BEES scores for osteopathic residency choice [35] resemble what was found in the allopathic study [76]. In the osteopathic longitudinal study, only 11 of the possible 23 residency specialties were selected by eight or more students. The top four positions, in descending order, were occupied by the Core specialties of pediatrics, family medicine, internal medicine, and Ob/Gyn. All of these were designated as "Average" according to Mehrabian [20], with the exception of men entering pediatrics where their combined BEES score was ranked at the 69th percentile and designated as "Slightly High." In contrast to the allopathic data, psychiatry was eighth out of 11 slots and was designated as "Slightly Low" (31st percentile). The bottom two rankings were for anesthesiology and diagnostic radiology, both at the 16th percentile and had "Moderately Low" BEES scores. It is currently unknown why the BEES scores for allopathic students entering into anesthesiology placed the specialty in the fifth slot (out of 15) vs. the BEES scores for the osteopathic students that placed anesthesiology in the 10th slot out of the 11 possible selections. This was the largest discrepancy found for residency choice between the allopathic vs. the osteopathic graduates.

JSE scores were slightly different for those residency specialties entered by the osteopathic graduates [35]. The five Core specialties were in the top 6/11 positions: In descending order, they were pediatrics, family medicine, Ob/Gyn, psychiatry, and internal medicine. Orthopedics (only selected by men) and anesthesiology were the bottom two positions. What is concerning is that when compared to the POMEE norms for third- and fourth-year osteopathic students [33], only women CUSOM graduates who entered into psychiatry had a percentile score that was above the 50th percentile (59th); all other percentiles for the men and women in Core specialties were between the 29–44th percentiles. Percentile JSE scores for the bottom two selected specialties were even lower and were between 12th and 21st percentiles. So, overall, only 10 women out of a cohort of 345 CUSOM graduates had JSE scores that were above the 50th percentile when compared to the POMEE norm.

# **8. Is it possible to blunt affective empathy while increasing cognitive empathy?**

One goal for any program that teaches health professionals should be to empower the students with the ability to have a certain amount of detached affective empathy. This

is where the affective response is blunted so that the health care provider can attend to the patient without allowing the visceral reaction to an emotionally charged situation mentally distract them from providing effective care [44]. Yet, over blunting affective empathy can lead to the development of a health professional who has inadequate social skills and will appear and act in a distant, detached manner from the patient. In this regard, it has been shown that establishing an empathic bond of trust with patients leads to a lower incidence of malpractice suits, increased patient compliance, and better health outcomes [77–81]. Ergo, the converse would be detrimental to patient satisfaction and compliance. Therefore, being able to adequately quell the affective response allows the health care provider to respond in a calm, reassuring fashion to the patient by using ToM and cognitive empathy, thereby establishing a bond of trust with the patient.

In reference to the above, a further analysis of the data from the CUSOM longitudinal study plotted BEES scores vs. JSE scores [70]. Scatter plots were used (**Figure 1**) to determine which students raised or maintained their cognitive empathy, via JSE scores, while decreasing their BEES (Those points enclosed in the box). JSE scores had to be at or above the 75th percentile for the CUSOM cohort, while BEES scores had to decrease by −0.50 to −1.49 s.d. off the population norm established by Mehrabian [20]. BEES scores in this range would be considered as "Slightly Low" to "Moderately Low". Decreasing BEES scores by ≥ −1.5 s.d. would place those students in the "Very Low" (7th percentile) to "Very Extremely Low" (0.6th percentile) portion of the population. These latter students would correspond to the scatter plot points to the far left and lower left in **Figure 1**. The BEES scores between −25 and − 75 suggest these individuals would have a very low affective response and may be perceived by patients as a callous, indifferent health care provider. In a similar fashion, those individuals who have BEES scores >80, i.e. ≥ +1.5 s.d., (top 7% of a normal population) may have an affective response that is too great and result in ineffective patient care. These students are represented by the upper right data points in **Figure 1**. In conclusion, only a small subset of students just before graduation (points enclosed in the box in **Figure 1**.) met

**Figure 1.** *catter plot of the CUSOM graduating classes of 2017–2019.*

*Perspective Chapter: Having Heart – The Different Facets of Empathy DOI: http://dx.doi.org/10.5772/intechopen.106517*

the criteria of blunting affective empathy while raising or maintaining their cognitive empathy scores.

When examining all five data collection points, only 20/169 men and 21/176 women, i.e. < 12% of the cohort, qualified as blunting affective empathy while raising or maintaining cognitive empathy scores [70]. Furthermore, when examining the data from the first year through the end of the fourth year, 32 students qualified at only one of the five data collection time points, eight at two time points, and only one person qualified for four of the possible five time points. Out of the 41 qualifying osteopathic students, 24 entered Core residencies, while 17 selected Non-Core residencies. These data are disturbing in that the efforts to teach effective communication skills, via standardized patient encounters, osteopathic manipulation labs, mock mass-casualty incidents, and didactic sessions dealing with subjects such as end-of-life, giving bad news, spirituality, or even a session on empathy, did not have a substantial impact on the student empathy scores.

# **9. Empathy and burnout**

It is possible that the large number of CUSOM students who have high BEES scores put themselves at risk of burnout, since it takes considerable cognitive effort to control affective empathic responses [82–84]. Many of the students/graduates with higher BEES and JSE scores prefer to enter into the Core, people-oriented, specialties [35, 76, 85]. Thus, having an increased amount of affective and cognitive empathy takes a toll on the health care provider, especially women, who have a greater rate of burnout than men [86–88]. Many women osteopathic graduates prefer to enter the Core specialties, especially pediatrics, Ob/Gyn, and family medicine at a rate of almost twice that of men [35, 85]. For the allopathic students at UAMS, only pediatrics and Ob/Gyn were predominated by women, once again at an almost 2:1 margin. Any allopathic or osteopathic student with blunted BEES scores may be better able to perform in the Non-Core, technical, or procedure-oriented specialties without an increased rate of burnout, with the caveat of not becoming too hardened. As an example, it has been shown that physicians who, by necessity, induce pain in their patients during a procedure blunt their affective response to the pain they are causing in their patients [89, 90]. This allows them to concentrate on the patient vs. thinking about the pain they are causing. For a more detailed discussion, see [44].

## **10. Conclusions**

This chapter points out that over the years, there have been many definitions of empathy, and some of them incorporate sympathy or compassion into the definitions. Over the past few decades, there has been a consensus there are two basic types of empathy: an affective or vicarious empathy and a cognitive or role-taking empathy. Each of these two types of empathy employ some unique CNS regions which makes each type distinct. However, like a Venn diagram, there is overlap in many of the regions, and this may be due to the type of imaging being used, e.g. fMRI, PET scans, transcranial magnetic stimulation, and/or the empathy- or sympathy-inducing scenarios being used by the investigators. Other studies have used patients with various CNS lesions to determine regions used by empathy. Although some authors feel that sympathy/compassion is the same as affective empathy, various studies show that "reward" regions of the CNS were consistently, uniquely activated when the subject is in a sympathy study. Consequently, this author feels that sympathy is not the same emotion as vicarious/affective empathy. One region that was recruited by both affective and cognitive empathy, as well as sympathy/compassion, was the ventromedial prefrontal cortex. Thus, this region may be a key moderator of emotional responses.

Virtually, all studies show that women have significantly higher affective (BEES) and cognitive (JSE) empathy scores. Longitudinal studies by the author and colleagues at an allopathic and osteopathic medical school indicate that both affective and cognitive empathy drops after the completion of the first basic science year of study and after the first clinical rotation year. These studies also show that those students with higher BEES and/or JSE scores preferentially enter into the Core, peopleoriented, specialties (i.e. family and internal medicine, pediatrics, Ob/Gyn, and psychiatry), while those students with lower empathy scores tend to gravitate toward the Non-Core, technical or procedure-oriented, specialties, e.g. diagnostic radiology, emergency medicine, anesthesiology, and surgical specialties.

Finally, the osteopathic longitudinal empathy study shows that educational efforts to boost effective communication skills and to partially blunt affective empathy are currently inadequate [70]. However, several other researchers are attempting to enhance cognitive empathic communication skills [91–94] to increase patient satisfaction and compliance [95]; while others ask for additional neuroscience studies to help improve medical student empathy [96, 97]. Nevertheless, medical students or recent graduates who have high BEES and JSE scores may be at risk for increased rates of burnout, especially women. As stated in a previous chapter [44], "Physicians walk a fine empathic line to ensure they can relate to the patient without becoming too hardened themselves."

