research articles about empathy

Cultivating empathy

Psychologists’ research offers insight into why it’s so important to practice the “right” kind of empathy, and how to grow these skills

Vol. 52 No. 8 Print version: page 44

Personality

In a society marked by increasing division, we could all be a bit more kind, cooperative, and tolerant toward others. Beneficial as those traits are, psychological research suggests empathy may be the umbrella trait required to develop all these virtues. As empathy researcher and Stanford University psychologist Jamil Zaki, PhD, describes it, empathy is the “psychological ‘superglue’ that connects people and undergirds co-operation and kindness” ( The Economist , June 7, 2019). And even if empathy doesn’t come naturally, research suggests people can cultivate it—and hopefully improve society as a result.

“In general, empathy is a powerful predictor of things we consider to be positive behaviors that benefit society, individuals, and relationships,” said Karina Schumann , PhD, a professor of social psychology at the University of Pittsburgh. “Scholars have shown across domains that empathy motivates many types of prosocial behaviors, such as forgiveness, volunteering, and helping, and that it’s negatively associated with things like aggression and bullying.”

For example, research by C. Daniel Batson , PhD, a professor emeritus of social psychology at the University of Kansas, suggests empathy can motivate people to help someone else in need ( Altruism in Humans , Oxford University Press, 2011), and a 2019 study suggests empathy levels predict charitable donation behavior (Smith, K. E., et al., The Journal of Positive Psychology , Vol. 15, No. 6, 2020).

Ann Rumble , PhD, a psychology lecturer at Northern Arizona University, found empathy can override noncooperation, causing people to be more generous and forgiving and less retaliative ( European Journal of Social Psychology , Vol. 40, No. 5, 2010). “Empathic people ask themselves, ‘Maybe I need to find out more before I jump to a harsh judgment,’” she said.

Empathy can also promote better relationships with strangers. For example, Batson’s past research highlights that empathy can help people adopt more positive attitudes and helping behavior toward stigmatized groups, particularly disabled and homeless individuals and those with AIDS ( Journal of Personality and Social Psychology , Vol. 72, No. 1, 1997).

Empathy may also be a crucial ingredient in mitigating bias and systemic racism. Jason Okonofua , PhD, an assistant professor of psychology at the University of California, Berkeley, has found that teachers are more likely to employ severe discipline with Black students—and that they’re more likely to label Black students as “troublemakers” ( Psychological Science , Vol. 26, No. 5, 2015).

These labels, Okonofua said, can shape how teachers interpret behavior, forging a path toward students’ school failure and incarceration. When Okonofua and his colleagues created an intervention to help teachers build positive relationships with students and value their perspectives, their increased empathy reduced punitive discipline ( PNAS , Vol. 113, No. 19, 2016).

Similarly, Okonofua and colleagues found empathy from parole officers can prevent adults on probation from reoffending ( PNAS , Vol. 118, No. 14, 2021).

In spite of its potential benefits, empathy itself isn’t an automatic path toward social good. To develop empathy that actually helps people requires strategy. “If you’re trying to develop empathy in yourself or in others, you have to make sure you’re developing the right kind,” said Sara Konrath , PhD, an associate professor of social psychology at Indiana University who studies empathy and altruism.

The right kind of empathy

Empathy is often crucial for psychologists working with patients in practice, especially when patients are seeking validation of their feelings. However, empathy can be a draining skill if not practiced correctly. Overidentifying with someone else’s emotions can be stressful, leading to a cardiovascular stress response similar to what you’d experience in the same painful or threatening situation, said Michael J. Poulin , PhD, an associate professor of psychology at the University at Buffalo who studies how people respond to others’ adversity.

Outside of clinical practice, some scholars argue empathy is unhelpful and even damaging. For example, Paul Bloom, PhD , a professor of psychology at Yale University, argues that because empathy directs helping behavior toward specific individuals—most often, those in one’s own group—it may prevent more beneficial help to others ( Against Empathy: The Case for Rational Compassion , Ecco , 2016).

In some cases, empathy may also promote antagonism and aggression (Buffone, A. E. K., & Poulin, M. J., Personality and Social Psychology Bulletin , Vol. 40, No. 11, 2014). For example, Daryl Cameron , PhD, an associate professor of psychology and senior research associate in the Rock Ethics Institute and director of the Empathy and Moral Psychology Lab at Penn State University, has found that apparent biases in empathy like parochialism and the numbness to mass suffering may sometimes be due to motivated choices. He also notes that empathy can still have risks in some cases. “There are times when what looks like empathy promotes favoritism at the expense of the outgroup,” said Cameron.

Many of these negative outcomes are associated with a type of empathy called self-oriented perspective taking—imagining yourself in someone else’s shoes. “How you take the perspective can make a difference,” said John Dovidio , PhD, the Carl I. Hovland Professor Emeritus of Psychology and a professor emeritus in the Institute for Social and Policy Studies and of Epidemiology at Yale University. “When you ask me to imagine myself in another person’s position,” Dovidio said, “I may experience a lot of personal distress, which can interfere with prosocial behaviors.” Taking on that emotional burden, Schumann added, could also increase your own risk for distressing emotions, such as anxiety.

According to Konrath, the form of empathy shown most beneficial for both the giver and the receiver is an other-oriented response. “It’s a cognitive style of perspective taking where someone imagines another person’s perspective, reads their emotions, and can understand them in general,” she said.

Other-oriented perspective taking may result in empathic concern, also known as compassion, which could be seen as an emotional response to a cognitive process. It’s that emotion that may trigger helping behavior. “If I simply understand you’re in trouble, I may not act, but emotion energizes me,” said Dovidio.

While many practitioners may find empathy to come naturally, psychologists’ research can help clinicians guide patients toward other-oriented empathy and can also help practitioners struggling with compassion fatigue to re-up their empathy. According to Poulin, people are more likely to opt out of empathy if it feels cognitively or emotionally taxing, which could impact psychologists’ ability to effectively support their patients.

To avoid compassion fatigue with patients—and maintain the empathy required for helping them—Poulin said it’s important to reflect on the patient’s feeling or experience without necessarily trying to feel it yourself. “It’s about putting yourself in the right role,” he said. “Your goal isn’t to be the sufferer, but to be the caregiver.”

Be willing to grow

Cameron’s research found that the cognitive costs of empathy could cause people to avoid it but that it may be possible to increase empathy by teaching people to do it effectively ( Journal of Experimental Psychology: General , Vol. 148, No. 6, 2019).

Further, research by Schumann and Zaki shows that the desire to grow in empathy can be a driver in cultivating it. They found people can extend empathic effort—asking questions and listening longer to responses—in situations where they feel different than someone, primarily if they believe empathy could be developed with effort ( Journal of Personality and Social Psychology , Vol. 107, No. 3, 2014).

Similarly, Erika Weisz , PhD, a postdoctoral fellow in psychology at Harvard University, said that the first step to increasing your empathy is to adopt a growth mindset—to believe you’re capable of growing in empathy.

“People who believe that empathy can grow try harder to empathize when it doesn’t come naturally to them, for instance, by empathizing with people who are unfamiliar to them or different than they are, compared to people who believe empathy is a stable trait,” she said.

For example, Weisz found addressing college students’ empathy mindsets increases the accuracy with which they perceive others’ emotions; it also tracks with the number of friends college freshmen make during their first year on campus ( Emotion , online first publication, 2020).

Expose yourself to differences

To imagine another’s perspective, the more context, the better. Shereen Naser , PhD, a professor of psychology at Cleveland State University, said consuming diverse media—for example, a White person reading books or watching movies with a non-White protagonist—and even directly participating in someone else’s culture can provide a backdrop against which to adopt someone else’s perspective.

When you’re in these situations, be fully present. “Paying attention to other people allows you to be moved by their experiences,” said Sara Hodges , PhD, a professor of psychology at the University of Oregon. “Whether you are actively perspective-taking or not, if you just pay more attention to other people, you’re likely to feel more concerned for them and become more involved in their experiences.”

For example, in a course focused on diversity, Naser encourages her graduate students to visit a community they’ve never spent time in. “One student came back saying they felt like an outsider when they attended a Hindu celebration and that they realized that’s what marginalized people feel like every day,” she said. Along with decreasing your bias, such realizations could also spark a deeper understanding of another’s culture—and why they might think or feel the way they do.

Read fiction

Raymond Mar , PhD, a professor of psychology at York University in Toronto, studies how reading fiction and other kinds of character-driven stories can help people better understand others and the world. “To understand stories, we have to understand characters, their motivations, interactions, reactions, and goals,” he said. “It’s possible that while understanding stories, we can improve our ability to understand real people in the real world at the same time.”

When you engage with a story, you’re also engaging the same cognitive abilities you’d use during social cognition ( Current Directions in Psychological Science , Vol. 27, No. 4, 2018). You can get the same effect with any medium—live theater, a show on Netflix, or a novel—as long as it has core elements of a narrative, story, and characters.

