation of these programs deserves increased attention. Additionally, the few studies that have been conducted suffer from limitations including sole reliance on self-report outcome measures (e.g., Hatcher et al., 1994), focus on limited aspects of empathic responding (e.g., Herbek & Yammarino, 1990), and limited practical versus statistical significance of results (Herbek & Yammarino, 1990).
With regard to intimate relationships specifically, Long et al. (1999) note that, while many programs aimed at couples focus on empathy-related skills such as conflict resolution and active listening, none have specifically aimed to increase empathy among relationship partners. In order to address this need, Long and his colleagues developed an intervention based on what they deemed to be the six components of empathy: empathic sensitivity, suspension of one’s thoughts and feelings, empathic listening, empathic communication, the communication of an understanding through paraphrasing, and empathic checking with a partner. As an example, in an attempt to increase empathic sensitivity, participants were shown a silent videotape of a couple interacting and asked to identify the emotions and messages portrayed based on nonverbal cues. These researchers found that their empathy training program increased both general and relationship-specific levels of empathy, relative to a wait-list control condition through a six-month follow-up period. Furthermore, change in perception of partners’ empathy was positively correlated with relationship satisfaction at the six-month mark.
While these results are promising, their generalizability is unclear, particularly because the participants in their study were community volunteers who may differ from the larger population of couples in need in important ways. Also, from the beginning of their report, Long et al. equate empathy with perspective-taking (what Duan and Hill, 1996, deem “intellectual empathy”). Thus, their empathy training program was not designed to address broader aspects of empathy, such as empathic concern (generally considered to be the “affective” component of empathy), which may be important in the cultivation of empathic responding among relationship partners. This is especially true when we consider that it may be easier to perceive nonverbal cues when one is in a neutral, rather than emotionally charged, state. Special attention may need to be given to the process of taking another’s perspective when emotionally aroused (Izard, 2001; Lopes, Salovey, Côté, Beers, & Petty, 2005).
Regardless, the work of Long et al. (1999) serves as an important example of the potential of empathy training approaches. The authors point out, however, that high preexisting levels of relationship conflict seemed to decrease the likelihood that partners would respond empathically toward one another. “From this point of view, expressing empathy to a partner may be highly unlikely, even with adequate empathy skills” (p. 241). Long et al. also highlight the importance, in the cultivation of perspective-taking, of suspending one’s own thoughts and feelings. Thus, despite the initial promise of empathy training programs, more research is needed to further develop and refine these programs. We contend that incorporating mindfulness-based methods into empathy training programs may address some of the acknowledged limitations of these approaches.
MINDFULNESS AND EMPATHY
Mindfulness-based methods may offer a unique set of tools in the quest to develop individuals’ capacity for empathy. While an integral part of Buddhism and other spiritual traditions for centuries (Kumar, 2002), mindfulness-based methods have recently been transported into the clinical domain with interventions including Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1990) and Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2002).
To some extent use of the term “mindfulness” has been fraught with similar vagaries and diversity as “empathy” (e.g., S. C. Hayes & Wilson, 2003). Specifically, “mindfulness is sometimes treated as a technique, sometimes as a more general method or collection of techniques, sometimes as a psychological process that can produce outcomes, and sometimes as an outcome in and of itself (S. C. Hayes & Wilson, 2003, p. 161). It can be challenging to untangle these various uses as there is much overlap and because how this is done depends in large part on the particular research questions of interest (Block-Lerner, Salters-Pednault, & Tull, 2005). Nonetheless, researchers are beginning to come up with agreed-upon operational definitions (e.g., Bishop, Lau, & Shapiro, 2004; also see Brown & Ryan, 2004; A. M. Hayes & Feldman, 2004; S. C. Hayes & Shenk, 2004, for a critical review of this conceptualization) and to discuss the multifaceted nature of this construct (e.g., Baer, Smith, & Allen, 2004; Block-Lerner et al., 2005). While we will discuss in some detail various mindfulness- and acceptance-based approaches that may serve to increase empathic responding (i.e., mindfulness as a technique or general method), our intent is to focus on mindfulness as a psychological process. Furthermore, while elements of empathic responding overlap with aspects of mindfulness as a process (to be discussed below), we conceptualize (hypothesized) increases in empathy as one of many outcomes of the process of mindfulness.