# **Acknowledgements**

Dr. Newton thanks the UAMS classes of 2001–2004 and the CUSOM classes of 2017–2019 for voluntarily participating in their respective Longitudinal Empathy Studies. He is also extremely grateful to Dr. Albert Mehrabian, emeritus professor of psychology, UCLA, for permission to use the BEES for educational purposes.

## **Author details**

Bruce W. Newton Campbell University Jerry M. Wallace School of Osteopathic Medicine, Lillington, North Carolina, USA

\*Address all correspondence to<EMAIL_ADDRESS>
© 2022 The Author(s). Licensee IntechOpen. Distributed under the terms of the Creative Commons Attribution - NonCommercial 4.0 License (https://creativecommons.org/ licenses/by-nc/4.0/), which permits use, distribution and reproduction for non-commercial purposes, provided the original is properly cited.

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# **Chapter 3**

# Roundtable: Raising Empathy through Virtual Reality

*Sara Ventura and Alison Jane Martingano*

## **Abstract**

Virtual reality (VR) has been described as the ultimate empathy machine; but does it deserve this reputation? Thanks to its features of embodied technology, VR can let users virtually walk in someone else's shoes. In addition, multi-sensory VR experiences can present evocative and heart-wrenching stimuli. For these reasons, VR seems to be a likely candidate to foster empathy. However, the published literature indicates that the impact of VR on empathy is complex and depends both on the type of VR and also the type of empathy being evaluated. The present chapter compares two meta-analyses which suggest that VR can elicit empathy, but the theoretical factors on which the technology has more efficacies are in contrast. In this chapter, these discordant meta-analyses are discussed, and the reasons why they find different results are theorized. We attempt to answer when and how VR could be an empathy machine. We conclude that low-tech but evocative storytelling is most likely to yield emotional empathy, and embodied experiences that encourage perspective-taking will improve cognitive empathy. Although we attempt to present the latest empirical evidence about empathy and VR, we are aware that the scientific consensus around this topic is likely to evolve in the future.

**Keywords:** empathy, virtual reality, meta-analysis review, body cognition

# **1. Introduction**

Empathy plays a key role in preserving human social relationships. Empathic people are more likely to engage in prosocial behavior, and less likely to engage in aggressive behaviors. Moreover, even temporary arousal of empathy can have positive impacts on behavior in the moment [1, 2]. Empathy is composed of both emotional and cognitive factors whose integration contributes to share and understand another person's perspective. Importantly, scholars have described empathy as a muscle, and as such it should be capable of growth and even regeneration with sufficient effort [3]. Following this logic, a variety of empathy training programs have been designed to explicitly teach empathy (e.g., [3]), and in fields such as medicine, where such programs are used regularly, they generally have sizable positive effects (g = 0.63, [4] for meta-analysis). These programs are generally based on taking the perspective of someone else with the aim to feel the others emotions, to understand them, and to regulate one's own feelings [5]. Yet as most people are unlikely to enroll in explicit empathy training without incentive, psychologists have begun to explore how engaging in other activities may improve empathy. Recent research has shown that written fiction [6], drama [7], and of course virtual reality [8, 9] show promise as empathy generators.

The most ardent supporters of Virtual reality (VR) claim it is "the ultimate empathy machine" [10]. In brief, VR is an advanced technology that allow users to be present and to interact with a three-dimensional environment [11]. There are a wide variety of VR experiences with different degrees of interaction currently available that are designed to promote social good. For example, 1000 Cut Journey allows viewers to become Michael Sterling, a Black man, and encounter racism as they try to complete everyday activities [12]. Users can interact with the experience by opening doors and picking-up objects using a controller. Other experiences, such as Clouds over Sidra, are less interactive but immerse the user in 360-video as they follow a day in the life of 12-year-old Sidra who lives in a refugee camp [13]. New VR experiences continue to be created by innovative designers the world over. In 2016, VR giant Oculus released their "VR for Good" initiative to incentivize designers to create prosocial content [14]. Not to be outdone by their leading competitor, HTC VIVE announced their \$10 million "VR for Impact" program in 2017 [15]. VR has also been embraced by various charitable organizations as part of their fundraising campaigns (e.g., [13, 16–18]).

# **2. Conflicting literature on VR and empathy**

Despite its popularity, experimental evidence for the empathy-building efficacy of VR generally, and 360-degree video specifically, is inconsistent. For example, although some VR experiences have led to increases in empathy [8, 19, 20], these positive effects do always exceed more traditional and low cost experiences, such as reading [9], asking people to imagine what it would be like to be in someone else's situation [21] or taking part in real world role play [22].

These conflicting results from individual research studies are compounded by two recent conflicting meta-analyses authored by ourselves. Meta-analyses normally serve to reduce confusion by reducing the impact of random errors and providing a more precise estimate of the average effect size. They even allow researchers to explore potential moderators that may explain why a result is true in some cases but not in others. However, for VR and empathy, even using meta-analysis we did not find a consensus. Using data from 43 studies Martingano et al. found that VR led to approximately a third of a standard deviation more emotional empathy (d = 0.325) but no significant increase in cognitive empathy [23]. However, using a more constrained definition of VR, Ventura et al. found that in 7 studies VR led to approximately half a standard deviation more cognitive empathy (d = 0.513) but had no significant effect on emotional empathy [24] the reversed results (see **Figure 1**). The reason, we argue, is because the impact of VR on empathy depends not just on one thing, but two interacting moderators, namely, the type of empathy and the type of VR.

#### **2.1 The impact of Virtual Reality depends upon the type of empathy**

Scholars and laypeople alike hold a variety of diverse and competing definitions of empathy [25]. In an influential paper on the topic, Daniel Batson listed eight definitions of empathy with the hope of reducing confusion by recognizing the term's complexity [26]. One of the reasons it is so difficult to define empathy

#### **Figure 1.**

*Overall standardized mean differences and 95% confidence intervals for published meta-analyses on the impact of VR on empathy.*

is because it is a multifaceted concept. It is not simply that researchers have not agreed on a single definition of empathy, but that empathy is not a single thing to begin with.

Although there is disagreement in the literature regarding exactly what counts as empathy, many scholars make a distinction between cognitive and emotional empathy. Emotional empathy (sometimes called affective empathy) involves experiencing emotions in response to others' emotions or expressions of emotions. On the other hand, cognitive empathy involves understanding others' thoughts and feelings without necessarily reacting emotionally [2]. This understanding is most often achieved via perspective-taking, so much so that perspective-taking is often used as a synonym for cognitive empathy. Given the definitional confusion surrounding the term empathy, in this chapter, we will discuss research and theory on empathy that is styled under many different names. Overall, cognitive and emotional empathy are best thought of as broad categories that each encompass a variety of different empathy types. Despite disagreement over which concepts are classified under each category, the distinction between emotional and cognitive empathy remains common [26, 27].

Despite our conflicting results, Martingano et al. [23] and Ventura et al. [24] both find the distinction between cognitive and emotional empathy is critical when discussing the impact of VR on empathy.

So why might VR impact emotional and cognitive empathy differently? Media scholars have argued that one of the strengths of VR is that it removes the cognitive burden normally associated with empathizing [28]. By virtually taking someone else's perspective on behalf of users, VR is doing the work of cognitive empathy for them. VR designers have made use of powerful graphics, motion-sensing technologies, and surround sound systems to place viewers in realistic environments and situations that they might find hard to imagine, such as refugee camps, homeless shelters, or the experience of racial discrimination. By doing the perspective-taking on behalf of users, it is hoped that VR can enhance empathy in people who are not otherwise motivated or able to empathize [29].