The more one practices empathy (e.g., by relating to fictional characters), the more perspectives one can absorb while not feeling that one’s own is threatened. “The foundation of empathy has to be a willingness to listen to other peoples’ experiences and to believe they’re valid,” Mar said. “You don’t have to deny your own experience to accept someone else’s.”

Harness the power of oxytocin

The social hormone oxytocin also plays a role in facilitating empathy. Bianca Jones Marlin , PhD, a neuroscientist and assistant professor of psychology at Columbia University, found that mice that had given birth are more likely to pick up crying pups than virgin animals and that the oxytocin released during the birth and parenting process actually changes the hearing centers of the brain to motivate prosocial and survival behaviors ( Nature , Vol. 520, No. 7548, 2015).

Oxytocin can also breed helping responses in those who don’t have a blood relationship; when Marlin added oxytocin to virgin mice’s hearing centers, they took care of pups that weren’t theirs. “It’s as if biology has prepared us to take care of those who can’t take care of themselves,” she said. “But that’s just a baseline; it’s up to us as a society to build this in our relationships.”

Through oxytocin-releasing behaviors like eye contact and soft physical touch, Marlin said humans can harness the power of oxytocin to promote empathy and helping behaviors in certain contexts. Oxytocin is also known to mediate ingroup and outgroup feelings.

The key, Marlin said, is for both parties to feel connected and unthreatened. To overcome that hurdle, she suggests a calm but direct approach: Try saying, “I don’t agree with your views, but I want to learn more about what led you to that perspective.”

Identify common ground

Feeling a sense of social connection is an important part of triggering prosocial behaviors. “You perceive the person as a member of your own group, or because the situation is so compelling that your common humanity is aroused,” Dovidio said. “When you experience this empathy, it motivates you to help the other person, even at a personal cost to you.”

One way to boost this motivation is to manipulate who you see as your ingroup. Jay Van Bavel , PhD, an associate professor of psychology and neural science at New York University, found that in the absence of an existing social connection, finding a shared identity can promote empathy ( Journal of Experimental Social Psychology , Vol. 55, 2014). “We find over and over again when people have a common identity, even if it’s created in the moment, they are more motivated to get inside the mind of another person,” Van Bavel said.

For example, Van Bavel has conducted fMRI research that suggests being placed on the same team for a work activity can increase cooperation and trigger positive feelings for individuals once perceived as outgroup, even among different races ( Psychological Science , Vol. 19, No. 11, 2008).

To motivate empathy in your own interactions, find similarities instead of focusing on differences. For instance, maybe you and a neighbor have polar opposite political ideologies, but your kids are the same age and go to the same school. Build on that similarity to create more empathy. “We contain multiple identities, and part of being socially intelligent is finding the identity you share,” Van Bavel said.

Ask questions

Existing research often measures a person’s empathy by accuracy—how well people can label someone’s face as angry, sad, or happy, for example. Alexandra Main , PhD, an assistant professor of psychology at the University of California, Merced, said curiosity and interest can also be an important component of empathy. “Mind reading isn’t always the way empathy works in everyday life. It’s more about actively trying to appreciate someone’s point of view,” she said. If you’re in a situation and struggling with empathy, it’s not necessarily that you don’t care—your difficulty may be because you don’t understand that person’s perspective. Asking questions and engaging in curiosity is one way to change that.

While Main’s research focuses on parent-child relationships, she says the approach also applies to other relationship dynamics; for example, curiosity about why your spouse doesn’t do the dishes might help you understand influencing factors and, as a result, prevent conflict and promote empathy.

Main suggests asking open-ended questions to the person you want to show empathy to, and providing nonverbal cues like nodding when someone’s talking can encourage that person to share more. Certain questions, like ones you should already know the answer to, can have the opposite effect, as can asking personal questions when your social partner doesn’t wish to share.

The important thing is to express interest. “These kinds of behaviors are really facilitative of disclosure and open discussion,” Main said. “And in the long term, expressing interest in another person can facilitate empathy in the relationship” ( Social Development , Vol. 28, No. 3, 2019).

Understand your blocks

Research suggests everyone has empathy blocks, or areas where it is difficult to exhibit empathy. To combat these barriers to prosocial behavior, Schumann suggests noticing your patterns and focusing on areas where you feel it’s hard to connect to people and relate to their experiences.

If you find it hard to be around negative people, for example, confront this difficulty and spend time with them. Try to reflect on a time when you had a negative outlook on something and observe how they relate. And as you listen, don’t interrupt or formulate rebuttals or responses.

“The person will feel so much more validated and heard when they’ve really had an opportunity to voice their opinion, and most of the time people will reciprocate,” Schumann said. “You might still disagree strongly, but you will have a stronger sense of why they have the perspective they do.”

Second-guess yourself

Much of empathy boils down to willingness to learn—and all learning involves questioning your assumptions and automatic reactions in both big-picture issues, such as racism, and everyday interactions. According to Rumble, it’s important to be mindful of “what-ifs” in frustrating situations before jumping to snap judgments. For example, if a patient is continually late to appointments, don’t assume they don’t take therapy seriously––something else, like stress or unreliable transportation, might be getting in the way of their timeliness.

And if you do find yourself making a negative assumption, slow down and admit you could be wrong. “As scientists, we second-guess our assumptions all the time, looking for alternative explanations,” said Hodges. “We need to do that as people, too.”

Measures of empathy and compassion: A scoping review

Contributed equally to this work with: Cassandra Vieten, Caryn Kseniya Rubanovich, Lora Khatib, Meredith Sprengel, Chloé Tanega

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Centers for Integrative Health, Department of Family Medicine, University of California, San Diego, San Diego, California, United States of America, Clarke Center for Human Imagination, School of Physical Sciences, University of California, San Diego, San Diego, California, United States of America

Roles Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

Affiliations Department of Psychiatry, University of California, San Diego, San Diego, California, United States of America, San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, San Diego, California, United States of America, T. Denny Sanford Institute for Empathy and Compassion, University of California, San Diego, San Diego, California, United States of America, T. Denny Sanford Center for Empathy and Technology, University of California, San Diego, San Diego, California, United States of America

Roles Conceptualization, Data curation, Formal analysis, Investigation, Visualization, Writing – review & editing

Affiliation Department of Psychiatry, University of California, San Diego, San Diego, California, United States of America

Roles Data curation, Investigation, Methodology, Project administration, Software, Writing – review & editing

Affiliation Human Factors, Netherlands Organisation for Applied Scientific Research (TNO), Soesterberg, The Netherlands

Roles Data curation, Formal analysis, Investigation, Project administration, Validation, Visualization, Writing – review & editing

Affiliation Clarke Center for Human Imagination, School of Physical Sciences, University of California, San Diego, San Diego, California, United States of America

Roles Data curation, Investigation, Validation, Writing – review & editing

¶ ‡ CP, PV, AM, GC, AJL, MTS, LE and CB also contributed equally to this work.

Affiliations U.S. Department of Veteran Affairs, VA Boston Healthcare System, Boston, Massachusetts, United States of America, Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America

Affiliation Compassion Clinic, San Diego, California, United States of America

Roles Writing – review & editing

Affiliation VA San Diego Center of Excellence for Stress and Mental Health, San Diego, California, United States of America

Roles Conceptualization, Writing – review & editing

Affiliations Department of Psychiatry, University of California, San Diego, San Diego, California, United States of America, VA San Diego Center of Excellence for Stress and Mental Health, San Diego, California, United States of America, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, San Diego, California, United States of America

Affiliation Departments of Family Medicine and Medicine (Bioinformatics), School of Medicine, University of California, San Diego, San Diego, California, United States of America

Affiliations Department of Psychiatry, University of California, San Diego, San Diego, California, United States of America, T. Denny Sanford Institute for Empathy and Compassion, University of California, San Diego, San Diego, California, United States of America, T. Denny Sanford Center for Empathy and Compassion Training in Medical Education, University of California, San Diego, San Diego, California, United States of America

Affiliations Department of Psychiatry, University of California, San Diego, San Diego, California, United States of America, T. Denny Sanford Institute for Empathy and Compassion, University of California, San Diego, San Diego, California, United States of America, T. Denny Sanford Center for Empathy and Technology, University of California, San Diego, San Diego, California, United States of America, T. Denny Sanford Center for Empathy and Compassion Training in Medical Education, University of California, San Diego, San Diego, California, United States of America

Cassandra Vieten,
Caryn Kseniya Rubanovich,
Lora Khatib,
Meredith Sprengel,
Chloé Tanega,
Craig Polizzi,
Pantea Vahidi,
Anne Malaktaris,
Gage Chu,

Published: January 19, 2024
https://doi.org/10.1371/journal.pone.0297099
Reader Comments

Evidence to date indicates that compassion and empathy are health-enhancing qualities. Research points to interventions and practices involving compassion and empathy being beneficial, as well as being salient outcomes of contemplative practices such as mindfulness. Advancing the science of compassion and empathy requires that we select measures best suited to evaluating effectiveness of training and answering research questions. The objective of this scoping review was to 1) determine what instruments are currently available for measuring empathy and compassion, 2) assess how and to what extent they have been validated, and 3) provide an online tool to assist researchers and program evaluators in selecting appropriate measures for their settings and populations. A scoping review and broad evidence map were employed to systematically search and present an overview of the large and diverse body of literature pertaining to measuring compassion and empathy. A search string yielded 19,446 articles, and screening resulted in 559 measure development or validation articles reporting on 503 measures focusing on or containing subscales designed to measure empathy and/or compassion. For each measure, we identified the type of measure, construct being measured, in what context or population it was validated, response set, sample items, and how many different types of psychometrics had been assessed for that measure. We provide tables summarizing these data, as well as an open-source online interactive data visualization allowing viewers to search for measures of empathy and compassion, review their basic qualities, and access original citations containing more detail. Finally, we provide a rubric to help readers determine which measure(s) might best fit their context.