Recently, effort has been made to delineate various facets of the process of mindfulness. A detailed review of these attempts is beyond the scope of this article. However, Linehan and colleagues’ (e.g., Dimidjian & Linehan; Linehan, 1993a, 1993b) conceptualization of mindfulness warrants mention. Both “what” (i.e., what one does when practicing mindfulness) and “how” (i.e., qualities related to the ways these activities are done) skills are considered integral to mindfulness. “What” skills include observing, noticing, bringing awareness; describing, labeling, noting; and participating, and one should be encouraged to cultivate a way of approaching these activities (i.e., the “how” skills) nonjudgmentally, with acceptance, allowing; in the present moment, with beginner’s mind; and effectively (Dimidjian & Linehan, 2003).
While identification of specific components of the process of mindfulness, as well as their overlap, and distinguishing elements, is an ongoing theoretical and empirical process, it is generally agreed that mindfulness involves awareness which is nonjudgmental and grounded in the present moment (i.e., Kabat-Zinn, 1994). Each of these facets of the process of mindfulness (i.e., attention or awareness, nonjudgmental or accepting nature of this awareness, presentmoment focus) may be seen as fostering the development and/or maintenance of aspects of empathic responding.
MINDFULNESS AND SPECIFIC COMPONENTS OF EMPATHIC RESPONDING
Overall, nonjudgmental present-moment awareness of one’s own emotions (i.e., mindfulness) would seem to facilitate aspects of empathic responding. In particular, the capacities to take another person’s perspective (PT) and to feel concern for others (EC), elements central to Davis’s (1983) characterization of empathy, imply a stance toward one’s own thoughts and feelings that is consistent with that presumed to be facilitated by mindfulness-based methods. Both PT and EC involve an awareness and understanding of how another is reacting to his or her experiences. PT involves the nonegocentric ability to adopt another’s psychological point of view (cognitively “putting one’s self in another’s shoes”), allowing for a better anticipation of the behavior and reactions of that person. This capability puts one at a greater advantage in the development of deeper interpersonal relationships. Similarly, feeling sympathy for another, central to EC, fosters helping behavior and may increase dialogue (Davis, 1983), both of which could contribute to deeper, more meaningful relationships.
Research in our laboratory supports the notion that perspective-taking and empathie concern are most closely related to the process of mindfulness. As part of a larger experimental study (Block-Lerner, Orsillo, & Plumb, 2004), a community sample of women (N = 40) was administered the Interpersonal Reactivity Index (IRI; Davis, 1983) and several measures of mindfulness, including the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R; Feldman, Hayes, Kumar, & Greeson, 2003; A. M. Hayes & Feldman, 2004). The CAMS-R is a 12-item instrument that assesses ways of responding to thoughts and feelings. Correlations between the CAMS-R and subscales of the IRI indicate that mindfulness is related to perspective-taking (r = .35, p
While the correlational nature of this data offers limited information about the nature of the relationship between mindfulness and empathy, these results, along with some of the identified limitations of existing empathy training approaches, support the utility of further exploring mindfulness-based methods in the development of components of empathy. Additionally, empirical support for mindfulness-based methods in a variety of populations has accumulated rapidly in recent years. The use of MBSR has been supported in a variety of medical (see Grossman, Niemann, Schmidt, & Walach, 2004 for a review, though this meta-analysis also includes “stressed nonclinical groups”) and nonmedical (e.g., Carson, Carson, Gil, & Baucom, 2004; Rosenzweig, Reibel, Greeson, Brainard, & Hojat, 2003; Shapiro, Astin, Bishop, & Cordova, 2005; Shapiro, Schwartz, & Bonner, 1998) populations. MBCT has been shown to be effective in preventing relapse for at least a subset of individuals experiencing depression (Ma & Teasdale, 2004; Teasdale et al., 2000) and has recently been used with other populations (e.g., Baer, Fischer, & Huss, 2005; Moustgaard, 2005). Related approaches that emphasize the development of experiential acceptance (to be discussed below) have also received empirical support of late (see Hayes, Masuda, Bissett, Luoma, & Guerrero, 2004, for a review; also see Hayes, Follette, & Linehan, 2004).