Perspective-taking is a difficult skill that requires attention and sufficient cognitive resources. Cognitive load hinders both emotion recognition [28, 30] and perspective-taking [31]. Moreover, neuroscientists have shown that the more difficult it is to predict another person's intentions, the more active the brain areas involved in cognitive empathy become. Therefore, it seems likely that cognitive empathy, like many other skills, benefits from the practice and that practice should occur within the zone of proximal development [32]. The zone of proximal development is defined as the space between what someone can do without assistance and what they can do with assistance. In other words, optimal skill development occurs a practice activity is not too difficult, but also not too easy. Practice activities known to enhance cognitive empathy include acting and creative writing, which require some little effort to recreate the mental states of fictional characters [33, 34]. The question is, does VR provide a suitable opportunity for users to practice cognitive empathy skills? In some cases, VR may be making it too easy for users by doing the perspective-taking work for them, alternatively, VR may overwhelm the senses making it too difficult for users to focus on understanding others' emotions. But importantly, in some cases, VR may provide the optimum level of support needed for users to practice and improve their perspective-taking, emotion recognition, and other cognitive empathy skills. We will discuss what features were used in the 7 studies included in Ventura and colleagues [24] meta-analysis that seemed to make them so effective at enhancing cognitive empathy in the next section and why the majority of studies included in Martingano and colleagues [23] meta-analysis were not, but first we ought to consider why VR might increase emotional empathy.

The idea that virtually taking another person's perspective would lead to emotional empathy is rooted in a long-standing assumption that perspective-taking is the mechanism by which emotional empathy occurs. This idea was borne from extensive research showing that if you ask someone to take someone else's perspective, they are more likely to feel emotional empathy towards them (e.g. [35]). However, researchers now know that people default to feeling emotional empathy for others who are suffering regardless of whether perspective taking instructions are given, and the apparent benefit of perspective-taking was actually from a dampening effect of control instructions [36, 37]. Indeed, neuroscientific evidence shows us that perspective-taking is not a required pathway to emotional empathy. Emotional empathic responses are fast, automatic, and occur spontaneously [38] even when participants are not consciously aware of what they are seeing [39]. In our daily lives, most of us are familiar with automatic emotional empathy, it's the sort that rushes over us when a refugee child is depicted on the news. VR may well arouse emotional empathy automatically if it depicts the suffering of another person, but this is unlikely to be due to the virtual perspective-taking feature and simply a result of displaying evocative stimuli. The differing results of our two meta-analyses found for emotional empathy, therefore, are likely due to the different emotionally arousing nature of the VR experiences included in each meta-analysis (see below).

#### **2.2 The impact on empathy depends on the type of virtual reality**

VR is an overarching term for a collection of computer hardware and software that immerses users in artificial environments. Both the hardware and the virtual content may impact whether a given VR experience is effective at arousing empathy. Commonly, VR experiences use a headset to display three-dimensional images and while wearing this system, a user's movements and orientation are tracked and fed

#### *Roundtable: Raising Empathy through Virtual Reality DOI: http://dx.doi.org/10.5772/intechopen.109835*

back into the system to adapt the presentation of the virtual environment. However, other hardware has been considered under the umbrella 'virtual reality'. Martingano et al. used a particularly all-encompassing definition of virtual reality that included "any computer technology that virtually simulates one or more senses (auditory, visual, olfactory, gustatory, and/or tactile simulations)". Within this definition desktop VR that plays on a normal computer screen is included as it stimulates vision and auditory senses, and so too are auditory-only simulations played on regular headphones (for example simulations of what it may be like to suffer from auditory hallucinations as a result of schizophrenia).

In contrast, the VR experiences included in Ventura et al.'s meta-analysis all used head-mounted display units making these experiences more immersive on average, benefiting from spatialized sound, stereoscopic visuals, greater image resolution, and a higher update rate. More immersive VR environments have been associated with creating a heightened feeling of presence in users [40]. Presence is the "perceptual illusion of non-mediation" [41], where a user fails to acknowledge the existence of the VR environment and responds as it were not there. More simply put, the user has a feeling of truly "being there" in the virtual environment [28]. Recent research suggests that the feeling of presence mediates the influence of VR on empathy [42]. This may be one reason why Ventura and colleagues found an overall positive impact of VR on cognitive empathy, but Martingano and colleagues did not.

In addition, to creating a sense of presence, immersive VR can also create feelings of embodiment. Developments in motion and voice detection have led to a tighter coupling of body and machine which may trigger feelings of body ownership in users [43]. VR allows users to see and hear as if they were experiencing someone else's point of view in the real world, in other words, to have an "embodied experience" [28]. In some cases, a VR experience is specifically designed to produce a "body ownership illusion" or "body-swap illusion" where users are deliberately given a virtual body that is different from their own. In Ventura's meta-analysis, 3 of the 7 studies used a body swap illusion (42.9%). However, in Martingano's meta-analysis only 7 of 43 studies (16.3%) used this illusion. Body swap illusions may be particularly effective at encouraging users to take the perspective of the person they are embodying [44], and provides another potential explanation for why Ventura found a positive impact on cognitive empathy. The utility of these illusions will be discussed more below.

# **3. When and how VR can increase empathy**

### **3.1 Change the body to change the mind: the key role of body ownership**

Embodied technology may be a key feature of VR that allows users to practice and improve their cognitive empathy skills. The sense of embodiment refers to the set of sensations related to having (ownership), being located in (location), and controlling (agency) a body [45]. The body contributes to the representation of ourself and, as explain by the author Blanke [46], human adults experience a 'real me' that 'resides' in 'my' body and is the subject (or 'I') of experience and thought. The multisensory bodily signals and their integrated neural representation are of fundamental importance for self-consciousness and the body is also central to our understanding of others. In general, we become aware of our bodies through exteroceptive signals such as the touch, and through interoceptive such as the heart rate and proprioceptive signals arising from within the body [47]. Then, we use the feelings from the body to sense

both our physical condition and emotional state. The perception of our body can be manipulated generating what is called the "body ownership illusion" or "body-swap illusion". The usual example is the rubber-hand illusion, during which synchronous stroking of a seen fake rubber hand and one's own unseen hand causes the rubber hand to be attributed to one's body [46]. The successful manipulations demonstrated the malleability of the mental representation of one's body, identity, and the emotions we feel.

In the past decades, several studies have demonstrated the ability of VR to induce body-swap illusions by altering the sense of embodiment. Through the advanced VR technologies such as the opt-track suit it is possible to alter the neuropsychological basis of self-experience and experiment a different "ontological self" by owning a virtual body of different race, size, and gender groups. According to Riva [48] there are three possible strategies that can be used to alter bodily self-consciousness using VR: (i) mindful embodiment, which consists in the modification of the bodily experience by facilitating the availability of its content in the working memory; (ii) augmented embodiment, which is based on the enhancement of bodily self-consciousness by altering/extending its boundaries; and (iii) synthetic embodiment, which aims to replace own body with synthetic self-consciousness (incarnation). Thanks to these characteristics, VR could facilitate cognitive empathy, specifically perspective taking, in challenging situations by offering compelling experience of what it feels like to walk in someone else's shoes [28].

## **3.2 Evocative stimuli to arouse emotions: creating a transformative emotional experience**

Many charitable organizations and philanthropic groups interested in using VR to increase empathy are largely turning to cheaper and less technological advanced VR experiences (that are not capable of producing the body-swap illusion) such as 360-degree video [13–15]. This choice is likely financially driven: 360-degree videos are much less expensive than computer generated environments, possibly costing as low as \$10 k/minute to create, whereas the same computer generated (CG) environment could cost nearly double that [49]. However, importantly, these experiences may be sufficient for their purposes of arousing emotional empathy and creating a transformative emotional experience.

A transformative experience is defined as an event in which a person's worldview is reconstructed, resulting in a shifted perspective of the world, or in the change on values and beliefs [50]. The transformative experiences induced in VR could facilitate social interaction by helping people to establish common ground and infer shared knowledge and beliefs between interactants [51]. Potentially even low-tech VR can generate high sense of engagement and social connectedness in people that naturally belong to the outgroup and therefore increase emotional empathy [23].

To do this, VR technology can be used to show emotionally evocative imagery. Particularly of children, animals, or other targets whom users can relate to, engage with, and feel connected to. This can be achieved by showing real-world footage of suffering individuals, with close-ups of emotion-laden faces, crescendo-ing music, and an invested narrator. A good example of this is, 'Clouds over Sidra', which is a documentary-style 360-video of a refugee camp depicting a young girl called Sidra who talks about her life in the camp and hopes for the future [13]. Another example is a 360-video showing female sexual harassment that has been shown to increase emotional empathy in a male sample (**Figure 2**) [52].