Citation: Vieten C, Rubanovich CK, Khatib L, Sprengel M, Tanega C, Polizzi C, et al. (2024) Measures of empathy and compassion: A scoping review. PLoS ONE 19(1): e0297099. https://doi.org/10.1371/journal.pone.0297099

Editor: Ipek Gonullu, Ankara University Faculty of Medicine: Ankara Universitesi Tip Fakultesi, TURKEY

Received: July 5, 2023; Accepted: December 21, 2023; Published: January 19, 2024

Copyright: © 2024 Vieten et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: CV received a grant from the T. Denny Sanford Institute for Empathy and Compassion at https://empathyandcompassion.ucsd.edu/ . Co-authors included faculty members affiliated with the T. Denny Sanford Institute who were involved in study design and reviewing/editing the manuscript. Other than that, the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Historically, psychological assessment has overwhelmingly focused on measuring human struggles, difficulties, and pathologies. However, converging evidence indicates that positive emotions and prosocial qualities are just as important for improving overall well-being as stress, depression, and anxiety are to detracting from health and well-being [ 1 ]. Across fields—from medicine, mental health care, and education to economics, business and organizational development—there is a growing emphasis on investigating prosocial constructs such as compassion and empathy [ 2 ].

Compassion, or the heartfelt wish to reduce the suffering of self and others, promotes social connection and is an important predictor of overall quality of life [ 2 ] and well-being [ 3 ]. Empathy, or understanding and vicariously sharing other people’s positive emotions, is related to prosocial behaviors (e.g., helping, giving, emotional support), positive affect, quality of life, closeness, trust, and relationship satisfaction [ 4 ]. Compassion and empathy improve parenting [ 5 ], classroom environments [ 6 ], and teacher well-being [ 7 ]. Compassionate love toward self and others is associated with disease outcomes as well, such as increased long-term survival rates in patients with HIV [ 8 ]. Self-compassion refers to being gentle, supportive, and understanding toward ourselves in instances of perceived failure, inadequacy, or personal suffering [ 9 ]. Research indicates that self-compassion appears to reduce anxiety, depression, and rumination [ 10 ], and increase psychological well-being and connections with others [ 11 , 12 ]. Both compassion and self-compassion appear to protect against stress [ 13 ] and anxiety [ 10 ].

In healthcare professionals, empathy is associated with patient satisfaction, diagnostic accuracy, adherence to treatment recommendations, clinical outcomes, clinical competence, and physician retention [ 14 – 16 ]. Importantly, it is also linked to reduced burnout, medical errors, and malpractice claims [ 17 ]. However, evidence indicates that empathy declines during medical training and residency [ 18 – 20 ]. This may present an opportunity to improve many aspects of healthcare by identifying ways to maintain or enhance empathy during medical training. It is also important to note that while empathy is beneficial for patients, the effects on healthcare professionals are more complicated. A distinction can be drawn between positive empathy and/or compassion versus over-empathizing , which can lead to what has been termed “compassion fatigue” and/or burnout.

Disentangling these relationships through scientific investigation requires selecting measures and instruments capable of capturing these nuances. In addition, growing evidence that empathy and compassion can be improved through training [ 21 , 22 ] relies on selection or development of measures that can assess the effectiveness of such training. While empathy and compassion training for healthcare professionals has shown positive outcomes, it still requires improvement. For example, in a recent systematic review, only 9 of 23 empathy education studies in undergraduate nursing samples demonstrated practical improvements in empathy [ 23 ]. Another systematic review of 103 compassion interventions in the healthcare context [ 24 ] identified a number of limitations such as focusing on only a single domain of compassion; inadequately defining compassion; assessing the constructs exclusively by self-report; and not evaluating retention, sustainability, and translation to clinical practice over time: all related to how compassion and empathy are conceptualized and measured. The researchers recommend that such interventions should “be grounded in an empirically-based definition of compassion; use a competency-based approach; employ multimodal teaching methods that address the requisite attitudes, skills, behaviors, and knowledge within the multiple domains of compassion; evaluate learning over time; and incorporate patient, preceptor, and peer evaluations” (p. 1057). Improving conceptualization and measurement of compassion and empathy are crucial to advancing effective training.

Conceptualizing compassion and empathy

Compassion and empathy are complex constructs, and therefore challenging to operationalize and measure. Definitions of compassion and empathy vary, and while they are often used interchangeably, they are distinct constructs [ 25 ]. Like many other constructs, both compassion and empathy can be conceptualized at state and/or trait levels: people can have context-dependent experiences of empathy or compassion (i.e., state), or can have a general tendency to be empathic or compassionate (i.e., trait). The constructs of empathy and compassion each have multiple dimensions: affective, cognitive, behavioral, intentional, motivational, spiritual, moral and others. In addition to their multidimensionality, compassion and empathy are crowded by multiple adjacent constructs with which they overlap to varying degrees, such as kindness, caring, concern, sensitivity, respect, and a host of behaviors such as listening, accurately responding, patience, and so on.

Strauss et al. [ 26 ] conducted a systematic review of measures of compassion, and by combining the definitions of compassion among the few existing instruments at the time, proposed five elements of compassion: recognizing suffering, understanding the universality of human suffering, feeling for the person suffering, tolerating uncomfortable feelings, and motivation to act/acting to alleviate suffering. Gilbert [ 27 ] proposed that compassion consists of six attributes: sensitivity, sympathy, empathy, motivation/caring, distress tolerance, and non-judgement.

Likewise, empathy has been conceptualized as having at least four elements (as measured by the Interpersonal Reactivity Index [ 28 ] for example): perspective-taking (i.e., taking the point of view of others), fantasy (i.e., imagining or transposing oneself into the feelings and actions of others), empathic concern (i.e., accessing other-oriented feelings of sympathy or concern) and personal distress (i.e., or unease in intense interpersonal interactions). Early work by Wiseman [ 29 ] used a concept analysis approach identifying four key domains of empathy: seeing the world the way others see it, understanding their feelings, being non-judgmental, and communicating or expressing that understanding. Other conceptualizations of empathy [ 30 ] include subdomains of affective reactivity (i.e., being emotionally affected by others), affective ability (i.e., others tell me I’m good at understanding them), affective drive (i.e., I try to consider the other person’s feelings), cognitive drive (i.e., trying to understand or imagine how someone else feels), cognitive ability (i.e., I’m good at putting myself in another person’s shoes), and social perspective taking. De Waal and Preston [ 31 ] propose a “Russian doll” model of empathy, in which evolutionary advances in empathy layer one on top of the next, resulting in their definition of empathy as “emotional and mental sensitivity to another’s state, from being affected by and sharing in this state to assessing the reasons for it and adopting the other’s point of view” (p. 499).

Compassion is conceptualized as generally positive, and “more is better” in terms of health and well-being. Empathy on the other hand can lead to positive outcomes such as empathic concern, compassion, and prosocial motivations and behaviors, whereas unregulated empathic distress can be aversive, decrease helping behaviors, and lead to burnout [ 32 ]. Compassion and empathy also appear to differ in underlying brain structure [ 33 ] as well as brain function [ 34 ]. Terms such as “compassion fatigue” are more accurately characterized as empathy fatigue, and some evidence indicates that compassion can actually counteract negative aspects of empathy [ 35 ].

When assessing compassion and empathy, it is often important to measure their opposites, or constructs that present barriers to experiencing and expressing compassion or empathy. Personal distress, for example, can be confused for empathy but in fact is a “self-focused, aversive affective reaction” to encountering another person’s suffering, accompanied by the desire to “alleviate one’s own, but not the other’s distress” [ 36 , p.72]. Personal distress is viewed as a barrier to true compassion, and experienced chronically, is associated with burnout (i.e. exhaustion, cynicism, and inefficacy due to feeling frenetic/overloaded, underchallenged/indifferent, or worn-out/neglected [ 37 ]).

Other constructs that have been measured as barriers to compassion include lack of empathy or empathy impairment, apathy, coldness, judgmental attitudes toward specific populations or conditions, and fear of compassion. In sum, compassion and empathy are not so much singular constructs as multi-faceted collections of cognitions, affects, motivations and behaviors. When researchers or program evaluators consider the best ways to assess empathy and compassion, they must often attend to measuring these constructs as well.