More direct, though preliminary, support for the efficacy of mindfulness-based methods impacting empathy comes from several sources. Shapiro et al. (1999) evaluated the efficacy of an 8-week MBSR program in premedical and medical students. In addition to reducing anxiety and overall psychological distress, the intervention significantly increased participants’ levels of empathy, relative to a wait-list control group. Such an effect, if replicated, could have significant implications for the inclusion of a mindfulness-based approach in medical education.
A mindfulness-based approach has also shown promise as a “relationship-enhancement” method for nondistressed couples (Carson et al., 2004). Carson and his colleagues adapted the MBSR protocol to include mindfulness exercises specifically aimed at enhancing intimate relationships. These included an emphasis on loving-kindness meditation, partner yoga exercises, and mindful touch exercises. This innovative intervention approach was demonstrated to increase couples’ reported satisfaction, relatedness, and acceptance, among other relationshiprelated and individual (e.g., optimism, spirituality) positive outcomes. Furthermore, a doseresponse relationship was observed both within and between subjects, such that higher levels of mindfulness practice were associated with improved outcomes (Carson et al., 2004). While these researchers did not specifically measure empathie responding, we might imagine that their intervention led to increased perspective-taking and empathie concern between members of the couple. Future research should directly address this question and examine whether empathie responding per se has an impact on relationship satisfaction and related measures (in both clinical and nonclinical samples).
Findings from the experimental study conducted in our laboratory, as mentioned above (Block-Lerner et al., 2004), also speak to the potential of a mindfulness-based approach. Participants in this study were randomly assigned to receive one of several brief interventions (consisting of spoken instructions and a message-consistent poem) or a relaxation control condition (i.e., listening to the sound of waves). The “mindful awareness” condition, based on the work of Segal et al. (2002), consisted of instructions that encouraged participants to be aware of, and accepting toward, whatever thoughts and feeling arose. For example, participants in this condition were instructed, “There is no need to try to control the breathing in any way … simply letting the breath breathe itself … as best you can, also bringing this attitude of allowing to the rest of your experience …” On the contrary, participants in the “positive thinking” condition (designed to be similar in structure to the mindful awareness condition, but instead encouraging the evaluation of, and attempts to have control over, one’s thoughts and feelings) received instructions such as the following: “Noticing that you can have control over your breathing … also bringing this strength and control to the rest of your experience … trying to achieve a state of positivity and calmness …” Participants in all three conditions were then asked to watch an emotionally evocative film clip and to write about their reactions to this stimulus. These narratives were then subject to coding with the Linguistic Inquiry Word Count program (Pennebaker & Francis, 1999).
Results suggested that participants in the mindful awareness condition may have demonstrated a greater capacity to take others’ perspectives, relative to individuals in the positive thinking condition. Specifically, those in the mindful awareness group wrote more about “other humans” (e.g., boy, woman, group) than participants in the positive thinking group (with relaxation control participants in between these two and not significantly different from either). Conversely, positive thinking participants used language in the first-person (singular) tense more than did those assigned to the mindful awareness condition (as well as participants in the relaxation control condition; individuals in this group also differed significantly from those in the positive thinking condition).
Writing more about other people, and less about oneself, may suggest more empathie responding on the part of participants in the mindful awareness condition. This capacity for empathie responding among mindful awareness participants may be a reflection of their taking a stance toward their private experiences characterized by “metacognitive awareness” (i.e., cognitive set in which thoughts and feelings are viewed as transient mental events, rather than as the self; Teasdale, Moore, & Hayhurst, 2002). On the other hand, positive thinking participants’ higher use of first-person language is consistent with research in both the depression (Rude, Gortner, & Pennebaker, 2004) and social anxiety (Hofmann & Barlow, 2002; Spurr & Stopa, 2002; Woody & Rodriguez, 2000) literatures that suggests that increased self-focused attention may be problematic and can lead to maladaptive outcomes in both clinical and nonclinical populations. While this pattern of findings suggests a complicated picture, preliminary support is offered for the processes of change posited by mindfulness- and acceptance-based behavioral interventions.