*Roundtable: Raising Empathy through Virtual Reality DOI: http://dx.doi.org/10.5772/intechopen.109835*

#### **Figure 2.**

*A participant watching the 360-degree video about sexual harassment into the female perspective.*

Charitable organizations have been aware of these techniques for years. Fundraising campaigns often feature vivid photographs and describe personal details about an individual and their plight. Social scientists have tested the effectiveness of such individuated appeals experimentally, with the phenomena earning itself the name *The Identifiable Victim Effect*. Identified victims have been found to evoke stronger feelings of empathic compassion than statistical victims [53] and this increased arousal mediates increased charitable giving [54]. In an important recent research study [55] demonstrated that regardless of the technology used, telling engaging narratives is key to the success of VR. This study helps to explain why more immersive VR experiences do not necessarily lead to more emotional empathy. People can engage in a narrative without surround sound or high-resolution graphics. In the same way a low-budget play can still transport us to another world, and a novel can lead us into another's psyche, a cardboard VR headset playing the right content can also generate emotional empathy. Understanding that narrative engagement is key to enhancing emotional empathy with VR also helps to explain why in some cases VR is not outperforming more low-tech solutions such as reading or watching a video [23].

# **4. Discussion**

Science grows continuously: answers provided by previous research leads to new research questions, and so on. The present chapter represents another turn in this cycle, as we attempt to understand when and how VR increases empathy. Our discussion arises from two published meta-analysis authored by ourself that present contrasting findings on which empathy factors are better fostered by VR: emotional empathy in Martingano and colleagues [23], and cognitive empathy in Ventura and colleagues [24]. We conclude that our results are a product of two interacting moderators: the type of empathy and the type of VR in question. Emotional empathy appears to be aroused most effectively by evocative stimuli and immersive storytelling, whereas cognitive empathy appears to benefit from embodied experiences which require more technological advanced VR experiences.

However, there are limitations to the confidence in which we can make these conclusions. First of all, like all meta-analyses, the quality and precision of our estimated effects was dictated by the nature of the studies available for inclusion. Although we feel it is unlikely, it is possible that the different results obtained in Martingano and colleagues and Ventura and colleagues are simply statistical artifacts. As can be seen from **Figure 1**, the 95% confidence intervals from both meta-analyses overlap, and so it is possible that the true size of this effect is captured within these bounds. More research, as always, would help tighten these estimations and we encourage other researchers to update our work as appropriate.

Second, content matters. In much the same way that not all television shows have the same effect, not all VR experiences do. Some television shows are educational, some are funny, and some are unsuitable for minors. Therefore, in the same way it is foolish to ask whether TV in general is educational, it is also mistaken to ask whether VR in general increases empathy. Although neither of our meta-analyses deliberately selected for content, both were restricted to VR experiences that had content that was more likely to elicit empathy because articles had to measure empathy to be included. Researchers who had gone to the effort to measure empathy generally did so because they expected their VR experience would impact it. It is not very likely that researchers are going to put users in a first-person shooter VR game and then measure empathy – at least we have not seen that done! Psychological research finds that the type of media content matters for whether outcomes are aggressive or prosocial [56]. Similarly, violent VR content is unlikely to have a positive effect on empathy and may even lead to more aggressive outcomes.

Third, the users of VR matter. The personal characteristics and demographics of VR users may influence their experiences within VR [57]. For example, users' perceptions of presence can vary dramatically in similar or even identical virtual environments [58, 59]. It is therefore likely that user characteristics will also influence the utility of VR for increasing empathy. In Martingano et al.'s meta-analysis they found, for example, that the positive impact of VR on empathy was three times larger for children with Autism. Recent research also indicates that the utility of the body ownership illusion depends on user psychological traits. For example, lower scores on the traits of machismo and alexithymia were demonstrated to be facilitators for male participants to embody a female victim of sexual harassment [60].

Finally, given the interaction between the type of VR and the type of empathy aroused there is no simple "one size fits all" answer to the most empathy-enhancing VR experiences. Unfortunately, our advice on how to promote emotional empathy using VR (evocative imagery and immersive storytelling) is in almost direct contradiction to our advice on how to use VR to increase cognitive empathy (subtle, ambiguous stimuli that challenge people to tell their own story). Clinicians, parents, charities, and educators should select VR experiences with care based on the empathic outcomes they wish to evoke. In the future, it may be possible to design VR experiences that are emotionally evocative while still leaving room for users to build upon the experience using their own imagination. Indeed, we hope that the insights provided in this chapter may help take a small step in that direction, and prompt further research into this area.

# **Acknowledgements**

This work was funded by a Margarita Sala postdoctoral fellowship for the requalification of the Spanish university system from the Ministry of Universities of the

Government of Spain and financed by the European Union NextGeneration EU (grant UP2021-044).

This work was supported by the Intramural Research program of the National Genome Research Institute.

# **Author details**

Sara Ventura1,2\* and Alison Jane Martingano<sup>3</sup>

1 Department of Psychology, University of Bologna, Bologna, Italy

2 Institute Polibienestar, University of Valencia, Valencia, Spain

3 Department of Psychology, University of Wisconsin, Green Bay, United States

\*Address all correspondence to<EMAIL_ADDRESS>
© 2023 The Author(s). Licensee IntechOpen. Distributed under the terms of the Creative Commons Attribution - NonCommercial 4.0 License (https://creativecommons.org/ licenses/by-nc/4.0/), which permits use, distribution and reproduction for non-commercial purposes, provided the original is properly cited.

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# **Chapter 4**

# From Empathy to the Aggression–Compassion Continuum

*Neil E. Grunberg and Erin S. Barry*

# **Abstract**

Empathy is relevant to but not sufficient to fully understand relationships. Recent research has proposed that empathy is part of a continuum—from pity to sympathy to empathy to compassion—and that compassion is the key to building good relationships because it includes actions. We offer an extension of this concept to include neutrality (apathy) and add four constructs of opposition—from antipathy to animosity to hostility to aggression. We describe all nine constructs with regard to cognitive, emotional, and behavioral support or opposition. Further, we propose that it is useful to consider these constructs in terms of character, competence, context, and communication at four psychosocial levels—personal, interpersonal, team, and organizational. We believe that relationships can be best addressed with these concepts in mind and that application of the support versus oppose poles of the aggression-compassion continuum are not equivalent to good and bad.

**Keywords:** compassion, empathy, sympathy, pity, apathy, antipathy, animosity, hostility, aggression

## **1. Introduction**

Over the past millennium, countless individuals have offered some version of the concept that actions are particularly important to human relationships. In the 1200s, Francisican friar Anthony of Padua is attributed with saying, "… let your words teach and your actions speak." In 1628, John Pym said, "… actions are more precious than words." In 1693, Thomas Manton wrote, "… Work and Scope … speak much louder than Words." In 1856, Abraham Lincoln said, "'Actions speak louder than words' is the maxim." Or, in modern vernacular, "Don't just talk the talk; walk the walk [1]." Yet, what we do depends on what we think and feel. Therefore, it is important to understand how thinking, feeling, and behaving relate to each other.

Psychology involves cognitions, motivations/emotions, and behaviors. Cognitions are what we perceive, think, and believe. Motivations/emotions are how we feel and underlie why we think and act as we do. Behaviors are actions that we take, for and against ourselves and others. What we think matters; what we feel matters; what we say matters; but what we actually do probably matters most, especially with regard to treatment and relationships with others.

During the twentieth century and continuing to this day, empathy has received interest and attention from counselors, educators, life coaches, spiritual leaders, political leaders, scholars, and researchers in the social sciences and neurosciences because of its relevance to all aspects of life and interactions with others. The fact that empathy is the subject of this volume exemplifies the breadth and depth of interest is this psychosocial concept.

Recently, the question has been raised whether empathy *per se* is sufficient to understand and to help improve relationships and the human condition or, instead, that actions must flow from feelings to truly matter. Hougaard and colleagues [2, 3] have proposed that empathy alone is necessary but not sufficient to optimize relationships; instead, compassion that includes actions is necessary to build better relationships. These authors further propose that empathy lies along a continuum of feeling and acting with regard to others, ranging from pity to sympathy to empathy to compassion. We agree that distinguishing among these concepts and how they relate to each other is valuable, but we believe that these concepts are a subset of a broader psychosocial continuum that ranges from aggression to compassion. In addition, we suggest that understanding the psychological constructs which exist along this broader continuum also requires consideration of four elements of each of us at four psychosocial levels [4–7]. This chapter addresses these topics.