Past systematic reviews focused on measurement of empathy and compassion sought to (1) review definitions [ 26 , 38 ]; (2) evaluate measurement methods [ 39 ]; (3) assess psychometric properties [ 40 ]; (4) provide quality ratings [ 26 , 41 , 42 ]; and/or (5) recommend gold standard measures [ 26 , 43 ]. To our knowledge, this review is the first scoping review focused on capturing the wide array of instruments measuring empathy, compassion, and adjacent constructs.

We conducted a scoping review and broad evidence map (as opposed to a systematic review or meta-analysis) for several reasons. Whereas systematic reviews attempt to collate empirical evidence from a relatively smaller number of studies pertaining to a focused research question, scoping reviews are designed to employ a systematic search and article identification method to answer broader questions about a field of study. As such, this scoping review provides a large and diverse map of the available measures across this family of constructs and measurement methodology, with the primary goal of aiding researchers and program evaluators in selecting measures appropriate for their setting.

Another unique feature of this scoping review is a data visualization that we have developed to help readers navigate the findings. This interactive tool is called the Compassion and Empathy Measures Interactive Data Visualization (CEM-IDV) ( https://imagination.ucsd.edu/compassionmeasures/ ).

The aims of this scoping review were achieved, including 1) identifying existing measures of empathy and compassion, 2) providing an overview of the evidence for validity of these measures, and 3) providing an online tool to assist researchers and program evaluators in searching for and selecting the most appropriate instruments to evaluate empathy, compassion, and/or adjacent constructs, based on their specific context, setting, or population.

The objective of this project was to capture all peer-reviewed published research articles that were focused on developing, or assessing the psychometric properties of, instruments measuring compassion and empathy and overlapping constructs, such as self-compassion, theory of mind, perspective taking, vicarious pain, caring, the doctor-patient relationship, emotional cues, sympathy, tenderness and emotional intelligence. We included only articles that were specifically focused on measure development or validation, and therefore did not include articles that may have developed idiosyncratic ways of assessing compassion or empathy in service to conducting experiments. We included self-report assessments, observational ratings or behavioral coding schemes, and tasks. This review was conducted according to the PRISMA statement for scoping reviews [ 44 ]. The population, concept, and context (PCC) for this scoping review were 1) population: adults and children, 2) concepts: compassion and empathy, and 3) context: measures/questionnaires for English-speaking populations (behavioral measures and tasks in all languages).

Eligibility criteria

Articles were included if they focused on development or psychometric validation/evaluation of whole or partial scales, tasks, or activities designed to measure empathy, compassion, or synonymous or adjacent constructs. Conference proceedings and abstracts as well as grey-literature were excluded from this review, as were articles in languages other than English or reporting on self-report scales that were in languages other than English. Behavioral tasks or observational measures that were conducted in languages other than English, but were reported in English and could be utilized in an English-speaking context, were included. Papers were excluded if they were in a language other than English, did not include human participants, or did not focus on reporting on development or psychometric validation of measures of compassion, empathy, or adjacent constructs.

Information sources

To identify the peer-reviewed literature reporting on the psychometric properties of measures of empathy and compassion, the following databases were searched: PubMed, Embase, PsychInfo, CINAHL, and Sociological Abstracts. See Table 1 to review the search terms and strategy applied for each database. All databases were searched in October 2020 and again in May 2023 by a reference librarian trained in systematic and scoping reviews at the University of California, San Diego library.

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https://doi.org/10.1371/journal.pone.0297099.t001

Abstracts of the articles identified through the search were uploaded to Covidence [ 45 , 46 ]. Covidence is a web-based collaboration software platform that streamlines the production of systematic and other literature reviews. Each article was screened by two reviewers and any conflicts reviewed in team meetings until the team reached 90% agreement. Thereafter, one screener included or excluded each abstract.

Full text screening

After articles were screened in, full text for all articles tagged as “Measure Development/Validation” were uploaded to the system. The project coordinator (MS) reviewed all articles that were included to ensure that they were tagged appropriately and that all articles reporting on development or validation of measures or assessments of psychometric properties were included in this review.

Each article was reviewed for its general characteristics and psychometric evaluation/validation data reported. General data extracted from each article included: the article title, full citation, abstract, type of study, the name of the scale/assessment/measure, the author’s definition of the construct(s) being measured (if stated), the specific purpose of the scale (context and population, such as “a scale for measuring nurses’ compassion in patient interactions”), whether the measure was conceptualized as assessing state or trait (or neither or both); whether the scale was self-report, peer-report, or expert observer/coder; the validation population, number, gender proportion, and location; and any reviewer notes.

See Table 2 for the psychometric data extracted from each article. In this scoping review we did not evaluate or record/analyze the results of the psychometric evaluations or validations. We only recorded whether or not they had been completed. Because some members of the team did not have enough experience/training to properly identify psychometric evaluations or assessments, data extraction was completed using two data extraction forms (i.e., one for general data and one for psychometric data) constructed in Survey Planet [ 47 ]. A group of four experienced coders completed both the general and psychometric data extraction forms, and a group of six less experienced coders completed only the general data extraction form with an experienced coder completing the psychometric data extraction form.

https://doi.org/10.1371/journal.pone.0297099.t002

Once the data were extracted, they were reviewed by the research coordinator or principal investigator and combined into a spreadsheet. After combining, the answers were reviewed by a team of four additional reviewers to ensure that the information extracted was correct. These four reviewers received additional training on how to confirm that the appropriate information was extracted from the article as well as how to clean the information in a systematic way.

Systematic literature search

A total of 29,119 articles were identified and 9,673 duplicates were removed, resulting in 19,446 titles/abstracts screened for eligibility ( Fig 1 ). A total of 10,553 full-text articles were assessed for inclusion based on the criteria previously described. A total of 6,023 articles were included in the final sample. Of these articles, 559 reported on the development or validation of a measure of empathy and/or compassion, 1,059 identified biomarkers of empathy and/or compassion, and 3,936 used a measure or qualitative interview of empathy or compassion in the respective study. This scoping review reports on the 559 measure development/validation articles.

https://doi.org/10.1371/journal.pone.0297099.g001

Measure development and validation studies

An overview of the 503 measures of empathy or compassion that were developed, validated, or psychometrically evaluated in the 559 articles can be found in the S1 Table . The majority of the studies ( n = 181) used a student population for development and/or validation. Student populations included undergraduate students, nursing students, and medical students. A total of 136 studies used samples of general, healthy adults (18 and older). Eighty-three (83) studies developed and/or validated a measure using health care workers, mostly comprising physicians and nursing staff. A total of 66 studies reported on a combined sample of populations such as clinicians and patients. There were 63 studies that used a patient population (e.g., cancer patients, surgical patients). A total of 34 studies used samples of individuals in other specific professions (e.g., military personnel), 32 used youth and adolescent samples (5–18 years old), 18 included older adults/aging populations, while 28 used samples in mental health care related professions (e.g., therapists). Nine studies used samples in other specific populations (e.g., spouses of depressed patients).

The number of possible psychometric assessments was 13 (see list below), and the total types of psychometric assessments reported for each measure ranged from 0 to 12. On average, each measure reported four types of psychometric assessments being completed. The measures with the highest number of psychometric assessments reported included the Interpersonal Reactivity Index (IRI) and the Self-Compassion Scale (SCS) with 12 psychometric assessments each. All scales with eight or more psychometric assessments reported in the articles we located can be found in S2 Table .

In regards to the type of psychometric assessments reported, a total of 409 studies assessed internal consistency, 342 used construct validity, 316 used factor analysis or principal component analysis, 299 assessed convergent validity, 218 used confirmatory factor analysis, 187 evaluated content validity, 165 tested for discriminant/divergent validity, 108 assessed test re-test reliability, 71 measured interrater reliability, 69 tested for predictive validity, 68 used structural equation modeling, 38 controlled for or examined correlations with social desirability, and 6 used a biased responding assessment or “lie” scale. Eighty studies performed other advanced statistics.

Measures of empathy and compassion

A total of 503 measures of compassion and empathy were identified in the literature. S3 Table is sorted alphabetically by the name of the measure, and includes a description of each measure, year developed, type of measure, subscales (if applicable), administration time (if provided), number of items, sample items, and response set. The majority of the scales were developed in the past decade (since 2013). Most of the measures identified were self-report scales (412 scales). Fifty-three (53) were peer/corollary report measures (descriptions of target individuals’ thoughts, feelings, motives, or behaviors), and 38 were behavioral/expert coder measures (someone who has been trained to assess target’s thoughts, feelings motives or behaviors). There were 370 measures with subscales and 133 measures without subscales. The number of items of each scale varied widely from 1 item to 567 items. The average number of items was 32 (SD = 45.2) and the median was 21 items. Most authors did not report on the estimated time it would take to complete the measure.