Limited evidence for the efficacy of empathy training interventions, in conjunction with (i) data that support the association between aspects of empathie responding and mindfulness, and (ii) studies that demonstrate the efficacy of mindfulness- and acceptance-based methods more generally, suggests that such approaches might be valuable interventions in and of themselves and/or useful adjuncts to existing empathy training approaches. Research suggests that perspective-taking (Davis, 1983; Hanson, 2003; Long et al., 1999) and empathie concern (Cliffordson, 2002) are the most amenable to change. What follows is a discussion of how several specific mindfulness/acceptance-based behavioral interventions might be employed toward this end.
ROLE OF MINDFULNESS- AND ACCEPTANCE-BASED BEHAVIORAL APPROACHES IN FACILITATING PERSPECTIVE-TAKING AND EMPATHIC CONCERN
Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1990) and Mindfulness-Based Cognitive Therapy (MBCT; Segal et al., 2002) are two interventions that attempt to directly facilitate a mindful stance toward experience, predominantly through both formal (e.g., sitting meditation, walking meditation) and informal (e.g., while washing dishes, while brushing one’s teeth) mindfulness practice. MBSR and MBCT attempt to foster a nonjudgmental, presentmoment orientation toward experience, and in so doing, may address a specific skill of empathie responding identified by Long et al. (1999). While these researchers call this “suspension of one’s own thoughts and feelings” (p. 236), experimental studies suggest that direct attempts at suppressing or otherwise avoiding one’s own private experiences, including cognitions, emotions, bodily sensations, and memories, may, in some contexts, backfire (see Purdon, 1999, for a review of the thought suppression literature). Thus, informing individuals that they should not focus on their own thoughts and feelings because this is inconsistent with experiencing and/or expressing empathy (without further guidance as to how this may be done) may only be counterproductive. Instead, by introducing mindfulness practice as a means to suspend judgments and evaluations (though such practice cannot intentionally be used to do so, or this would not be considered true “willingness,” i.e., Hayes, Strosahl, & Wilson, 1999) or nonjudgmental awareness, this potentially crucial skill of empathie responding may be developed.
If one is “metacognitively aware” (i.e., Teasdale et al., 2002) of his or her feelings, over time he or she may learn to anticipate the kinds of experiences that lead to particular emotions and to grasp at a deeper level the nature and impact of these emotions. This awareness of one’s own emotional processes would seem to be essential in developing the capacity to understand the experiences of others. In support of this notion, Hughes, Tingle, and Sawin (1981) found that when children were made aware of their own emotional reactions, they were better able to understand the feeling states of others. Similarly, after presenting data that demonstrated that a self-run group intervention designed to increase empathy also increased self-disclosure, Brems, Fromme, and Johnson (1992) speak to the reciprocal relation between empathy and self-awareness. They indicate that “this finding is consistent with a developmental perspective that suggests that people need to possess self-knowledge before they can empathize with others and that once people are able to empathize they are also likely to be aware of their own feelings” (p. 197).
Mindfulness practice keeps us in the present moment. This is important because, especially in heated interpersonal moments, rumination about past events and worries about the future can easily take us out of the here and now. If such private experiences are simply acknowledged and attention returned to an unfolding interaction, an individual is able to focus on what is actually unfolding before his or her eyes. Such “balanced engagement” with one’s thoughts and feelings, versus under- or overengagement (A. F. Hayes & Feldman, 2004), would seem to facilitate empathy as per Rogers’s (1992) definition, which emphasizes maintaining a sense of separateness, even with strong feelings of connection and understanding (i.e., the “as if quality).
Furthermore, bringing awareness to the present moment on a regular basis would likely permit individuals to learn more about the contingencies that shape their behavior and thus allow for more precise and useful prediction and control (Skinner, 1974). Borkovec and Sharpless (2004) and Roemer and Orsillo (2002) also speak to a related function (i.e., increased sensitivity to environmental contingencies) of mindfulness practice. This increased awareness and sensitivity would likely lead to heightened appreciation of how one’s own actions impact others.