This chapter begins with a discussion of the scholarly origins of empathy because of the substantial attention already given to this particular concept and because empathy is the focus of this volume. That discussion introduces the importance of actions beyond thoughts and feelings. Next, we present nine different psychological constructs along an aggression-compassion continuum that includes two dimensions. Each construct is defined and briefly explained. Then, we present four biopsychosocial aspects of people—character, competence, context, communication—and four psychosocial levels—personal, interpersonal, team, organizational. We relate these eight elements to the constructs of the Aggression-Compassion Continuum. Finally, we discuss how the constructs that appear on the Aggression-Compassion Continuum are distinguished from good and bad cognitions, emotions, and behaviors.

# **2. Scholarly origins of "empathy"**

*Empathy* refers to cognitive and emotional responses aligned with others' thoughts and feelings. According to the Merriam-Webster Dictionary, empathy is "understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner [8]."

Interestingly, in 1871 Charles Darwin described how humans and animals come to help others. Darwin's discussion of what he called "sympathy" included concern and actions that are more similar to what we now refer to as "empathy" and "compassion [9]." This focus on concern and actions for the welfare of others complemented Darwin's notions of competition and survival of the fittest [10].

Consistent with Darwin's Theory of Continuity of Species, primatologist Frans de Waal has noted that apes and other infrahuman species also demonstrate behaviors that involve caring for others and, perhaps**,** feeling the emotions of others [11]. Shortly after Darwin's [9] discussion about humans and animals helping others, the German concept of "Einfühlung"—or "feeling into"—was introduced by Robert Vischer in 1873 to explain relations of people to others and to artwork [12]. This

*From Empathy to the Aggression–Compassion Continuum DOI: http://dx.doi.org/10.5772/intechopen.106516*

particular application of "feeling into" to understand other people as well as reactions to artwork was further discussed by Theodor Lipps [13, 14] (cf. Curtis and Elliott [15] for a historical overview). Edward Titchener [16] and James Ward (cf. Lanzoni [17]) translated this concept with the English word "empathy [12]."

In the twentieth century, empathy has been addressed in more detail by authors, scholars, and scientists with a wide range of interests and expertise. The study and analysis of empathy and how it relates to other psychological constructs, such as sympathy and compassion, is ongoing among psychologists and neuroscientists.

For example, author and motivational speaker Brené Brown has offered that empathy involves four qualities that distinguish it from sympathy [18–21]:

Other researchers have differentiated between "emotional or affective empathy" and "cognitive empathy," where "affective empathy" involves sensations and feelings in response to others' emotions and "cognitive empathy" involves identification and understanding of others' emotions [22, 23].

Emotional empathy consists of three separate components, according to Hodges and Myers:

Cognitive empathy (or empathic accuracy) refers to how well we can perceive and understand the emotions of another [23, 24].

Psychologists Daniel Goleman and Paul Ekman have identified three components of empathy, that include cognitive and emotional (or affective) and adding "compassionate empathy"— a prelude to Hougaard and Carter's distinction between empathy and compassion [22]. With regard to these three components of empathy [11, 22, 25]:

Denworth [26] has suggested that empathetic concern is "compassion" and includes motivation to help; i.e., to take action. Neuroscientists also are studying empathy and compassion and are seeking to identify neural circuits and specific regions of the brain that are involved in and that distinguish between these constructs [27, 28]. Empathy requires the involvement of neural networks that underlie perception of others' emotions, ability to connect with them emotionally and cognitively, and ability to distinguish between our own and others' emotions [29].

Social neuroscientists have offered two theories of empathy: (a) Simulation Theory and (b) Theory of the Mind. Simulation Theory proposes that empathy occurs because when we see another person experiencing an emotion, we simulate that to know what it feels like. It has been suggested that this phenomenon involves "mirror neurons" that are activated when we observe and experience emotion and that the medial prefrontal cortex is primarily involved. Theory of Mind proposes that we use thought processes to explain the mental state of others. In addition, context and situation affect which of these empathetic responses occur [23, 28, 30].

With regard to compassion, Gilbert [31] has suggested that compassion arose from the evolutionary advantage of caring for others, especially offspring, kin, and in-group allies. Rasmus Hougaard [32] has proposed that compassion is better for humanity than empathy for four reasons:

He also argues that: compassion can be developed; we should have more selfcompassion; and that we should practice compassion daily [32].

Neff has emphasized the importance of self-compassion as well as compassion for other people [33–35]. Hougaard and colleagues [2, 3] went even further and proposed that empathy alone is not sufficient to optimize relationships. Instead, these authors emphasized that compassion is necessary to influence relationships because compassion includes actions. These authors offered a pictorial representation of a continuum of feeling and acting with regard to others, ranging from pity to sympathy to empathy to compassion. We believe that this representation is important and relevant to consider in building relationships, but that it is only part of a broader continuum and additional, related concepts.

### **3. The aggression-compassion continuum**

**Figure 1** depicts nine constructs that we believe are relevant to human relations and well-being (including self, dyads, teams, and organizations): Aggression, Hostility, Animosity, Antipathy, Apathy, Pity, Sympathy, Empathy, Compassion. The four constructs that appear in the upper right quadrant and in the manner presented in **Figure 1** are based on Hougaard and Carter [2]. The addition of the other five constructs with the particular two-dimension labels is new. We have labelled the axes differently from Hougaard and Carter [2] to capture the three key aspects of psychology: cognitions, emotions, and behaviors. The x-axis is labelled "Cognitive and Emotional"

#### **Figure 1.**

*Agg ss on-compassion continuum.*

ranging from "Opposition" on the far left to "Support" on the far right; the y-axis is labelled as "Behaviors" from "Opposition" on the bottom to "Support" on the top. In addition, each construct appears in **Figure 1** in a location meant to correspond to the relative amount of each type of support or opposition. Each of the nine constructs is defined and differentiated in this section of the chapter following a comment about word meanings.

# **3.1 A comment about word meanings**

The study of the origin of words and the way in which their meanings change (Etymology) is relevant to understand the distinctions among the concepts along the Aggression-Compassion continuum. Words with the "–ion" suffix (including Aggression and Compassion) are nouns of state, condition, or action. Words with the "–ity" suffix (including Pity, Apathy, Antipathy, Animosity, Hostility) are nouns of condition or quality of being. Words that include "–path" refer to "suffering" and "–pathy" refers to "one versed in" (for example, Apathy, Antipathy) [36]. Based on this information about word origins, Aggression and Compassion are appropriate poles on the Action (Behavior) axis of **Figure 1**.

# **3.2 The "support" quadrant of the aggression-compassion continuum**

The upper right quadrant of **Figure 1** lists four psychological constructs and can be broadly categorized as the "support" quadrant because all of the constructs that appear in this quadrant provide some sort of support. The support can be cognitive and emotional; it also can be behavioral support. The four constructs that appear in this quadrant increase in amount of all types of support provided from pity to sympathy to empathy to compassion.

*Pity* refers to one's own cognitive response to another's negative experiences or an expression of sorrow. The Merriam-Webster Dictionary defines pity as "sympathetic sorrow for one suffering, distressed, or unhappy [37]." Pity can be summed up by, "I feel sorry for you [2, 38]."

*Sympthy* refers to one's own thoughts and deep feelings of concern for others. The Merriam-Webster Dictionary defines sympathy as "an affinity, association, or relationship between persons or things wherein whatever affects one similarly affects the other [39]." Sympathy involves a deeper, more personal level of concern than pity with pity as an expression of sorrow. Sympathy involves understanding from one's own perspective and does not include shared emotion with others. Sympathy can be summed up by, "I feel for you [2]."

*Empathy* refers to cognitive and emotional responses aligned with others' thoughts and feelings*.* It involves a cognitive and emotional connection that assumes the perspective and feelings of others and includes understanding why others feel as they do. According to the Merriam-Webster Dictionary, empathy involves "understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner [8]." Empathy can be summed up by, "I feel with you [2, 40]."

*Compassion* refers to cognitive, emotional, and behavioral responses (or intention to act) in response to others' thoughts and feelings. The Merriam-Webster Dictionary defines compassion as "sympathetic consciousness of others' distress together with a desire to alleviate it [41]." Compassion can be summed up by, "I am here to help and support you [2, 35]."

