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P: Does empathy need a face? 

S: Well, observers of emotional pain faces show some activity in the facial musculature that appears to indicate empathy via mimicry, although inattention to the emotional quality of the expression, as when doubting its sincerity, may impair this response. 

P: Suppose a person with Möebius Syndrome observes a person in pain. There can be no activity in her facial muscles. Is the capacity for empathy for pain thereby reduced or diluted in this individual? 

S:  There is qualitative evidence suggesting that the experience of emotion in some adults with Möebius might be diluted and reduced. In some cases, emotion is intellectualized: people think happy, or think sad. One person told me: 

‘I have to say this thought is a happy thought and therefore I am happy. When there are things that are sad I tell the person that I feel very sorry for you but I’m thinking that rather than feeling it’. 

In other cases, there is an almost disconnection from emotion in oneself and from others, and possibly, a reduced capacity for empathy and sympathy. 

P: Why is this? 

S:  I stated earlier that the face is for human interactions a rich and primary source of information. In these encounters, the face provides a dynamic, embodied representation of emotion, sharing feelings and moods from moment to moment. Human interactions are, in part, facial conversations, usually mutually reinforcing. Through facial conversation, an individual can enter into the subjective experience of another, sharing feelings and moods. 

P: An inability to engage in facial interaction and to receive reinforcement from others may reduce the capacity for empathy. 

S: It appears that congenital facial paralysis reduces self-awareness. Reduced self-awareness with regard to one’s own emotions may diminish empathy for pain in others because the individual’s recognition of her own feelings is the basis for identification with the feelings of others. 

P: Here is a question: is empathy conceived as ‘emotional resonance’ related to the instigation of effective helping behavior? 

S: Certainly, in professional settings dispassionate concern for the patient is encouraged in the interests of objective care. 

P: This may be worth exploring: does similarity in facial expression mean greater similarity in affective responses, thereby affecting helping behavior? By contrast, do children and adults with Möebius typically instigate care? 

S: Earlier, I noted that the reactions of infants to pain are shaped and transformed during development into socially responsive patterns of behavior. I sense that these transformations may answer our question: does empathy need a face? 

Infant reactions to pain are global and non-reflective, as previously mentioned. They experience pain in a ‘catastrophic’ way. Catastrophic pain pushes for direct discharge in fixed responses. For example, apathetic or tense immobility, intense writhing or squirming.

In human development, however, infants can learn to ‘tame’ catastrophic pain patterns. Early to midway in the first year of life, caregivers help babies begin to learn how to transform catastrophic pain into interactive signals. 

The mother turns to look at her baby as he cries out in distress. She approaches him vocalizing concern, and he turns to look at her. She responds with a soft soothing facial expression of ‘what’s the matter’, and, with hands out, an offer to pick him up and cuddle him. Baby moves his head to find her and greets her eyes with a softening of his facial grimace and a look of expectation. Mother responds with soothing sounds and they continue to exchange calming facial expressions and sounds. Later, the parent is holding the baby, snuggling, and patting his back, and the baby relaxes. The tension in his face and body dissipates and he has a look of calm. 

P: Contrast this pattern with one in which signaling does not occur. A baby cries in pain and a mother, preoccupied with her own thoughts, ignores the overture. Baby tries again with more intensity, vocalizing more loudly, and squirming even more, but with obvious strain. The mother still ignores the overtures. Soon, the baby becomes passive and disinterested. 

S: For the signaling to occur in the first case, the baby needs to have been wooed into an intimate relationship with one or a few caregivers so that there is another human being toward whom he experiences deep emotions and, therefore, with whom he wants to communicate. 

P: The baby needs to have his facial display become part of a back-and-forth interaction by being responded to. 

S: Yes. Through his relationship to his caregiver(s), he is becoming more intentional. I think the baby is learning to signal with his emotions to mean intent rather than engage in a catastrophic response. Is that right? 

P: In the first case, facial signaling interrupts a fixed response. Mother responded to the baby’s signal of threat, not intent. He responded back and together they negotiated an outcome characterized by shared soothing calm rather than an intense pain-display. 

In development, the baby becomes better and better able to signal danger and threat without escalating into direct action. 

S: Let’s put it like this: by having his expression of danger responded to, the baby learns to modulate the intensity of his distress and pain. He is learning to regulate his state. The baby is learning to show distress, to negotiate, and to get his needs met. There is less of a tendency to explode into desperate action. Infants and toddlers quickly sense that they and their caregivers are regulating one another when there is a back-and-forth, finely-tuned nuance system of emotional interaction involving lots of mutual exchanges. 

P: How does this relate to empathy? 

S: First, it is likely that excessively empathic observers would be characterized as catastrophic, agonizing unduly and having difficulty in delivering effective helping behavior. 

P: I see. To provide effective care, an observer must have the ability to regulate her own aversive distress, since this may lead observers to focus primarily upon their own needs. 

This is really important in health-care. Health care professionals face the challenge of finding the balance that allows them to pay attention to the details of a patient’s pain experience and resonate with the patient’s pain experience without becoming emotionally over-involved. Catastrophic reactions may well preclude effective medical management and even lead to burnout. 

S: I think effective regulation of empathy, such as keeping distress at a moderate level, may promote other-oriented affective responses. Empathy for others comes from investing other human beings with one’s own feelings. This capacity, I claim, begins with first relationships. It depends on nurturing care that creates, through mutual facial expressions with caregivers, a sense of intimacy. 

P: Since a sense of ‘self’ is crucial for empathy, how does the infant develop it? 

S: When an adult responds reciprocally, the baby makes a discovery: ‘I can make something happen’. This teaches the baby to take initiative: crying in pain gets a concerned look from mom or dad. A sense of ‘self’ is developing, for it’s ‘me’ making something happen. As a toddler’s repertoire of emotional signaling grows richer and she begins to discern patterns in her own and others’ behavior, she adds these observations to the map delineating herself as a person. Her mother usually responds when she is pain, but not when she’s cranky. Her father likes to play, but not to sing lullabies. Grandmother is a good deal less strict than either parent. With the growing capacity to perceive and organize patterns, these types of experiences continue to define a developing sense of self even before words are used. 

Despite the apparent advantages of accurate empathy (e.g., in clinical settings), are there advatages to an indeterminate or less than perfect empathy for pain?

– In ‘less than perfect’ empathy for pain, intellectual and emotional demands would be diminished and intense personal distress of the observer is less likely. Emergency or burn units can be extremely stressing for health care professionals. Observers have a considerable need to know what is happening to others in pain, but they need not suffer unduly (Craig, 2009).

The indeterminacy of empathy for pain is due to complex social and psychological reactions and the complex nature of human beings: the concept of pain facial expression must be flexible and elastic because human expression, and our reaction to it, is diverse and unpredictable.

Typical observers find it easier to describe a person as ‘in pain’ than to describe his pain-behavior in precise physical terms, and do not identify affectively relevant features of pain from austere physical ones. Astute observers often know the conclusions of such alleged inferences without knowing their premises (Wittgenstein, 1958).

References
1. Craig, K.D. (2009). The Social Communication Model of Pain. Canadian Psychology 50(1), 22-32.
2. Wittgenstein, L. (1958). Philosophical Investigations. ed. G.E.M. Anscombe and R.Rhees. tr. G.E.M. Anscombe, 2nd edition. Oxford: Blackwell.

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