We view this process as a bidirectional one, transactional in nature. Experiencing empathie concern for another or really coming to understand his or her perspective likely leads to additional thoughts and feelings that may be seen as grist for the mill of mindfulness practice. Similarly, the private experiences that arise in the course of meditation or other forms of mindfulness practice may, when held in awareness without judgment, lead to additional insights about another’s emotional experience and, perhaps, insight about how best to convey this understanding. We view this as an ongoing process, one that individuals must constantly work toward (i.e., neither mindfulness nor empathy are states that may be achieved permanently; Orsillo & Roemer, 2007).
While arguably inherent in the present-moment awareness component (i.e., Brown & Ryan, 2003), the nonjudgmental and/or accepting facets of mindfulness also deserve mention for their potential in cultivating empathie responding. Recent developments in “third wave” cognitivebehavioral therapies have also begun to include mindfulness techniques within a larger framework of therapeutic intervention, and in many ways, specifically target this process of experiential acceptance. We contend that facilitating acceptance of one’s own experiences is an important step toward fostering empathy for others.
Acceptance and Commitment Therapy (ACT; Hayes et al., 1999) is one intervention that includes several mindfulness elements and facilitates experiential acceptance from a more aware, less evaluative or judgmental stance. While a full discussion of this approach is not warranted here, in ACT, psychopathology can be viewed as experiential avoidance, fusion with thoughts as reality, and lack of committed action. Experiential avoidance (i.e., Hayes, Wilson, Gifford, Follette, & Strosahl, 1996) is denned as avoidance of, or escape from, unwanted private experiences such as thoughts, feelings, memories, or bodily sensations. It is thought to arise from some basic universal processes. First, ACT recognizes that human beings are constantly evaluating, categorizing, and judging their internal experiences. second, ACT proposes that humans can become fused with their internal experiences, not perceiving them as transient thoughts, emotions, and physiological states, but instead as reflections of the self. Fusion with negatively evaluated internal states is thought to elicit strong attempts to avoid these states and any activities that may elicit them. Experiential avoidance is presumed to paradoxically increase one’s internal distress. Further, efforts to avoid situations and activities that may elicit negatively evaluated internal states may lead to a severe restriction in ones behavioral repertoire, and an associated decrease in quality of life. ACT seeks to increase defusion from one’s internal experience (e.g., to recognize that one is separate from the transient experience of particular thoughts, images, and feelings) and to decrease attempts at experiential avoidance while encouraging more flexible behavioral responding aimed at value-based committed action.
ACT mindfulness techniques (such as meditation, contact with the present moment) are utilized throughout the intervention to increase individuals’ awareness of their internal experiences as simply thoughts, feelings, or bodily sensations, and not things that need to be changed, escaped from, or avoided as a general rule. Mindfulness in this context is a tool that facilitates acceptance of internal experiences as they are, not as the person’s thoughts dictate or as one evaluates them to be (e.g., as good or bad). It is from this accepting, defused, and mindful place that individuals commit to valued action. Researchers in this area postulate that increasing acceptance of one’s own experiences (as they are, not as their evaluations of them) may help to increase experiential acceptance in children at a young age and help families interact in a more effective manner (Murrell, Coyne, & Wilson, 2004).
A brief case example can demonstrate this process. “Sara” sought treatment for anxiety problems and also reported significant impairment in her relationships with her husband and children due to her debilitating anxiety. She had thoughts that she had to reduce her anxiety before she would be able to engage in activities with her family, such as attending her children’s soccer games or participating in social activities with her husband. Additionally, she reported feeling overwhelmed by her husband’s and children’s problems and unable to help them when they came to her for advice.
Sara’s treatment focused heavily on the mindfulness component of ACT, and her progress was bolstered by the values clarification process. Sara reported significant distress at not “being able” to engage in activities she cared about since her values were to be intimately connected with others, particularly her family, and to be a woman who engaged in the world rather than hiding from it. Through a number of emotional processing exercises, she became more aware of the personal importance of these values and of the ways in which her unwillingness to experience anxiety was restricting her values-consistent behavior.