#### **3.3 The neutral point of the aggression-compassion continuum**

*Apathy* refers to a lack of thoughts or feelings. The Merriam-Webster Dictionary defines apathy as a "lack of feeling or emotion; impassiveness; lack of interest or concern; indifference [42]." Apathy turns a blind eye to issues, situations, and people. It is, therefore, the "neutral" point on the Aggression-Compassion Continuum and can be summed up by, "I don't care [40]."

#### **3.4 The "Oppose" quadrant of the aggression-compassion continuum**

The lower left quadrant of **Figure 1** lists four psychological constructs and can be broadly categorized as the "oppose" quadrant because all of the constructs that appear in this quadrant provide some sort of opposition. The opposition can be cognitive and emotional; it also can be behavioral opposition. The four constructs that appear in this quadrant increase in amount of all types of opposition provided from antipathy to animosity to hostility to aggression.

*Antipathy* refers to dislike according to the Merriam-Webster Dictionary [43]. It includes opposition in feeling, aversion, dislike, repugnance, distaste. Antipathy can be summed up as, "I don't like you [44]."

*Animosity* refers to a stronger dislike. The Merriam-Webster Dictionary defines animosity as "a strong feeling of dislike or hatred; ill will or resentment tending toward active hostility; an antagonistic attitude [45]." Animosity is violent hatred leading to opposition and active enmity. Animosity can be summed up as, "I strongly dislike you [44]."

*From Empathy to the Aggression–Compassion Continuum DOI: http://dx.doi.org/10.5772/intechopen.106516*

*Hostility* refers to dislike that is so strong that it may include intent to take action against others. The Merriam-Webster Dictionary defines hostility as "deep-seated usually mutual ill will, conflict, opposition, or resistance in thought or principle [46]." Both animosity and hostility refer to strong dislike and opposition, but hostility includes unfriendliness or opposition that can lead to actions. Hostility can be summed as, "I strongly dislike you and might oppose you [47]."

*Aggression* refers to taking actions to oppose, dominate, or injure others. According the Merriam-Webster Dictionary, aggression is "a forceful action or procedure especially when intended to dominate or master; the practice of making attacks or encroachments; hostile, injurious, or destructive behavior or outlook [48]." Aggression has action associated with the thoughts and feelings and can be summed up as, "I am here to oppose you [49]."

# **4. Psychosocial elements to consider**

With regard to the nine psychological constructs on the Aggression-Compassion continuum, there may be a tendency to think about these nine psychological constructs as involving relationships only between oneself and another individual. In fact, they are relevant to four psychosocial levels: Personal, Interpersonal, Team, Organizational. These four categories have been described as part of the Leader-Follower Framework (LF2) because they refer to and help guide understanding of the individual (personal or self), relationships between two people (interpersonal), interactions within small teams, and consideration of large groups, cultures, systems (organizational). The LF2 also distinguishes among four biopsychosocial aspects of people: character (who we are), competence (what we think, feel, and do), context (when and where we are), and communication (how we express ourselves and seek understanding). Each of these topics is described below [4–7]:

*Character* (Who we are) refers to biological, psychological, and social aspects of each person or group (e.g., physical characteristics, demographics, personality, attitudes, beliefs, values, biases). Character includes integrity, reliability, responsibility, dependability, and moral compass, but also can include the opposite of each of these admirable qualities.

*Competence* (What we know and do) refers to knowledge, skills, and attitudes (KSAs) relevant to a particular role, position, task, or situation as well as to more general KSAs (e.g., critical thinking, decision-making, problem solving, open-mindedness, emotional intelligence).

*Context* (When and Where we are) includes physical (outside and inside us), psychological, social, and cultural environments, such as time of day, climates, nutritional state, sleep, mental and behavioral health, size of group, relationships within a group, societal practices, and belief systems. Context also includes effects of physical and mental stress or misunderstanding that can alter thoughts, feelings, and behaviors.

*Communication* (How we strive for understanding) includes sending and receiving information, verbally and nonverbally.

*Personal* refers to psychological, biological, and experiential aspects of the individual or oneself. *Personal Character* includes demographics, attitudes, values, beliefs, biases, personality, emotions, motivations, and self-awareness. *Personal Competence* includes knowledge, skills, abilities, and actions. *Personal Context* includes physical,

psychosocial, and situational environments outside and within ourself. *Personal Communication* includes abilities to take in and record information (e.g., reading, understanding, notes, reflections, how others perceive us vs how we perceive ourself).

*Interpersonal* refers to dyadic relationships between two people. *Interpersonal Character* includes shared or opposing cognitions and emotions. *Interpersonal Competence* includes shared or opposing actions. *Interpersonal Context* includes physical and psychosocial environments relevant to the dyad. *Interpersonal Communication* involves sharing information and understanding (or lack thereof) between the dyad.

*Team* is a small group of people mutually committed to common goals. *Team Character* refers to shared values and trust among the members. *Team Competence* refers to understanding the KSAs of the members. *Team Context* refers to the environments and situations in which the members exist. *Team Communication* involves shared understanding among the members.

*Organizational* refers to large groups of people, institutions, and systems. *Organizational Character* refers to the large group's values and mission. *Organizational Competence* refers to the large group's KSAs. *Organizational Context* refers to the large group's culture. *Organizational Communication* involves understanding among the members of the large groups.

# **5. Relating the LF2 elements to the constructs of the aggressioncompassion continuum**

We submit that all eight of the LF2 elements should be applied to better understand each of the nine constructs along the Aggression-Compassion Continuum. This type of analysis will likely reveal contributing factors to each of the constructs. Such understanding may suggest how to better work with others.

For example, consider Aggression and each of the LF2 elements. Is the reason an individual acts aggressively because of character (e.g., personality, differing values, mental health), competence (e.g., KSAs to act aggressively or the lack of KSAs to control oneself and to not act aggressively), context (e.g., hunger, tiredness, stress, situation, existential threat), or communication (e.g., the only option to convey intended meaning or lack of options to reach understanding)? Is the individual acting aggressively towards oneself (personal), one other (interpersonal), a team, or an organization/culture system? Also, is the individual acting aggressively because of personal (e.g., self-hate, frustration), interpersonal (e.g., disagreement with a single other person), team (e.g., going along with others or opposing particular others), or organizational (e.g., the culture of the larger group) reasons? A similar analysis can be applied to the other three constructs in the Opposition Quadrant of the Aggression-Compassion Continuum: Hostility, Animosity, Antipathy.

As another example, consider Apathy and each of the LF2 elements. Is the reason an individual does not care, does not express any emotions, and does not take any actions because of character (e.g., personality, perception of hopelessness, physical illness, mental illness, picking their battle), competence (e.g., lacks the KSAs to take any action relevant to the situation at hand, overwhelmed with other things on their plate), context (e.g., lack of necessary resources to act, exhaustion, overwhelming odds or opposition), or communication (e.g., lacking any way to communicate, not receiving any communication that the issue or situation is worth addressing)? Is the lack of caring directed at oneself, one other, a team, an organization? Also, is the reason that an individual does not care because of personal (e.g., lack of self-esteem, lack of self-confidence), interpersonal (e.g., perception that no concern or action will affect the other person, that the other person will do what they want anyway, or that the other person does not matter), team (e.g., lack of respect from or connection with the team, belief that nothing can be done to affect the team), or organizational (e.g., experience or belief that there is no way to alter the organization, culture, or system) reasons? A similar analysis can be applied to the other three constructs in the Support Quadrant of the Aggression-Compassion Continuum: Pity, Sympathy, Empathy.

In addition, consider Compassion and each of the LF2 elements. Is an individual acting compassionately because of character (e.g., personality, understanding their own and others values and beliefs), competence (e.g., having the KSAs to act and perform compassionate acts), context (e.g., the needs of the recipient(s) of the compassionate acts are overwhelmingly heart-breaking, understanding of the stress with the individual, team, or organization), or communication (e.g., the recipient(s) of the compassionate acts effectively expressed need for help, the provider(s) of the compassionate acts can effectively understand and communicate with others to understand what they are saying and discuss what is needed)? Is the individual acting compassionately towards oneself (personal), one other (interpersonal), a team, or an organization/culture system? Also, is the individual acting compassionately because of personal (e.g., acting in accordance with one's own values), interpersonal (e.g., concern for that particular person), team (e.g., commitment to the team), or organizational (e.g., commitment to the particular organization) reasons?

