Of course, empathy has to be defined before it can be measured and, as with so many words, this one is slippery. Although empathy is normally thought of as a positive quality, too much empathy can be crippling. Physicians learn to protect themselves from an excess of empathy. How could they do their jobs if they didn’t? Living a moral life is probably a complicated mélange of empathetic feeling, an abstract sense of social justice, and guilt. In order to avoid the miserable pangs of guilt, many people do their best to steer clear of the situations that will produce the unpleasant feeling. Guilt is a social emotion that develops in children as they negotiate their way through their relations with other people and increasingly understand that they are responsible for their own actions. Infants are not guilty. Guilt seems to emerge sometime in the second year of life and is, not surprisingly, linked to a capacity for empathy. It is easy to understand that a subtle view of morality must take development into account. Although human beings may well be born social, to reduce the complexity of human relations to a “moral compass” in the brain or to a simplistic notion of morality as “hardwired” in the brain are modes of thinking that use a hammer when a tweezers is the instrument needed.
Moral life is probably not possible without empathy, and to have empathy is also to have guilt. Although too much guilt can be pathological, no guilt or very little of it is a characteristic of the psychopath, a person whose lack of both empathy and guilt may lead to criminal behavior. Psychopaths are also famously incapable of controlling their impulses. Something is missing or fails to develop in the psychopath, although no one knows how to explain these deficits. A reasonable hypothesis is that they are related to the prefrontal cortex, often called the executive part of the brain, which develops over time.359 It is now generally agreed that experience affects how it develops. A paper by Bryan Kolb and colleagues summarizes the story: “Pre- and postnatal environmental events, such as sensory stimuli, hormones, parent-child relationships, stress, and psychoactive drugs, modify cerebral development and, ultimately, adult behavior.”360 There is always a story.
Parents of more than one child often testify to visible differences between siblings that appear shortly after birth. Some newborns are highly sensitive to stimuli while others are sleepy and placid. An infant’s temperament can be understood as a product of epigenetic factors. A baby’s highly sensitive temperament can be exacerbated or dampened depending on what happens to him in his relations with important people as his life unfolds, relations that literally become part of his body and brain and therefore what we call character. As McGraw understood so well, however, asking what is experience and what is constitution in that growing person may be impossible to answer. It is probably also the wrong question to ask.
Memory, Placebo, and Weird Body Symbolism
The placebo effect—that mysterious mind-body or psychosomatic phenomenon—may begin to look somewhat less bizarre when understood from an embodied, relational perspective. Richard Kradin argues that the placebo response is linked directly to attachment. The physiological effects of placebo are in his words “a developmental achievement,” born of the dynamic interactions a person had with a caretaker, which are unconscious memories. In other words, certain encounters call on “somatic markers” or old bodily melodies, a soothing relational state that returns involuntarily when, for example, the kindly doctor hands you a bottle of promising pink or purple pills.361 Kradin is a research physician and a psychoanalyst. He moves easily from references to the works of Freud, Jung, Bowlby, and Winnicott to studies in neurobiology. According to Kradin, the placebo effect is a nervous system response triggered by behaviors in others that mimic those of attachment figures. His argument shifts the emphasis from a lone human being magically healing himself through “positive thinking” to a human being with a developmental history intimately connected to and dependent on other people, which is now part of his internal bodily reality. Placebo becomes a form of self-regulation through unconscious memory rather than the magical properties of the mental acting on the physical.
I would take this a step further. In their paper on placebo, Benedetti and his colleagues stress that the placebo response is an interaction between complex psychological factors and neurophysiological ones, a distinction that emphasizes a psyche-soma divide. In his book on the subject, Benedetti distinguishes between conditioning and expectation, both key to placebo response. Conditioning, he argues, is unconscious: “After repeated pairings between a conditioned contextual stimulus (e.g. the color and the shape of a pill) with an unconditioned stimulus (the pharmacological agent inside the pill) the conditioned stimulus alone can produce an effect (a conditioned response.)”362 He understands expectation, on the other hand, as a conscious quality. But “expectations,” he writes, “ . . . are unlikely to operate alone, and several other factors have been identified and described, such as memory and motivation and meaning of the illness experience.”363 We again enter the murky territories of words, their definitions, and where to draw lines.
A conditioned response is clearly unconscious. Pavlov’s dogs salivated at the sight of the man who brought them food. They did not need to see the food itself or make a thought connection between man and food. But isn’t a conditioned response itself a form of implicit memory? And isn’t that implicit memory necessarily meaningful? Man means food means happy. I am sometimes aware of what I expect to happen, but as Helmholtz and later researchers have shown, unconscious inference is often at work in perception, and those inferences are the result of learning that has become habit and are therefore automatic and outside consciousness. Is this conditioning? Can conditioning be so readily distinguished from expectation, or is it fuzzy? Isn’t conscious expectation an imaginative form of memory, an example of what Vico called fantasia? Expectation draws on the past to predict the future. Can I expect something that I have never experienced? Why does Benedetti separate expectation from memory and meaning? Isn’t expectation a form of repetition and reenactment? Isn’t it essentially a kind of meaningful memory? And won’t a patient’s response to the smiling doctor with the pink pills depend on her or his developmental history?