A large part of treatment was aimed at increasing Sara’s awareness of her internal experiences, her attempts to avoid them, and the personally experienced consequences of experiential avoidance. Sara engaged in formal and informal mindfulness practices involving noticing her physical, emotional, and cognitive responses, observing them as transient events rather than chronic reflections of herself, and bringing compassion to their presence.
As Sara engaged in mindfulness-based treatment, she slowly came to recognize her thoughts and emotions as normal, human transient responses. Her ability to bring understanding and compassion to her own experiences and to see them as separate from herself allowed her to decrease her efforts to avoid them (which paradoxically decreased their frequency and intensity). Through this changed relationship with her own private experiences, she also became more willing to interact with her family members when they were experiencing painful thoughts and emotions. This acceptance stance allowed her to engage in previously avoided activities with her family, even when her anxiety was present. Further, guided by her value to be a woman who engaged with life, she committed to increasingly challenging goals that comported with her values (such as soccer practice, then a match, then a camping trip with her family). As treatment progressed, Sara reported that she increased her capacity to help problem-solve with her family when they needed her; no longer overwhelmed by her own anxiety in these situations, she was able to respond empathically and tended to accept both her own emotions and those of her family members.
The focus on valued action in ACT might be seen as addressing one of the limitations of empathy training approaches as per Long et al. (1999). As noted above, Long and colleagues reported that, for a subset of couples participating in their program, high levels of relationship conflict precluded their expression of empathy, even among couples who demonstrated adequate empathy skills. We argue that an acceptance- or a mindfulness-based behavioral approach to empathy training may be able to address the needs of these couples. First, we would recommend values exercises aimed at helping couples to identify their personal values related to communication and/or intimacy in relationships. second, we propose that acceptance/mindfulness training would directly address the thoughts, feelings, and sensations related to relationship conflict that may be inhibiting the use of empathy skills.
Dialectical Behavior Therapy (DBT) combines mindfulness techniques from Zen meditation with principles of traditional (i.e., “second-wave”; Hayes, Follette, et al., 2004) cognitivebehavioral therapy and is the first treatment with proven efficacy for symptoms of borderline personality disorder (Linehan, Armstrong, & Suarez, 1991; Linehan, Heard, & Armstrong, 1993). Recent work by Fruzzetti and colleagues (Fruzzetti & Fruzetti, 2003; Fruzzetti & Iverson, 2004; Fru/zetti, Shenk, Mosco, & Lowry, 2003) has also linked aspects of this approach to empathie responses among couples (to be discussed below).
Individuals with BPD often have difficulty maintaining fulfilling and effective relationships with others and often invalidate their own internal experiences (Linehan, 1993a). Therefore, skills aimed at increasing interpersonal effectiveness and emotion regulation are employed, in conjunction with core mindfulness skills, to increase both experiential acceptance of one’s own emotions and the effectiveness of responding to others in their environment when emotionally aroused. The posture of DBT is that when individuals are aware of their internal experiences and more accepting of them as states that ebb and flow, they are also able to make choices about the most effective action to take in the moment, especially when relating to others. This stance may be seen as consistent with ACT’s focus on valued action.
Recently, researchers have focused on facilitating communication of understanding and acceptance of another’s emotions and behaviors in the service of increasing couples’ effectiveness (Fruzzetti & Iverson, 2004). Validation, or communicating to another that one’s responses are understandable within the context of one’s life situation (Linehan, 1997), is an important part of DBT that comports with our discussion of empathy. Fruzzetti and Iverson (2004) put forth a model of couples’ intervention that involves mindful awareness of one’s own experiences, validation of another’s experience, and effective communication. Validating another’s experience communicates acceptance and understanding and results in lower arousal and vulnerability (Fruzzetti & Fruzetti, 2003); this capacity requires both perspective-taking and empathie concern. Conversely, invalidating another’s experiences imparts lack of empathy and weakens the relationship, as invalidation can communicate criticism, disregard, and illegitimacy, which often leads to less emotional expression in the future (Fruzzetti et al., 2003).
