In December of 2014, a study was published suggesting that mental health professionals experience different degrees of empathy for patients with a mental disorder, depending on whether the disorder is explained using biological (genetic and neurobiological) factors or psychosocial (experiential or life history) factors. The study presented participating providers with a number of fictional scenarios in each of which a hypothetical patient is suffering from one of several different disorders (schizophrenia, social phobia, major depression, or obsessive-compulsive disorder). The explanatory account of the disorder would vary in different scenarios, between a biological and a psychosocial account. The study found that mental health clinicians (including both those with and those without a medical degree) felt greater empathy as well as optimism about the utility of psychotherapy when considering patients with an experiential account of their disorders than when considering patients with a biological account of their disorders. In this column, I will consider why clinicians might have reacted in the ways that they did and what this might tell us about how providers think about their patients.
A Surprising Finding
I first learned about the empathy study described above when Professor Michael Perlin of New York Law School posted a message about it to the CrimProf listserv. In his message, he proposed that the finding seemed counterintuitive, given how jurors typically react to biological evidence of mental disorders in the courtroom. When a defendant is on trial for a criminal defense and offers a mental-disorder-related excuse (such as insanity), jurors tend to be more inclined to accept and believe the defendant’s exculpatory evidence in the presence of biological evidence to support it.
Such biological evidence might include a scan of the defendant’s brain and an account of how it differs from the brains of “normal” people. If jurors are less inclined to blame the defendant for his actions (and thus, presumably, more likely to feel empathy) when there is an apparent biological foundation for the defendant’s mental disorder, then why wouldn’t clinicians too feel greater empathy for the same sorts of people who walk into their offices presenting with mental disorders that have a clear biological cause?
On the CrimProf list, several people, including me, responded to the apparent puzzle with variations on the following theme: Jurors who must assess whether to credit a defendant’s mental-disorder-based defense to a crime are not primarily engaged in an empathic exercise. Instead, they are attempting to figure out whether the defendant truly suffers from the disorder that he purports to have. If the defendant says that he suffers from a psychiatric illness that caused him to commit the crime, but there is no way for jurors to “see” the illness manifested in the patient’s brain or genetics, then the jurors may infer that the defendant is lying about his mental disorder, that he is in fact “normal” and is therefore criminally responsible for the conduct in which he engaged.
If, by contrast, jurors can look at the defendant’s brain image and learn that (and how) it differs from that of the “normal” brain in the way that the brains of people suffering from the claimed disorder characteristically differ, then the jury has a powerful basis for concluding that the defendant’s account of his crime is accurate (or at least that the defendant has satisfied the first necessary condition for the success of his account—the genuine existence of a mental disorder).
Does the fact that jurors are primarily engaged in figuring out whether a criminal defendant has a mental disorder necessarily mean that empathy plays no role in an acquittal? No. To find a person not guilty by reason of insanity, jurors need to determine not only whether there is an illness at all but how best to explain the conduct of the defendant in committing the offense in question. To the extent that jurors feel antipathy rather than empathy for the mentally disordered defendant, one could easily imagine the jurors deciding to bring back a guilty verdict, notwithstanding the authenticity of the claimed disorder. One can, after all, be both guilty and mentally ill.
It seems likely, then, that jurors who decide to acquit a defendant do feel some level of empathy for that defendant, at least enough to attribute the commission of the bad act to an illness from which the individual suffers rather than to the individual himself. Does feeling this empathy, then, mean that jurors are behaving in some importantly different way from the mental health clinicians who participated in the study described above, such that the former experience greater empathy than the latter under similar circumstances? Not necessarily.
Reconciling the Seeming Contradiction
There is a plausible account of what happens when jurors acquit by reason of insanity in the presence of biological evidence that would allow us to reconcile their reactions with those of clinicians. Jurors may feel some empathy for a defendant suffering from a verifiable mental disorder, as proved by biological evidence, but only as compared to a mentally healthy defendant who committed the same crime and who pretended to have an illness that he did not in fact have. In other words, if jurors hear the defendant present an insanity defense on the basis of a mental illness that the jurors conclude he does not really have (due to the absence of biological proof), then the jurors are likely to perceive a real criminal who is attempting to get away with his actions by feigning a mental disability.
What we almost certainly do not have, when juries convict in such cases, are jurors who believe that the defendant truly has a mental disorder linked to experiences (such as childhood trauma) but who are nonetheless unwilling to accept the defense because it is based in experience rather than in biology. Jurors’ behavior in insanity and other similar cases tells us only about how they react to one group of mentally-disordered people—those with an apparently biological account of the illness; it tells us little or nothing about how jurors react to another group of mentally-disordered people—those whose illness is based in life experiences. It may well be that in a context in which the jurors felt no skepticism about the diagnosis of mental illness, they might feel greater empathy for the sufferer for whom experience rather than biology was the cause, just as the clinicians in the study did.
Returning to the study, then, why would clinicians feel less empathy for a patient whose illness was biological rather than experiential in nature? The study authors offer a theory for the empathy gap. They suggest that when biology fully (or predominately, as in a variation of the study) accounted for the mental illness of the patient, the patient might have seemed to the clinician like a totally different sort of entity from normal people, i.e., a sort of outsider to whom the clinician may have had a difficult time relating.