Interactive data visualization

Data visualizations are graphical representations of data designed to communicate key aspects of complex datasets [ 48 ]. Interactive data visualizations allow users to search, filter, and otherwise manipulate views of the data, and are increasingly being used for healthcare decision making [ 49 ]. We used Google Data Studio to create an online open-access interactive data visualization ( Fig 2 ) displaying the results of this scoping review. Access it at: https://imagination.ucsd.edu/compassionmeasures/

https://doi.org/10.1371/journal.pone.0297099.g002

The purpose of this Compassion and Empathy Measures Interactive Data Visualization (CEM-IDV) is to assist health researchers and program evaluators in selecting appropriate measures of empathy and compassion based on a number of parameters, as well as learning more about how these constructs are currently being conceptualized. Visualization parameters include: number of types of psychometric assessments completed (1–12) on the y-axis, number of items on the x-axis (with measures with over 70 items appearing on a separate display, not shown in Fig 2 ), and the bubble size indicating the number of participants in the validation studies. Search filters include Population in which the measure has been validated (e.g. students, healthcare workers, general adults), Construct (e.g. empathy, compassion, caring, self-compassion), and Type of Measure (e.g. self-report, behavioral/expert coder). Users can also search measures by name of the parent measure. For example, there are multiple versions of the Jefferson Scale of Empathy (JSE) (e.g., for physicians, for nurses, for medical students). To retrieve all articles reporting on any version of the JSE, one would search for the parent measure (i.e., “Jefferson Scale of Empathy”). If a measure does not have multiple versions (for example, the Griffith Empathy Measure), this search would yield all articles on that single version.

A robust science of compassion and empathy relies on effective measures. This scoping review examined the broad literature of peer-reviewed published research articles that either developed, or assessed the psychometric properties of, instruments measuring compassion and empathy. The review also includes overlapping and related constructs such as self-compassion, theory of mind, perspective-taking, vicarious pain, caring, the doctor-patient relationship, emotional cues, sympathy, tenderness, and emotional intelligence.

Our review indicates that the field of measuring compassion and empathy is maturing. Strides have been made in recent years in conceptualization, definition, and assessment of compassion and empathy. Since the time of earlier critical reviews of measurement of compassion and empathy, several measures have gained more psychometric support: S2 Table shows that 34 measures have been subjected to 9 or more types of psychometric validation. Multiple measures in this review demonstrate consistent reliability and validity along with many other strengths.

Newer measures align more closely with experimental, theoretical and methodological advances in understanding the various components of compassion and empathy. For example, the newer Empathic Expressions Scale [ 50 ] recognizes that actual empathy behaviors are different from cognitive and affective aspects of empathy. In another example, increasing understanding of the role of warmth and affection as an important component of empathy has led to the development of the Warmth/Affection Coding System (WACS) [ 51 ]. That measure also includes both micro- and macro-social observations, recognizing that implicit and explicit behaviors are important for assessment.

As measurement becomes more precise, assessments have also reflected increasing understanding of the differences between compassion and empathy, and the interaction between the two. For example, the Compassion Scale [ 52 ] subscales include kindness, common humanity, mindfulness and indifference (reverse-scored), whereas the family of the Jefferson Scale(s) of Empathy include compassion as well as “standing in the patient’s shoes” and “understanding the client’s perspective.” Recognizing recent research on how compassion could temper consequences of empathic distress such as burnout, it becomes important for researchers and program evaluators to not only avoid conflating the two, but also measure both separately.

Empathy and compassion in specific circumstances for specific populations have also been developed, such as the Body Compassion Questionnaire [ 53 ] with clear relevance for adolescents and young adults, as well as those with eating and body-dysmorphic disorders, or the modified 5-Item Compassion Measure [ 54 ] created specifically for patients to assess provider compassion during emergency room visits.

In our review, we included self-report assessments, peer/corollary observational measures, and behavioral tasks/expert coder measures, for adults and children in English-speaking populations. A discussion of the utility of each of these types of measures follows, along with a rubric for measure selection that researchers and program evaluators can use with the assistance of the tables and/or CEM-IDV online tool.

Self-report measures

The vast majority of measures of empathy and compassion are self-report measures (surveys, questionnaires, or items asking people to report on their own compassion and empathy). While perhaps the most efficient way to assess large numbers of participants, historically self-assessments of compassion and empathy have been riddled with challenges. Over a decade ago, Gerdes et al. [ 38 ] in their review of the literature noted that:

In addition to a multitude of definitions, different researchers have employed a host of disparate ways to measure empathy (Pederson, 2009). A review of the literature pertaining to empathy reveals that as a result of these inconsistencies, conceptualisations and measurement techniques for empathy vary so widely that it is difficult to engage in meaningful comparisons or make significant conclusions about how we define and measure this key component of human behaviour. (pp. 2327).

While a 2007 systematic review of 36 measures of empathy identified eight instruments demonstrating evidence of reliability, internal consistency, and validity [ 40 ], a systematic review of 12 measures of empathy used in nursing contexts [ 41 ] revealed low-quality scores (scoring 2–8 on a scale of 14), concluding that none of the measures were both psychometrically and conceptually satisfactory.

Our scoping review did not assess psychometric robustness other than the number of psychometric assessments completed, but a 2022 systematic review of measures of compassion [ 26 ] continued to reveal low-quality ratings (ranging from 2 to 7 out of 14) due to poor internal consistency for subscales, insufficient evidence for factor structure and/or failure to examine floor/ceiling effects, test-retest reliability, or discriminant validity. They concluded that “currently no psychometrically robust self- or observer-rated measure of compassion exists, despite widespread interest in measuring and enhancing compassion towards self and others” (pp. 26).

Several issues have been identified as potentially explaining shortcomings of compassion and empathy measures. For example, definitions of compassion and empathy vary widely in scholarly and popular vernacular, which can lead to variability in respondents’ perceptions. In addition to issues of semantics, the vast majority of compassion and empathy measures are face valid, relying on questions such as “I feel for others when they are suffering,” or “When I see someone who is struggling, I want to help.” These questions can increase the risk for social desirability bias (i.e., the tendency to give overly positive self-descriptions either to others or within themselves) and other response biases. Indeed, feeling uncompassionate can be quite difficult to admit, requiring not only a large degree of self-reflection and insight, but also an ability to manage the cognitive dissonance, shame, or embarrassment that could accompany such an admission. This difficulty may be particularly true among healthcare professionals.

Using self-report measures to assess the impact of compassion-focused interventions can also be confounded by mere exposure and demand characteristics, particularly when compared to standard-of-care or wait-list controls. In other words, after spending eight-weeks learning about and practicing compassion, it is not surprising that one might more frequently endorse items with respect to compassion due to increased familiarity with the concept, or implicit desire to satisfy experimenters, as opposed to increased compassionate states or behaviors. On the other hand, interventions could paradoxically result in people more accurately rating themselves lower on these outcomes once they investigate more thoroughly their own levels of, and barriers to, compassion and empathy, potentially masking improvements.

Peer/corollary and behavioral/expert coder measures

With increasing technological, statistical, and conceptual sophistication, we can innovate new measures that can increase validity by triangulating more objective measures with self-perceptions. In fact, multiple measures using observation and ratings by peers, patients, or trained/expert behavioral coders have been developed to do just that. We identified 61 measures utilizing observational measures or peer/corollary reports, some involving a spouse, friend, supervisor, client or patient completing a questionnaire, rating form or checklist regarding their observations of that person. These measures may also include ratings of a live or recorded interaction by someone who has been trained to assess, or is an expert in assessing, compassion or empathy behaviors. Compassion or empathy behaviors include verbalizations and signals such as eye contact, tone of voice, or body language. Similarly, qualitative coding of transcribed narratives, interactions, or responses to interview questions or vignettes can be conducted with human qualitative coders, which is increasingly supported by artificial intelligence.

These methods have the clear benefit of avoiding self-report biases and providing richer data for each individual (for use in admissions or competency exams for instance). However, they can be labor intensive, can introduce potential changes in behavior due to knowing one is being observed, and can introduce another layer of subjectivity on the part of the observer/rater (which can be overcome in part by measures of agreement between two or more raters). They also tend to have fewer psychometric assessments testing their validity or reliability than other measures.

Behavioral tasks

Laboratory-based behavioral tasks have been useful for assessing empathy and compassion under controlled conditions while reducing self-report biases and taking less time than qualitative/observational measures. These lab protocols involve exposure to stimuli designed to induce empathy and compassion or related constructs. For example, respondents might view a video-recorded vignette that reliably results in responses to seeing another person who is suffering [ 55 ] or write a letter to a prison inmate who has committed a violent crime [ 56 ]. Game theory has been used to create tasks focused on giving people options to share with, withhold from, or penalize others with cash, points, or goods. These are used to assess prosocial behaviors and constructs adjacent to empathy and compassion such as altruism and generosity [ 57 ].