For example, suppose a couple reported to treatment for difficulties relating to each other without verbal arguments escalating into physical violence. Therapy would initially be aimed at increasing individual mindfulness skills (both formally and informally), which would encourage each partner to be able to notice his or her own emotions and allow their presence (rather than struggling with them or attempting to push them away) and increase the ability to make effective choices in behaving rather than acting on emotions when highly aroused. Next, partners would practice responding to each other in a validating way, recognizing their partner’s emotional reactions, and responding more effectively to each other rather than criticizing or communicating that the other’s experience is wrong or unwarranted. Increasing levels of validation coupled with more behavioral response choices (other than physical violence) would potentially increase the couples’ ability to express more emotion in the future and help maintain a healthier relationship.
This approach is quite consistent with Integrative Behavioral Couple Therapy (IBCT; Christensen & Jacobson, 2000), an intervention that attempts to balance acceptance and change strategies in the treatment of couples.
CONCLUSIONS AND FUTURE DIRECTIONS
This review of the literature, as well as the preliminary findings presented, suggests that the relationship between various aspects of mindfulness and facets of empathy warrant further consideration. More specifically, additional research should focus on examining the areas of overlap and distinctiveness of these two constructs. Such designs would also do well to include multimodal operationalizations (Duan & Hill, 1996) of both empathy and mindfulness, rather than solely relying on self-report.
Further, the efficacy of acceptance- and mindfulness-based methods in increasing individuals’ capacity for empathy (in couples’ interventions and otherwise) should be examined in randomized controlled trials. Such interventions should be tailored for the particular populations and/or pathological processes targeted (i.e., Teasdale, Segal, & Williams, 2003). Integration of the most relevant components from the treatment packages reviewed above might be a particularly fruitful avenue to explore. For example, one could argue that combining values work from ACT, mindfulness practice exercises from MBSR/MBCT (perhaps with modifications for couples, along the lines of those made by Carson et al., 2004), and the interpersonal effectiveness skills training module from DBT might most effectively target empathie responding; such an integrated package could then be subjected to empirical scrutiny. In addition, the value of adding a mindfulness component to existing empathy training approaches (such as the one developed by Long et al., 1999, and discussed above) should be explored; traditional empathy training interventions might be compared with mindfulness-enhanced packages.
While we have emphasized the application of mindfulness- and acceptance-based methods in the cultivation of empathie responding in couples, we see these approaches being potentially valuable adjuncts to psychotherapeutic work with families as well. In support of this notion, Brems et al. (1993), in their discussion of a parent education program based on self psychology principles, highlight the importance of attending to the parents’ own emotional needs as modifications to parenting practices are attempted. Specifically, Brems and her colleagues suggest that parents learn to empathize with each other and themselves about the ways in which their own developmental histories and current feelings and needs may be impacting interactions with their children. Mindfulness- and acceptance-based methods would likely be very helpful in this process, and indeed, researchers are beginning to develop models and empirically examine the efficacy of such approaches (e.g., Murrell et al., 1974; also see Kabat-Zinn & Kabat-Zinn, 1997).
In conclusion, given that higher levels of empathy allow for more meaningful and successful interpersonal functioning (which, on a broader scale, has powerful implications for societal change; Kabat-Zinn, 2005), it is important to investigate methods to increase this ability. Mindfulness and experiential acceptance-based approaches appear to be a viable means for cultivating levels of empathy. As individuals are more mindfully attentive to the thoughts and feelings they and others experience in the present moment, they are more likely to find common ground and greater intimacy in their relationships, engage in higher levels of valued action, and increase their overall quality of life in the process-one moment at a time.
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Jennifer Block-Lerner
La Salle University
Carrie Adair
Skidmore College
Jennifer C. Plumb
University of Nevada-Reno
Deborah L. Rhatigan
University of Tennessee-Knoxville
Susan M. Orsillo
Suffolk University
Jennifer Block-Lerner, PhD, La Salle University; Carrie Adair, BA, Skidmore College; Jennifer C. Plumb, BS, University of Nevada-Reno; Deborah L. Rhatigan, PhD, University of Tennessee-Knoxville; Susan M. Orsillo, PhD, Suffolk University.
Address correspondence to Jennifer Block-Lerner, Department of Psychology, La Salle University, 1900 West Olney Avenue, Philadelphia, Pennsylvania 19141; E-mail: lerner@lasalle.edu
Copyright Blackwell Publishing Ltd. Oct 2007
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