To understand and enhance relationships, we suggest that it is useful to consider which of the LF2 elements contribute to the particular psychological state and which of these elements may be key to modulate (either to increase or to decrease) the given psychological construct. With regard to the nine constructs along the Aggression-Compassion continuum, it is important to consider that there likely is a tendency to think of each construct as relevant especially to relationships and interactions with one other person (interpersonal) or a group of people. But each construct also can be applied to oneself and to organizations. We need to act with compassion and not with aggression towards ourselves as well as consider to whom and in what context we should allow ourselves to experience and exercise each of the nine constructs. In other words, we need to maximize our emotional and social intelligence so that we are aware of motivations and emotions that accompany and underlie our own thoughts and actions as well as the motivations and emotions that accompany and underlie the thoughts and actions of others [50–53].

# **6. Support and oppose are positive and negative, respectively; but positive and negative do not equal good and bad**

Another important point to consider is that although "Support" and "Oppose" can be considered as corresponding to "good" and "bad" poles of the Aggression-Compassion continuum, that type of identity simply is not true. Most if not all publications about pity, sympathy, empathy, compassion imply or state explicitly that these concepts and corresponding actions (in the case of compassion) are, indeed, "good." Conversely, it is implied or explicitly stated that antipathy, animosity, hostility, and aggression are "bad." Neither of these generalizations is correct.

Providing cognitive, emotional, and behavioral support— as is done when exercising the four constructs depicted in the upper right—for kindness, generosity, altruism, open-mindedness, liberty, freedom, democracy, and so on certainly would be

considered as "good." But consider, for example, what it means when one is "supporting" in thoughts, emotions, and actions bigotry, robbery, hatred, dishonesty, cruelty, slavery, authoritarianism; then, exercising and expressing pity, sympathy, empathy, and compassion for these particular thoughts and actions would be considered as "bad."

The same dichotomy of good and bad applies to the "opposing" poles of the Aggression-Compassion Continuum dimensions. Aggression, hostility, and the other constructs on the "oppose" cognitive, emotional, and behavioral poles certainly would be considered "bad" when the opposition is to kindness, generosity, altruism, open-mindedness, liberty, freedom, democracy. Conversely, opposing in thoughts, emotions, and actions bigotry, robbery, hatred, dishonesty, cruelty, slavery, authoritarianism, and so on, would be considered as "good."

So, it is important to recognize that supporting others can be good or bad. And opposing others can be for good or bad. Aggression and Compassion involve actions of opposition or support, respectfully, and, thereby, set the poles of a psychological continuum with regard to self and others, but who and what we are opposing or supporting determines what is good and bad from each of our perspectives and based on each of our values. Generalizations such as "both sides are to blame" and "there are good people on both sides," are not always true.

Additionally, it is important to recognize that the value and accompanying good or bad of each construct along the Aggression-Compassion Continuum also depends on the situation and people involved. For example, empathy can be so powerful that feeling the pain or suffering of another can be damaging to the well-intentioned empath. Also, empathy can be so absorbing that it freezes or prevents the empath from taking action to help others. Compassion, despite providing well-intentioned support, can be counter-productive if provided to someone(s) who does not want the actions of support or who needs to learn to act for themselves. A common dilemma confronts parents who act to help their children with every challenge, even when their children are not in danger and need to learn to handle their own challenges and to accept and to be resilient after experiencing their own disappointments or failures. Conversely, aggression, even when opposing dangers, can be bad if the individuals being helped want to handle the situation themselves or need to learn to handle the situation themselves.

# **7. Conclusion**

The Aggression-Compassion Continuum includes nine psychological constructs that involve different amounts of cognitive and emotional support or opposition and different amounts of action. It is important to understand where you are along this continuum to optimize relationships with others as well as your own well-being. We believe that applying the eight elements of the Leader-Follower Framework when considering relevant points on the Aggression-Compassion Continuum also will help to enhance emotional and social intelligence.

# **Acknowledgements**

The authors greatly appreciate discussions with colleagues about the psychosocial constructs and topics addressed in this chapter.

# **Conflict of interest**

The authors declare no conflict of interest.

# **Disclaimer**

The opinions and assertions contained herein are the sole ones of the authors and are not to be construed as reflecting the views of the Uniformed Services University of the Health Sciences or the Department of Defense.

# **Author details**

Neil E. Grunberg\* and Erin S. Barry Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA

\*Address all correspondence to<EMAIL_ADDRESS>
© 2022 The Author(s). Licensee IntechOpen. Distributed under the terms of the Creative Commons Attribution - NonCommercial 4.0 License (https://creativecommons.org/ licenses/by-nc/4.0/), which permits use, distribution and reproduction for non-commercial purposes, provided the original is properly cited.

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# **Chapter 5** Empathy and Dark Personalities

*Anja Wertag*

# **Abstract**

Callousness or low empathy is a key feature of the so-called dark personality traits, in which the interest has been exponentially rising. The most prominent dark personality traits models are the Dark Triad, comprising three distinct, but overlapping traits: Machiavellianism, narcissism, and psychopathy, and the Dark Tetrad, with the addition of sadism. Although both theoretical conceptualizations and empirical findings point to impaired empathy as the core of dark personalities, the associations between specific forms of empathy and dark traits are not so consistent. Thus, this chapter aims to provide a critical review of existing findings on the relationship between dark personality traits and specific forms of empathy. Moreover, it aims to offer interesting insights into empathy intervention possibilities in individuals with pronounced dark traits.

**Keywords:** empathy, dark personality traits, Machiavellianism, narcissism, psychopathy, sadism

# **1. Introduction**

In the past 20 years, the interest in the so-called park personality traits in the area of individual differences has been exponentially rising. What is creditable for this is the introduction of the Dark Triad of personality [1], which consists of three distinct, but conceptually and empirically overlapping traits: Machiavellianism, narcissism, and psychopathy, while relatively recently sadism was added to this constellation, forming the Dark Tetrad [2, 3]. It is important to note that, although these traits (apart from Machiavellianism) migrated from clinical literature and practice and are similar to respective personality disorders (i.e. narcissistic personality disorder and antisocial personality disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, DSM-5, by American Psychiatric Association [4], and sadistic personality disorder defined in earlier versions of DSM [5]), they refer to subclinical variants in the Dark Triad/Tetrad constellation (for a more detailed overview of Dark Triad and Tetrad traits, see [6, 7], respectively). Machiavellianism is characterized by duplicitous interpersonal style, manipulation, a cynical disregard of morality and a focus on self-interest and personal gain [8], narcissism by grandiose self-concept and attentioncraving [9], and psychopathy by impulsivity and callous thrill-seeking [10], while sadism is characterized by the enjoyment of other people's suffering [11]. However, although each of the traits has its specific features, they also share a common core of callousness (i.e. low empathy) and antagonism (e.g. [12–14]).

If we look at conceptualizations of the clinical counterparts of the dark traits, it can be noticed that a lack of empathy is one of the essential features of narcissistic personality disorder. More specifically, narcissistic personality disorder refers to a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, and one of the criteria for this disorder listed in DSM-5 is "lacks empathy: is unwilling to recognize or identify with the feelings and needs of others" ([4], p. 670). The essential feature of antisocial personality disorder is a pervasive pattern of disregard for, and violation of, the wishes, rights, or feelings of others, and callousness is one of the DSM-5 criteria for this personality disorder (specifically, "lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another" ([4], p. 659). The sadistic personality disorder was defined by a pervasive pattern of sadistic and cruel behavior and was identified in DSM-III-R as: using physical cruelty or violence to establish dominance in a relationship; humiliating others; treating, or disciplining others harshly; being amused or taking pleasure in the psychological or physical suffering of others; lying to harm others; intimidating others to get them to do what he/she wants; restricting the autonomy of close ones; and/or being fascinated by violence, weapons, injury, or torture [5]. Thus, callousness, lack of empathy, and antagonism are the defining features of each of these three personality disorders.

As noted earlier, Machiavellianism had a different etiology than the other three Dark Tetrad traits. Rather than a clinical syndrome (i.e. a personality disorder), this concept was named after the renaissance philosopher Nicolo Machiavelli and resembles a manipulative and callous character with a cynical worldview, duplicitous tactics, and strategic planning (see [15]). Moreover, it has been noted that the lack of empathy plays a causal role in determining Machiavellian behavior [16]. Analogously to the lack of empathy as the key common feature of dark traits' clinical counterparts, the common feature explaining both the theoretical and empirical overlap between the Dark Tetrad traits is callousness, or lack of empathy toward others [7].