The association of these implicit measures of compassion and empathy with real-world settings or with subjective perceptions of empathy and compassion is unknown. A meta-analysis of 85 studies ( N = 14,327) indicates that self-report cognitive empathy scores account for only approximately 1% of the variance in behavioral cognitive empathy assessments [ 58 ]. This finding could demonstrate the superiority of implicit measures and a rather damning verdict for the accuracy of self-perceptions, or could imply that these different types of measures are capturing very different constructs (a problem that exists across many psychosocial versus behavioral measures, see [ 59 ]).

Selecting measures

Our review revealed that there is not one or even a few measures of empathy and compassion that are best across all situations. Rather than providing overarching recommendations, therefore, we emphasize that measurement is context-dependent. As such, we recommend a series of questions researchers and program evaluators might ask themselves when selecting a measure.

We encourage readers to use the online CEM-IDV as a decision-aid tool to identify the best measure for their specific needs. To select the most appropriate instrument(s), we offer the following questions (in a suggested order) to provide guidance:

Which precise domains of empathy, compassion, or adjacent constructs do you want to measure? For example, is it the participant’s experience of empathy, or a skill or behavior? See the “General Construct” dropdown menu. Because definitions of empathy, compassion and related constructs are often imprecise, investigate whether the sample items, factors, and authors’ definition of the construct matches the outcome or variable you actually want to measure.
What measurement type is best suited to answering your research/evaluation question, or what is feasible for your setting and sample size? For example, if you have limited time or a large sample size, you may prefer a self-report survey, whereas if you are concerned about self-report bias, you might consider a direct observation or behavioral task/expert coder measure. Use S1 Table to examine measures by type of measure, or use the “Type of Measure” filter in the CEM-IDV.
What measure length, number of items, or time it takes to complete the assessment is feasible for the study? Refer to the X-axis of the CEM-IDV tool.
What population (s) are you working with? Use the population filter to explore whether the measures you are considering have been validated in those populations.
Do you want to differentiate the domain you are measuring from other adjacent constructs , such as sympathy or altruism, or distinguish between empathy and compassion? Select and include measures of each construct in order to make this distinction. Finally, now that you have selected several candidate measures, ask:
How valid and reliable is the measure? Use S1 Table or the Y-axis of CEM-IDV tool to determine which psychometric assessments have been completed, and click on the measure in the table below to review the full text of the papers to discover the strength of those assessments, as well as familiarizing oneself with the recent literature on the measure. Evidence for the validity, factor structure, or length of measures is often hotly debated, and it can be that a measure has been improved or its interpretation cautioned by recent literature.

For example, imagine you are conducting a study of emergency room outcomes, including number of admissions, time from registration to discharge, and patient satisfaction. You would like to include emergency-room healthcare-provider empathy and/or compassion as a potential predictor or mediator of outcomes. After reviewing the literature on the topic and the definitions, you decide that compassion is the specific domain you are most interested in (Question 1). Because you are aware of the limitations of self-report measures, you decide not to use a self-report measure. You recognize that peer-reports, behavioral tasks, or expert coders are not appropriate for the fast-paced environment and number of interactions, but decide that patient reports of provider compassion would be ideal (Question 2). You recognize that the questionnaire must be brief, given the existing measurement burden and limited time participants have (Question 3). The population is emergency room clinicians and patients (Question 4). In this case, you are not interested in differentiating compassion from other similar constructs because that is not relevant to the question you are trying to answer: whether emergency room physician compassion predicts or mediates patient outcomes (Question 5).

In this case, you might use the CEM-IDV tool to select the population “Patients” and the construct “Compassion.” Your search yields eight potential measures, and upon reviewing each, you find that the 5-item Compassion Scale [ 54 ] has sample items that reflect what you are hoping to measure and was validated with emergency room patients and their clinicians. It demonstrates good reliability and validity and is an excellent choice for your project.

Strengths and limitations

This scoping review has several strengths. First, it covers a wide breadth of literature on ways to assess empathy, compassion, and adjacent constructs using different types of measures (i.e., self-report, peer/corollary report, and behavioral/expert coder). Second, the findings were integrated into an accessible interactive data visualization tool designed to help researchers/program evaluators identify the most suitable measure(s) for their context. Third, the review team included individuals with expertise in conducting reviews, with the project manager having received formal training in best practices for systematic reviews, and an experienced data librarian helping to develop the search string and conduct the literature search. Fourth, the literature search was conducted without a start date limitation, thus capturing all measures published prior to October 2020. Fifth, the review team employed a comprehensive consensus process to establish study inclusion/exclusion criteria and utilized state-of-the-art review software, Covidence, to support the process of screening and data extraction.

There are also several limitations to consider. First, our literature search was limited to five databases (i.e., PubMed, Embase, PsychInfo, CINAHL, and Sociological Abstracts), and excluded grey literature, conference proceedings/abstracts, and measures not written in English. We also included only articles specifically focused on development and/or psychometric validation of measures. Thus, it is possible we missed relevant measures. Second, although we captured how frequently a measure was validated and the types of available psychometric evidence for each measure, we did not review the quality of the evidence. Measures with greater numbers of psychometric assessments may not necessarily be the most appropriate in all contexts or for particular settings, and psychometric studies can lead to conflicting results/interpretations. Importantly, the number of psychometric assessments might be skewed in favor of older measures that have existed in the scientific literature longer, and allegiance biases are possible. Thus, we reiterate that readers would benefit most from using the questions recommended above when selecting measures. Third, this scoping review provides a static snapshot of available measures through October 2020 and does not include measures that may have been published after that time.

Finally, the scoping review does not identify gold-standard measures to use. While systematic reviews typically include quality assessments, scoping reviews do not. Rather, scoping reviews seek to present an overview of a potentially large and diverse body of literature pertaining to a topic. As such, this review did not evaluate the quality of design, appraise the strength of the evidence, or synthesize reliability or validity results for each study. It may therefore include multiple studies that may have weak designs, low power, or evidence inadequate to the conclusions drawn.

Given the multitude of problems facing society (e.g., violence and war, social injustices and inequities, mental health crises), learning how to cultivate compassion and empathy towards self and others is one of the most pressing topics for science to address. Furthermore, studies of compassion, empathy, and adjacent constructs rely on the use of appropriate measures, which are often difficult to select due to inconsistent definitions and susceptibility to biases. Our scoping review identified and reviewed numerous measures of compassion, empathy, and adjacent constructs, extracting the qualities of each measure to create an interactive data visualization tool. This tool is intended to assist researchers and program evaluators in searching for and selecting the most appropriate instruments to evaluate empathy, compassion, and adjacent constructs based on their specific context, setting, or population. It does not replace reviewers’ own critical evaluation of the instruments.

How a construct is measured reflects how it is being defined and conceptualized. Reviewing the subscales/factors and individual items that make up each measure sheds light on how each of these measures conceptualizes empathy and compassion. Ongoing research by our team is using these subscales, factors and items across measures to construct a conceptual map of compassion and empathy, which will be reported in a future paper. In the meantime, a useful feature of the CEM-IDV is that the list of articles yielded by searches includes subscales and sample items from each measure/article. These allow for a snapshot of how each measure or its authors have defined the constructs being assessed.

Future directions for measurement of empathy and compassion should consider incorporating advances in measurement and technology, and strive to bring together two or more assessment methods such as self-report, peer or patient reports, expert observation, implicit tasks, and biomarkers/physiological data to provide a more well-rounded picture of compassion and empathy. Innovations such as voice analysis and automated facial expression recognition may hold promise. Brief measures dispersed across multiple time points such as ecological momentary assessment and daily experience sampling may be useful. In conjunction with mobile technology and wearables, artificial intelligence and machine-learning data processing, could facilitate these formerly labor and time-intensive assessment methods.

Supporting information

S1 table. measure populations and psychometric assessments..

https://doi.org/10.1371/journal.pone.0297099.s001

S2 Table. Measures with 8+ psychometric assessments.

https://doi.org/10.1371/journal.pone.0297099.s002

S3 Table. Measures of compassion and empathy.

https://doi.org/10.1371/journal.pone.0297099.s003

Acknowledgments

Thank you to Omar Shaker for his work to create the online interactive data visualization.

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A systematic review of research on empathy in health care

Affiliations.

1 Health Care Management Department, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
2 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
3 Life Sciences and Health Care Practice, Deloitte Consulting, LLP, New York, New York, USA.
PMID: 35765156
PMCID: PMC10012244
DOI: 10.1111/1475-6773.14016

Objective: To summarize the predictors and outcomes of empathy by health care personnel, methods used to study their empathy, and the effectiveness of interventions targeting their empathy, in order to advance understanding of the role of empathy in health care and facilitate additional research aimed at increasing positive patient care experiences and outcomes.

Data source: We searched MEDLINE, MEDLINE In-Process, PsycInfo, and Business Source Complete to identify empirical studies of empathy involving health care personnel in English-language publications up until April 20, 2021, covering the first five decades of research on empathy in health care (1971-2021).

Study design: We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

Data collection/extraction methods: Title and abstract screening for study eligibility was followed by full-text screening of relevant citations to extract study information (e.g., study design, sample size, empathy measure used, empathy assessor, intervention type if applicable, other variables evaluated, results, and significance). We classified study predictors and outcomes into categories, calculated descriptive statistics, and produced tables to summarize findings.