In his book, Benedetti is keenly aware of the doctor’s role in placebo effects and argues for a “biopsychosocial” model as a way to think about illness, which includes psychological and social as well as biological factors, although he admits that “we do not know very much about the neural underpinnings of complex social interactions, like trust and compassion.”364 I am all for integrating these influences. I wonder, however, whether this unhyphenated word “biopsychosocial,” a word I have frequently used myself, is up to the task of describing the complexity involved. If human biology is inherently social and what we call the “psyche” is a dynamic biological phenomenon that develops through living with other people and becomes increasingly complex with language use, then perhaps this term retains divisions that are counterproductive. The classic neuroscience model, adopted from computational cognitive science, maintains distinct levels, which hover one on top of the other. At the bottom are neurons. On top of those neurons is the psyche, and above or beyond or around the psyche is the social. How these three fit together is left unexplained. The model is also essentially static. What is often left out is the story of nervous system development, attachment history, memory, and memory’s close cousin, the imagination. It is fascinating to see the degree to which theoretical models not only generate thought but also constrain it.
Alzheimer’s patients with damage to their prefrontal cortices have dampened placebo effects. Benedetti conducted the experiment: “The more impaired the prefrontal connectivity, the smaller the placebo response.”365 When parts of the brain related to executive functions are damaged, so are the body’s imaginative self-healing properties. It is interesting to connect this deficit to neurological patients with prefrontal damage and to psychopaths who have impaired empathy and an inability to plan for the future, people who lack both inhibition and moral imagination. Is it n
ot possible then to hypothesize that some placebo responses are related to social development?
There are researchers who have linked the effects of psychotherapy to placebo.366 Perhaps people who benefit from the act of talking to a sympathetic person are under the sway of placebo-like suggestions, which inevitably involve different forms of memory.367 A memory is not “stored” in the brain. It is not a fixed original datum to be retrieved at will. A memory is subject to editing and change. The memories that stay with us are emotionally potent, but they, too, can be altered when they are retrieved.368 Therefore our conscious, autobiographical memories are also always imaginative. Presumably the memory deficits that afflict Alzheimer’s patients also affect their imaginative capacities to expect an event, to imagine it in the future, thereby making it more difficult to anticipate the rewards that may arrive with any kind of treatment. There have been brain scan studies on the effects of psychotherapies of various kinds on the brain, and the results suggest they are, in fact, not identical to placebo.369 This seems only reasonable. One would expect placebo effects to be more focused than the effects of psychotherapy, which has a far broader scope and purpose. A good alliance between therapist and patient may result in what Tronick called a “dyadic expansion of consciousness.” This expansion is never purely verbal or intellectual; it is also always emotionally meaningful.
Placebo is not a cure-all. Although there are anecdotes about malignant tumors that shrank to nothing and other miraculous cures due to “wishful thinking” and placebo has been shown to affect the nervous, immune, endocrine, respiratory, gastrointestinal, and other systems in the body, it has a far greater effect on some illnesses than others. The American fantasy that optimism and good thoughts or, conversely, that fortitude, accompanied by psychological warfare on a ravaging disease, will alter its outcome must be tempered. It should be noted that the positive-thinking fantasy is generally framed as an individual drama, not one that is interpersonal. By sheer willpower, the ill person thinks himself to wellness. In fact, placebo effects dismantle the fantasy. There is reason to understand them as intersubjective phenomena that involve memory, of which the imagination is a crucial part.
We live in a culture that has come to mistrust nonpharmaceutical therapies as “unreal.” But the effects of psychotherapy are real and physiological, and they change people’s lives. Freud’s idea of the transference, the dynamic process between patient and doctor through which the doctor might assume the role of an important person in the patient’s life—father, mother, sister, brother; in short, an attachment figure—developed over time. Did the patient project onto the doctor his own desires and fantasies? Or is the doctor also involved? If the doctor is involved, then the problem of “suggestion” comes up with its hypnotic associations. If doctors implant ideas into their patients’ heads, doesn’t this contaminate the process? It certainly can, as epidemics of false memory have shown. Freud came to believe transference is a two-way street and that it is not limited to therapeutic encounters but is part of everyday human relations. Could placebo and nocebo be thought of as forms of transference? To what extent do the vocabularies of various disciplines prevent us from seeing similarities rather than differences?
If a human being’s connection to other people is truly intersubjective and intercorporeal, if metaphor is not decorative word fluff but rises out of motor-sensory, emotional, and cultural experience that become patterns, that inform and accompany conscious imaginative and linguistic experience as unconscious memories, then we have moved far from classical computational theory of mind. If metaphor, symbolization, and language belong to a shared reality, which in turn affects our lived experience, can an embodied and relational model of the mind help explain how ideas literally become people in ways that seem almost supernatural? Will we finally understand how the molecule becomes the message?