It is important to note that, from the evolutionary perspective, dark traits are adaptive, and the lack of empathy as a central feature of the dark traits may have an evolutionary advantage, enabling the dark personalities to get ahead. For example, in accordance with frequency-dependent selection, a small number of cheaters with exploitative tendencies can flourish in a society where the majority is oriented toward cooperation [17] (see [18] for more details on the evolutionary perspective on the Dark Triad traits). Similarly, fundamental neural mechanisms explaining sadism have been postulated [19–21]. More specifically, sadism can be viewed as a physiological response to, for example, war-induced callousness: an indifference to the suffering of others could be gradually transformed by evolutionary selection into the enjoyment of cruelty, especially if victims are perceived as dangerous outgroups, and the sadistic behavior could promote fitness via the maintenance of personal and social power.

In line with theoretical conceptualizations and clinical observations, empirical findings consistently show that dark traits are related to empathy deficits [22, 23]; however, the associations between specific forms of empathy and dark traits are not so consistent. Furthermore, there are indications that there are individuals high both on empathy and dark traits [24], and that individuals with elevated dark traits can be empathic in certain circumstances [25, 26]. Thus, let us closely explore the findings on relations between dark personality traits and specific forms of empathy.

# **2. Dark traits and specific forms of empathy**

Albeit there are different conceptualizations of empathy, there is a consensus that it comprises two components: a cognitive (i.e. the cognitive assessment of affective experiences of others) and affective one (i.e. sharing and adequately responding to affective experiences of others), which have been confirmed in neuropsychological research [27].

In line with the callous, manipulative, and exploitative nature of dark personalities, it may be assumed that individuals high on dark personality traits should have a good understanding of the affective experiences of others (i.e. have high cognitive empathy) which enables them to manipulate and exploit others, but at the same time, they should not care about the feelings of others (i.e. have low affective empathy) to behave in such a manner. Indeed, research consistently points to deficits in affective empathy in individuals with pronounced dark personality traits [23, 28–34], with psychopathy showing the strongest negative relationship with this form of empathy, followed by Machiavellianism and sadism. However, the situation is not so clear when it comes to cognitive empathy. Namely, while some studies indicate that at least one of the dark traits is linked to impaired cognitive empathy [23, 35, 36], others point to a positive relationship of at least one of the dark traits with cognitive empathy [23, 24, 32, 34], with narcissism most often being that trait.

Given the narcissistic tendency of overestimating their abilities to read and understand the emotions of others [37], a question arises is the positive link between cognitive empathy and narcissism due to this tendency. However, findings are showing that narcissism is also positively associated with emotion recognition tasks [34, 38] that are considered closely related to cognitive empathy, indicating that narcissism is in fact linked to higher cognitive empathy. The plausible explanation of this positive link is that the narcissistic need for admiration and reinforcement of their grandiose view of themselves requires a better understanding of how others see them, implying a need for a slightly superior cognitive empathy.

Similar considerations regarding the empirically observed positive link between narcissism and cognitive empathy can be found in the proposed criteria of narcissistic personality disorder in the alternative DSM-5 model for personality disorders, which states that narcissistic personality disorder can be characterized by being "excessively attuned to reactions of others, but only if perceived as relevant to self" ([4], p. 767). On the other hand, the antisocial personality disorder in this model can be characterized by a "lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another" ([4], p. 764), indicating more serious empathic impairments associated with this disorder. Indeed, psychopathy, observed in the Dark Triad constellation, exhibits the strongest negative relations with adverse psychosocial outcomes, such as emotional deficits (i.e. lack of empathy), aggression, impulsivity, and interpersonal problems (see [39]). Comparingly, some studies on moderation between empathy and psychopathy indicated that, if trait psychopathy is high, then individuals with higher levels of cognitive empathy are more likely to engage in aggressive behavior such as trolling [31, 36]. Moreover, there are findings that the lack of cognitive empathy mediates the relationship between psychopathy and specific forms of prosocial behavior (for details see [40]), highlighting the importance of the psychopathy-empathy relationship.

As one of the characteristics of Machiavellianism is the use of strategic manipulation, it is assumed that Machiavellianism is linked to higher cognitive empathy.

However, some studies failed to find any connection between cognitive empathy and Machiavellianism (e.g. [41, 42]). One of the reasons for inconsistent findings of previous studies may lay in using different measures of empathy, reflecting somewhat different conceptualizations of this construct, such as the Interpersonal Reactivity Index (IRI [43], defining empathy as reactions of one individual to the observed experiences of another [44]), Basic Empathy Scale (BES [45], conceptualizing empathy as the understanding and sharing in another's emotional state or context), or Empathy Quotient (EQ [46], which conceptualizes empathy as the ability to recognize and understand the thoughts and feelings of others, as well as to respond to others' thoughts and feelings with appropriate emotion). Thus, Turner et al. [32] examined the relationship of Dark Triad traits with cognitive and affective empathy using multiple questionnaires for both empathy (i.e. BES, EQ , and one more independent measure) and the dark traits and through simultaneous consideration of all constructs in a single latent variable model, and on a large sample (over 1000) of participants. Their results indicated that dark traits are related more to affective than to cognitive empathy: all three dark traits were related to lower levels of affective empathy, but this relationship was weaker for narcissism, while cognitive empathy was positively related to narcissism and Machiavellianism, but unrelated to psychopathy. Results regarding sadism are following the same pattern, with sadism being more strongly related to affective than cognitive empathy [3, 31, 36].

It should be noted that, although the Dark Tetrad traits share a common core of callousness/low empathy, due to the unique features of each of the traits, the manifestation of this characteristic could be different among each trait [7], as well as the psychological processes beneath the exploitative behavior common for the dark traits [18]. More specifically, individuals high on narcissism might lack empathy for those they step on in their quest for public admiration, and the exploitation of others may be a result of their self-centeredness. Individuals high on psychopathy impulsively reach for what they want, caring little if others will get hurt along the way. Individuals high on Machiavellianism may take care while taking advantage of others and exhibit interpersonal indifference if someone interferes with their goals. Finally, individuals high on everyday sadism will seek opportunities to observe or even induce suffering in others.

Furthermore, a recent meta-analytical finding that empathy and aggression are, despite the assumptions regarding the importance of empathy for aggressive behavior, virtually unrelated [47], indicated that current conceptions of affective empathy could be too narrow, failing to capture the full range of the construct. Thus, Vachon and Lynam [48] proposed a new measure of empathy: Affective and Cognitive Measure of Empathy (ACME). ACME conceptualizes cognitive empathy as empathic accuracy (i.e. the ability to detect and understand what others are feeling), and affective empathy distinguishes between affective resonance, conceptualized as most traditional measures of affective empathy (i.e. empathic concern, sympathy, compassion, involving an emotional response in the observer congruent in valence to the target) and affective dissonance, conceptualized as the experience of a contradictory emotional response (e.g. taking pleasure in others' pain or feeling annoyed with others' happiness). In line with previous findings linking *schadenfreude* (i.e. pleasure and joy derived from another person's misfortune) with dark personality traits [49, 50], dark traits indeed generally exhibit stronger relations to affective dissonance than resonance [48, 51, 52]. The extension of the range of affective empathy from high levels of resonance (i.e. empathy) to low levels of resonance (i.e. indifference and callousness) to include the dissonant responses is especially important for the dark traits research.

#### *Empathy and Dark Personalities DOI: http://dx.doi.org/10.5772/intechopen.107446*

Therefore, including this aspect of empathy in future research is advisable to shed more light on the relationship between dark traits and specific forms of empathy.

Another problem with research on the relationship between empathy and dark personality traits is that most of the previously described findings were obtained using exclusively self-report measures of empathy. Thus, it is advisable to also include some other empathy measures in future research, such as behavioral (e.g. picture viewing tasks and stories [53]), physiological (e.g. heart rate, electroencephalogram (EEG)), and/or neuroscientific measures (e.g. magnetic resonance imaging (MRI) and functional magnetic resonance imaging (fMRI)). Namely, including different modalities of empathy measures could provide a comprehensive approach to empathy assessment and enable finer insights into the relationship between dark traits and empathy. In fact, some of the studies [25, 26] using the multi-modal approach to empathy provided valuable insights that will be discussed in detail in the next section.