Having a measurably different brain or genetic makeup, then, might mark the patient as abnormal in a fundamental way that distances the clinician from him. By contrast, the patient whose suffering is fully (or primarily) attributable to traumatic experiences seems more like ordinary people and therefore within the circle of individuals to whom the clinician can relate. “We have the same basic brain and genetic makeup,” the clinician might unconsciously conclude, “and I can accordingly feel connected and close to this individual.”
The study authors suggest that if this is what is happening, then the clinicians seem to be operating from a mind/body dualism, in which two people who feel the exact same feelings and who manifest the exact same behavioral symptoms can be regarded as radically different from one another when one of them feels the way he does because of his body (including the brain), while the other one feels the way he does because of his “mind,” something separate from the brain. This differentiation assumes that the “mind” and the events in the world that make their impact on the mind exist outside of the body. If this is what is happening, then it evidences irrationality on the part of clinicians, because everything that happens to us is mediated through our bodies in some way, including “talk therapy” and the benefits that it can provide to people suffering from mental illness.
I find this account of the results in the study compelling. In thinking about the study itself, though, I wonder whether the presented scenarios themselves implicitly endorsed a mind/body dualism that accordingly invited the participating clinicians to do the same. The implicit suggestion, when one is told that a hypothetical potential patient’s illness is explained by having a structurally different brain or different genes, while another’s illness is caused by experiences, is that experiences can make people mentally ill without having any physical and biological effect on the person, by contrast to biologically-caused illness. The reality, though, is that when people undergo a traumatic experience and become ill as a result, their biology has necessarily changed as well.
If a person becomes phobic of large gatherings after being stabbed while attending a large gathering, this phobia is manifest because the brain has physically and neuro-chemically changed in response to the traumatic experience of being stabbed. Indeed, it is at least sometimes going to be true that one can see the physical changes wrought by experience with a functional Magnetic Resonance Imaging (fMRI) picture of the patient’s brain. Over time, moreover, it may become increasingly possible to witness the biological correlates of such experience-generated mental disorders. At this point, though, we often cannot readily observe the neurological manifestations of mental disorders.
By offering biology and experience as distinct explanatory accounts of patients’ mental disorder, then, the study is premised on the notion that a mental disorder is caused by either biology or experience or some mix of the two rather than that a mental disorder is in fact caused by biology every time, with experiences having a significant impact on biology (and often triggering the expression of genes for mental illness that go unexpressed in others without similar experiences). This is why schizophrenia, a mental disorder that has a strong genetic basis, can appear in one identical twin but not the other. By hypothesis, the two twins have identical genes, but something about their brains diverge in response to different experiences.
What does this all tell us, then, about clinicians and perhaps, too, about the people who design studies of clinicians? It tells us, first, that it may be best for mental health providers to meet their patients and to get to know the life story of a patient who suffers from a mental disorder before learning of the biological manifestations of the disorder. This may allow clinicians and others coming into contact with the mentally ill population to feel a greater connection with and openness to the people whom they serve and a greater optimism about the interpersonal interventions that clinicians will deploy in their attempts to alleviate the tremendous suffering of their patients. It may be that after connecting with an individual patient, learning of biological manifestations will no longer have the same empathy-blocking impact.
As the study notes, pessimism about psychotherapy—which, in this study, accompanied the biological account of a disorder—can hurt the patient’s prospects for success in psychotherapy, yet another fascinating indication of how experiences (and the experience of being judged fundamentally abnormal) can affect the brain. It is therefore best if a clinician can maintain both empathy and optimism by focusing on the life experiences that have led up to the person who has come to ask for the clinician’s help. At the same time, it might behoove clinicians to begin to question the mind/body dualism that appears to infect their thinking (and the thinking of those designing studies). If we all come to accept that our minds emerge directly from what is happening in our bodies and, specifically, our brains, which in turn change in response to experiences in the world, we can perhaps arrive at a time when the clinician’s response to learning that a patient’s brain reflects the illness from which he suffers would be to say “Of course it does. Now I am going to try to help.”
A brilliant, nuanced look at a key issue in mental health (and, apparently, jurisprudence.)
Scholarly insights from a keen academic, but presented in an approachable and readable way. Interesting, unusual premise – very thought provoking. Will take printouts to the next NAMI family support meeting to share and spark discussion.
Hope this prof. stays active writing and sharing her thoughts with a mainstream audience as well as fellow academics and attorneys. The braintrust of the academy is too often locked away, available just to insiders (and students whose tuition allows them access to their classes, lol.)
Thanks for tweeting this –
a superb article, sherry! having been written by an attorney rather
than a clinican, it includes the kind of detail required in legal
arguing but that is rarely seen in clinical articles. that most
important point – of ongoing experience-brain interaction – is crucial
to clinicians’ understanding of the patients they work with, and it
should be a required part of clinical education. it wasn’t eons ago
when i received my education; hopefully that deficit has been corrected.