Principal findings: Of the 2270 articles screened, 455 reporting on 470 analyses satisfied the inclusion criteria. We found that most studies have been survey-based, cross-sectional examinations; greater empathy is associated with better clinical outcomes and patient care experiences; and empathy predictors are many and fall into five categories (provider demographics, provider characteristics, provider behavior during interactions, target characteristics, and organizational context). Of the 128 intervention studies, 103 (80%) found a positive and significant effect. With four exceptions, interventions were educational programs focused on individual clinicians or trainees. No organizational-level interventions (e.g., empathy-specific processes or roles) were identified.

Conclusions: Empirical research provides evidence of the importance of empathy to health care outcomes and identifies multiple changeable predictors of empathy. Training can improve individuals' empathy; organizational-level interventions for systematic improvement are lacking.

Keywords: empathy; health personnel; impact; intervention; patient experience; systematic review.

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‘I Feel Your Pain’: The Neuroscience of Empathy

Developmental Psychology
Forecasting
Neuroscience
Sensory Systems

Whether it’s watching a friend get a paper cut or staring at a photo of a child refugee, observing someone else’s suffering can evoke a deep sense of distress and sadness — almost as if it’s happening to us. In the past, this might have been explained simply as empathy, the ability to experience the feelings of others, but over the last 20 years, neuroscientists have been able to pinpoint some of the specific regions of the brain responsible for this sense of interconnectedness. Five scientists discussed the neuroscience behind how we process the feelings of others during an Integrative Science Symposium chaired by APS Fellow Piotr Winkielman (University of California, San Diego) at the 2017 International Convention of Psychological Science in Vienna.

Mirroring the Mind

Cultural emphasis on ingroups and outgroups may create an “empathy gap” between people of different races and nationalities, says Ying-yi Hong .

“When we witness what happens to others, we don’t just activate the visual cortex like we thought some decades ago,” said Christian Keysers of the Netherlands Institute for Neuroscience in Amsterdam. “We also activate our own actions as if we’d be acting in similar ways. We activate our own emotions and sensations as if we felt the same.”

Through his work at the Social Brain Lab, Keysers, together with Valeria Gazzola, has found that observing another person’s action, pain, or affect can trigger parts of the same neural networks responsible for executing those actions and experiencing those feelings firsthand. Keysers’ presentation, however, focused on exploring how this system contributes to our psychology. Does this mirror system help us understand what goes on in others? Does it help us read their minds? Can we “catch” the emotions of others?

To explore whether the motor mirror system helps us understand the inner states behind the actions of others, Keysers in one study asked participants to watch a video of a person grasping toy balls hidden within a large bin. In one condition, participants determined whether or not the person in the video hesitated before selecting a ball (a theory-of-mind task). Using transcranial magnetic stimulation (TMS) in combination with fMRI, Keysers showed that interfering with the mirror system impaired people’s ability to detect the level of confidence of others, providing evidence that this system indeed contributes to perceiving the inner states of others. Performing fMRI and TMS on other brain regions such as the temporoparietal junction (TPJ) further suggests that this motor simulation in the mirror system is then sent onward to more cognitive regions in the TPJ.

“Very rapidly, we got this unifying notion that when you witness the states of others you replicate these states in yourself as if you were in their shoes, which is why we call these activities ‘vicarious states,’” Keysers said.

Studies have suggested that this ability to mentalize the experiences of others so vividly can lead us to take prosocial steps to reduce their pain, but Keysers also wanted to investigate the depth of this emotional contagion — how and to what extent we experience other people’s suffering. To do this, Keysers’ lab studied two very different populations: human psychopaths and rats.

While witnessing the pain of others is correlated with activity in the insula, which is thought to contribute to self-awareness by integrating sensory information, and the anterior cingulate cortex (ACC), which is associated with decision making and impulse control, the researchers found that psychopaths who passively observed an aggressor twisting someone’s hand exhibited significantly less brain activity than their neurotypical peers. When the psychopathic individuals were asked to attempt to empathize with the person in the video, however, their brain activity increased to baseline levels.

This suggests that the current model of empathy as a one-dimensional scale with empathic individuals at one end and psychopaths at the other may be overly simplistic, Keysers said.

“Psychopaths are probably equally high on ability, it’s just that they don’t recruit this spontaneously, so their propensity is modified,” he explained.

These findings could lead to more effective interventions for psychopathic individuals, as well as to future research into where people with autism spectrum disorders may fall on these axes.

Shared Pain

Studies of emotional contagion in animal models have allowed researchers to further examine the role of deep brain activity, which can be difficult to neurostimulate in humans. Keysers’ work with rats has found that these animals are more likely to freeze after watching another rat receive an electric shock if they themselves had been shocked in the past.

Inhibiting a region analogous to the ACC in the rats’ brains reduced their response to another rat’s distress, but not their fear of being shocked themselves, suggesting that the area deals specifically with socially triggered fear, Keysers said.

Claus Lamm, University of Vienna, investigates the processes that regulate firsthand pain and those that cause empathy for pain through numerous studies on the influence of painkillers.

In these experiments, participants who took a placebo “painkiller” reported lower pain ratings after receiving a shock than did those in the control group. When those same participants watched a confederate get shocked, they reported a similar drop in their perception of the actor’s pain.

“If you reduce people’s self-experienced pain, if you induce analgesia, that not only helps people to deal with their own pain, but it also reduces empathy for the pain of another person,” Lamm said.

On the neural level, Lamm said, fMRI scans showed that people in the placebo group displayed lower levels of brain activity in the anterior insula and mid cingulate cortex in both cases. These results were further confirmed in another study that compared participants who received only the painkiller placebo with those who received both the placebo and naltrexone, an opioid antagonist that prevents the brain from regulating pain.

This resulted in a “complete reversal” of the placebo effect, causing participants to report both their own pain and the pain of others at near baseline rates, supporting Lamm’s previous claims about the pain system’s role in empathy.

“This suggests that empathy for pain is grounded in representing others’ pain within one’s own pain systems,” Lamm said.

The Self/Other Divide

Empathy may not give us a full sense of someone else’s experiences, however. When observers in one of Keysers’ studies were given the opportunity to pay to reduce the severity of the electric shocks a confederate was about to receive, on average participants paid only enough to reduce her pain by 50%.

Lamm studied this self/other distinction through a series of experiments that measured people’s emotional egocentricity bias. To do so, participants were presented with visuo-tactile stimulation that was either congruent or incongruent with that of a partner under fMRI. In an incongruent pair, for example, one participant might be presented with an image of a rose and be touched with something that felt like a rose, while the other was shown a slug and touched with a slimy substance.

Participants’ own emotions were found to color their perception of other people’s affect at a relatively low rate — however, when researchers inhibited the right supramarginal gyrus (rSMG), a region of the brain previous associated mainly with language processing, this egocentricity bias increased, suggesting that the rSMG may be responsible for maintaining a self/other divide, Lamm said.

“Empathy not only requires a mechanism for sharing emotions, but also for keeping them separate. Otherwise we are getting ‘contaged,’ emotionally distressed and so on,” he said.

The rate of rSMG activation also changes significantly across a lifetime, Lamm added, with the area’s developmental trajectory causing emotional egocentricity to be more common in adolescents and the elderly.

Developing Division

Researchers are working to unite neuroscientific and psychological perspectives on feelings, empathy, and identity, says Piotr Winkielman .

Rebecca Saxe (Massachusetts Institute of Technology) said her work with developmental psychology confirms this trend. In one series of experiments, Saxe monitored the brain networks that 3- to 5-year-old children used to consider a character’s mind (the temporoparietal junction, posterior cingulate, and prefrontal cortex) and body (the secondary somatosensory cortex, insula, middle frontal gyrus, and ACC) throughout a short film.

Saxe found that while these brain regions may interact with each other, there were no points of overlap between the mind and body networks’ activities.

“When we’re getting information from the same source and about the same people, we still nevertheless impose a kind of dualism where we alternate between considering what their bodies feel like and the causes of their minds,” Saxe said.

Furthermore, Saxe and her colleagues found that while these networks were more distinct in children who were able to pass an explicit-false-belief task (e.g., if Sally puts her sandwich on a shelf and her friend moves it to the desk, where will she look for it?), the division was present in participants of all ages.

“Most people have treated explicit false belief as if it were the milestone,” Saxe said. “Actually, the false-belief task is just one measure of a much more continuous developmental change as children become increasingly sophisticated in their thinking about other people’s minds.”

Next, Saxe scaled this experiment down to test the theory of mind of infants as young as 6 months, this time measuring their response to children’s facial expressions, outdoor scenes, and visual static. This time period may be key to understanding the neuropsychology of empathy because most of the brain’s cognitive development happens within the first year of life, she explained.

“A baby’s brain is more different from a 3-year-old’s brain than a 3-year-old’s brain is from a 33-year-old’s brain,” Saxe said.