“Theory is good,” Jean-Martin Charcot is reported to have said, “but it doesn’t prevent things from existing.”370 What does it mean that blindness, paralysis, seizures, and deafness can be induced by an idea? No one is surprised if a person studying for exams develops a rash and her doctor explains it as a stress response, but then, rashes do not have the symbolism that conversion disorders often have. On the other hand, if a grieving man can wish himself into some of the physical signs of pregnancy with the help of hypnotic suggestion, then mental imagery can’t be locked inside a person’s head, can it? Explaining the inexplicable is part of science, but if the conceptual boxes that exist cannot contain a particular phenomenon, it is more than likely to be ignored. Fitting a particular case into a broader system is one thing; investigating a case that seems to explode the system itself is another.
Why are some people more suggestible than others? Placebo research has shown that optimism, ego resiliency, altruism, and straightforwardness have been associated with a positive placebo response and anger-hostility with a lack of response. The reasons for this seem fairly obvious. Could suggestibility be connected to attachment style?
There has been some investigation into how attachment and suggestibility might be linked. One study in 2011, “Hypnotic Suggestibility and Adult Attachment” by Peter Burkhard and his colleagues, noted that attempts to link suggestibility to personality have had mixed results. Although some have connected it to positive characteristics such as creativity, imagination, and empathy, others have linked it to pathology. These authors found a correlation between insecure attachment and hypnotic suggestibility.371 Their findings contradict the placebo findings, despite the fact that placebo involves a form of suggestibility, as it seems does hysteria or conversion disorder.
Although scientists are laboring to understand conversion disorders at the moment, they have mostly failed to move beyond the idea of the neural underpinnings or correlates of conversion experiences and address why a patient goes blind, for example, rather than deaf. In a paper first published in Clinical Neurophysiology, I discussed the many cases of Cambodian women living in California who arrived at an eye clinic to be treated for blindness.372 Despite the fact that no damage to their brains could be found that would explain their visual impairments, they had all witnessed atrocities committed by the Khmer Rouge. Doesn’t blindness serve as a perfect bodily metaphor for what these women saw, sights they found unbearable? The meanings of some conversions seem obvious, but the still dominant models in neuroscience often make it hard to include them as part of the illness. Indeed, this is why the earlier theories of Janet and Breuer and Freud remain more commodious than most contemporary research.
To truly understand such phenomena, it is necessary to let go of the Cartesian body as a thoughtless machine precariously attached to a floating mind filled with computing symbols, a model that has stubbornly survived in science in multiple guises. Rom Harré writes, “Mental phenomena are not distinguished from neural phenomena as attributes of different substances, the one immaterial and other material. That way lies 350 years of philosophical frustration and badly formed psychologies.”373 I am inclined to agree with him, but reshaping our understanding of “psychology” will not be easy. Although it is vital to track brain regions and processes that are affected in hysteria, for example, or in any other illness, whether it falls under the traditional category “mental” or “physical,” the meanings of an illness or symptom for the patient cannot be ignored because those personal meanings play a role in the course of the illness itself. If the first-person experience of an illness cannot be reduced to third-person investigations of brain and nervous system or some other part or system of the body, then first-person meanings must accompany third-person or objective investigations into any and all sickness. Further, first-person meaning is always also second-person meaning. To conceive of a human being as “an island,” to borrow from John Donne, is a fundamental error.
Further, those personal meanings and beliefs, which cannot be neatly separated from collective meanings and beliefs, influence scientists and science. Michael Polanyi writes, “We often refus
e to accept an alleged scientific proof largely because on general grounds we are reluctant to believe what it tries to prove.”374 He cites Pasteur among others as examples of people whose ideas met with strong resistance in their time. In a footnote he then relates the case of Esdaile, a physician who performed three hundred major operations under mesmeric trance in the nineteenth century in India but could not get any medical journal, either in India or England, to publish his results. When W. S. Ward amputated a patient’s leg painlessly in 1842 under hypnosis, the medical establishment balked and accused him of fakery. The patient later signed a paper testifying to the fact that he had felt no pain. Scientists are always looking to explain the as yet unexplained, but if that unexplained phenomenon threatens to explode the conceptual boxes that already exist, only the most courageous among them will work on the problem.
I believe that formulating an adequate notion of the “mind” requires an expanded idea of the imagination and the passions, concepts that have been subordinated to reason since the Greeks. Both Cavendish and Vico elevated emotion and the imagination as human attributes that played a primary, not a secondary or inferior, role in human life. Human beings are image makers. When the outside world vanishes in sleep, we create an inside world in dreams, and evidence is accumulating that dreams resemble more closely what I call the memory-imagination continuum than waking perception.375 Some of us have vivid hypnagogic images before we sleep, and others hallucinate during fever and illness. Still others who are not sick have visions of dead people they loved, often in dreams, sometimes in waking hallucinations. These hallucinatory experiences are part of normal grief reactions. When the day is gone, we call it back in pictures, however imperfectly, or we look to a new day with pictures of what it may be like, images not qualitatively different from the ones in our memory. It seems that human beings under the sway of highly emotional experiences may unconsciously transform their bodies into metaphorical vehicles. I cannot live with what I saw. Now I am blind.
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