The study published in Pain by Makikio Yamada and Jean Decety [19] investigates the unexplored relation of perceived pain to the emergence of empathic concern. According to the authors, the question itself appears problematic. For, how can detected pain at once urge observers to avoid the source of threat and also instigate approach-behaviors in the form of empathy and provision of care? In this letter, we claim that the pathway to empathy for pain is not paradoxical, but is paved by the human capacity to separate perceptions from aversive self-oriented responses and, thereby, to free up those perceptions to acquire symbolic and interactive meaning. 

Pain warns of physical threat and danger on the one hand and also signals an opportunity to care for and heal the person in pain on the other [17]. The protective function of pain instigating behavioral escape perhaps is more primitive, because self-focus likely precedes the care of others [2]. Intense self-focus in observers perceiving another person’s state is linked to aversive self-oriented emotions (e.g., discomfort, anxiety) that may be negatively associated with regulatory capacities [7]. By contrast, sympathy for others is positively related to the capacity of observers to voluntarily limit their emotional response to a zone that is arousing but not aversive [8]. With respect to pain, higher levels of aversive self-focus have been found in individuals who experience the threat-value of pain in their child [9] or their spouse [15] in a personally distressing way. These individuals would be expected to have a reduced capacity to voluntarily regulate their emotional state and an initial tendency to focus on their own emotional needs [6]. Other-oriented emotional responses such as empathy would likely be inhibited or delayed [1; 9]. Since sympathy is positively associated with regulatory capacities, sympathy for pain should promote recognition of the other’s state because the observer’s regulation of her own emotions is the basis for identification with the emotions of others [5]. The ability to manage or ‘tame’ an emotion-based response to the other in pain therefore permits an observer to attend to the emotional needs of the other and may facilitate sympathy for pain and helping behaviors [7]. Put another way, a response that remains ‘catastrophic’ tends to undermine interpersonal exchanges and empathy; but a regulated emotion can be used for interacting with others [13].  

Observers able to control their response to detected pain in others can voluntarily reflect on their own emotions, and the possible emotions of the other in pain. Adults and older children can say, ‘Are you hurt?’, and see how the other person responds to this statement. Or perhaps an observer thinks to herself, ‘Help him now’. In both situations, the observer is exploring options based on a process of reflective thinking involving the use of symbols rather than an aversive emotional response based on the perception of pain in the other and a potential threat to oneself [13]. Consulting a symbol enables an observer to know consciously the state he is in; he can now reflect on the emotion rather than let it overwhelm him [13]. We propose that emotion-based reactions and voluntary regulatory capacities are positively linked [6] to the degree in which an emotion is transformed into a symbolic and interactive form [13]. By contrast, if an emotional reaction remains catastrophic, it pushes for an aversive response; there is awareness of the physiologic states but not an understanding of other emotions or reactions. For example, an observer to pain in another person might think, ‘My heart is beating fast. I need to get out of here because I am scared’ (and then the person runs) [6]. But individuals who can fully symbolize the emotion and reflect on the feeling can describe how it feels to be distressed and can connect it with similar experiences in oneself or even others [13]. This pattern may link accessing long-term memories to process emotional responses at a deeper level [13], and planning effective helping and caring behaviors [7]. 

In healthy development, emotions such as fear and anger tend to be transformed from fixed catastrophic reactions into interactive patterns and symbols in the second half of year one and the second year of life and thereafter [11;12;13]. The catastrophic responses of infants to tissue pathology become shaped by parents and caregivers into differentiated and socially responsive patterns of behavior [14]. The infant who looks to a parent or caregiver when in pain is learning to show distress, to negotiate [16], and to get her needs met [4; 10]. As this happens, emotional responses are no longer locked into patterns of intense self-focus; preschoolers able to bring a parent to provide help when others are in pain can modulate their aversive response through interactions with others [4; 10]. The development of normal language allows children to use words and sentences to symbolize pain. This may facilitate other-oriented interactions and reflective thinking through sharing emotions and ideas. For example, a toddler may represent painful distress in role-playing scenarios to direct or manipulate the attention of parents and siblings [4]. Just as a baby or infant exists in the social circumstance of a baby/caregiver relationship [18], an emotional response that has become an interactive symbol exists in the circumstance of its interactive pattern [11]. Without the modulating influence of an interaction, the child’s response to a person in pain may grow more intense and she may be left using the aversive self-oriented feelings. Her expression of emotion is, therefore, not part of a fine-tuned regulated symbolic system: it may be simply a self-oriented emotional response. We argue that the separation of a perception from its aversive response may explain how perceived pain shapes its threat values and instigates empathic behavior.  



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