Under fMRI, the infants’ brains were found to have many of the same regional responses that allow adults to distinguish between faces and scenes. Their brains didn’t show any regional preferences for objects and bodies, however.

This level of regional specificity suggests that the Kennard Principle, the theory that infants’ brains possess such resilience and plasticity because the cortex hasn’t specialized yet, may be only partially true. There does appear to be some functional organization of social process, Saxe said, with gradually increasing specialization as the child ages.

Empathy in Action

Brian D. Knutson says analysis of individuals’ brain activity when considering a purchase may be predictive of aggregate market choices.

On the surface, neuroforecasting sounds like a concept that would be right at home in the world of Philip K. Dick’s Minority Report — a science fiction thriller about a society that stops crime before it happens based on the brainwaves of three mutant “precogs” — said APS Fellow Brian D. Knutson (Stanford University), but someday it could play a very real role in the future of economics.

Knutson’s research on the brain mechanisms that influence choice homes in on three functional targets: the nucleus accumbens (NAcc) for gain anticipation, the anterior insula for loss anticipation, and the medial prefrontal cortex (mPFC) for value integration.

Using fMRI, Knutson was able to predict participants’ purchases in a simulated online shopping environment on the basis of brain activations in these areas. Before participants chose to buy a product, increased activity in the NAcc and mPFC was paired with a decrease in the insula, while the reverse was true of trials in which participants chose not to make a purchase.

“This was very exciting to me as a psychologist to be able to say, ‘Wow, we can take activity out of the brain and, not knowing anything else about who it is and what product they’re seeing, we can predict choice,’” Knutson said.

His economist colleagues weren’t as impressed: They were interested in market activity, not individual choice. Knutson said he accepted this challenge by applying his neuroanaylsis to large-scale online markets such as Kiva and Kickstarter.

Knutson asked 30 participants to rate the appeal and neediness of loan requests on Kiva and found that posts with photos of people displaying a positive affect were most likely to trigger the increased NAcc activity that caused them to make a purchase — or in this case, a loan. More importantly, the averaged choices of those participants forecasted the loan appeal’s success on the internet. Two similar studies involving Kickstarter campaigns also suggested a link between NAcc activity and aggregate market activity.

While brain activity doesn’t scale perfectly to aggregate choice, Knutson said, some components of decision making, such as affective responses, may be more generalizable than others.

“The paradox may be that the things that make you most consistent as an individual, that best predict your choices, may not be the things that make your choices conform to those of others. We may be able to deconstruct and decouple those components in the brain,” Knutson said.

Global Empathy

The neuroanatomy of our brains may allow us to feel empathy for another’s experiences, but it can also stop us from making cross-cultural connections, said APS Fellow Ying-yi Hong (Chinese University of Hong Kong).

“Despite all these neurobiological capabilities enabling us to empathize with others, we still see cases in which individuals chose to harm others, for example during intergroup conflicts or wars,” Hong said.

This may be due in part to the brain’s distinction between in-group and out-group members, she explained. People have been found to show greater activation in the amygdala when viewing fearful faces of their own race, for example, and less activation in the ACC when watching a needle prick the face of someone of a different race.

The cultural mixing that accompanies globalization can heighten these responses, Hong added. In one study, she and her colleagues found that melding cultural symbols (e.g., combining the American and Chinese flags, putting Chairman Mao’s head on the Lincoln Memorial, or even presenting images of “fusion” foods) can elicit a pattern of disgust in the anterior insula of White Americans similar to that elicited by physical contaminant objects such as insects.

These responses can also be modulated by cultural practices, Hong said. One study comparing the in-group/out-group bias in Korea, a more collectivist society, and the United States, a more individualistic society, found that more interdependent societies may foster a greater sense of in-group favoritism in the brain.

Further research into this empathy gap should consider not just the causal relationship between neural activation and behavior, she said, but the societal context in which they take place.

“What I want to propose,” Hong said, “is that maybe there is another area that we can also think about, which is the culture, the shared lay theories, values, and norms.”

There is some fantastic research going on in empathy. From an evolutionary point of view however it’s important to distinguish an evolved motivation system from a competency. Empathy is a competency not a motivation. Empathy can be used for both benevolent but also malevolent motives. And psychopaths have a competency for empathy but what they lack is mammalian caring motivation. Insofar as part of the reproductive strategy of the psychopath is to exploit others and even threaten them then having a brain that turns off distress to the suffering they cause would be an advantage to them. Psychopaths are much more likely to be prepared to harm others to get what they want. Mammalian caring motivation, when guided by higher cognitive processes and human empathy gives rise to compassion. Without empathy compassion would be tricky but without compassion you can still have empathic competencies

Gilbert, P. (2017). Compassion as a social mentality: An evolutionary approach. In: P. Gilbert (ed). Compassion: Concepts, Research and Applications. (p. 31-68). London: Routledge

Gilbert. P. (2015). The evolution and social dynamics of compassion Journal of Social & Personality Psychology Compass, 9, 239–254. DOI: 10.1111/spc3.12176

Catarino, F., Gilbert, P., McEwan., K & Baião, R. (2014). Compassion motivations: Distinguishing submissive compassion from genuine compassion and its association with shame, submissive behaviour, depression, anxiety and stress Journal of Social and Clinical Psychology, 33, 399-412.

Gilbert, P., Catarino, F., Sousa, J., Ceresatto, L., Moore, R., & Basran, J. (2017). Measuring competitive self-focus perspective taking, submissive compassion and compassion goals. Journal of Compassionate Health Care, 4(1), 5

Very interesting article. The research behind what links our empathy to our actions determining the agenda is fascinating. As social creatures, we seem to inhibit empathetic tendencies naturally in our genetic makeup when studied. Since we have the highest empathetic behavior compared to other animals, who also show empathetic behavior, I wonder if it falls more on our social norms. What we consider relatable is worthy of our empathy. If we don’t relate, we may be less inclined to put ourselves in the other position.

I have what I call empathy pain. It radiates an aching pain in my legs and I can barely stand it. I’ve googled it in attempts to validate it is real. It seems people either do not believe me or can’t understand stand when I tell them it makes my legs ache. Seeing someone’s cuts, surgical incisions, bloody wounds. I can’t describe all the triggers, but I can 100% say the pain I feel in response is intense, even when they say “oh, it didn’t hurt” or “it’s not hurting”. Well, it hurt ME seeing it.

I am currently writing a literature review for my psychology course in University, based on what I am writing about I believe you may have Mirror Touch Synesthesia. This condition is characterized by viewing others being touched and feeling tactile sensations, and this seems quite similar to what you shared. I would recommend doing a bit of research on MTS, and see if it relates to you.

Since I was 7 years old I felt others pain Then I thought everyone could . I came to realize I feel so much more than most . I feel what I see, I feel what I hear. My sensitive to touch is more like pain but my pain level is very high, I can take a lot of pain.

What about feeling pain or illness without observing it or even having knowledge of someone else’s pain? Such as the phenomenon of twins. I’m looking for research of this outside of the twin sibling relationship.

When carrying out functional mapping of the amygdala cortex by means of electrical stimulation in one of my patients with focal epileptic seizures who was being evaluated for resective epilepsy surgery of the orbitofrontal, opercular, and anterior insular cortex the stimulation caused the patient to reminisce over video films he had seen of cartoons (animaniacs) as a child, at the same time empathizing with the suffering of those characters. I had probably activated a limbic pathway connected to the limen insulae where I was administering electrical stimulation at that time. The visual imagery stopped as soon as the stimulus train was over but the patient still empathized with the cartoon characters for about 20 seconds after the stimulation was over and reported his feelings to me.

Wow… I thought I was alone in the way I feel everyone’s pain and joy. I find that I can not watch scenes of torture or violence on tv, thus I hate most movies, unless it’s a children flick. I get pulled into every story I read. On 911 I thought my heart really was breaking, it consumed my entire body. I can’t watch history shows of Pearl Harbor, or nazis. If I do, sometimes those images stay with me for years and come back as nightmares. It’s not easy living with this in today’s world.

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The psychology of emotional and cognitive empathy.

The study of empathy is an ongoing area of major interest for psychologists and neuroscientists in many fields, with new research appearing regularly.

Empathy is a broad concept that refers to the cognitive and emotional reactions of an individual to the observed experiences of another. Having empathy increases the likelihood of helping others and showing compassion. “Empathy is a building block of morality—for people to follow the Golden Rule, it helps if they can put themselves in someone else’s shoes,” according to the Greater Good Science Center , a research institute that studies the psychology, sociology, and neuroscience of well-being. “It is also a key ingredient of successful relationships because it helps us understand the perspectives, needs, and intentions of others.”

Though they may seem similar, there is a clear distinction between empathy and sympathy. According to Hodges and Myers in the Encyclopedia of Social Psychology , “Empathy is often defined as understanding another person’s experience by imagining oneself in that other person’s situation: One understands the other person’s experience as if it were being experienced by the self, but without the self actually experiencing it. A distinction is maintained between self and other. Sympathy, in contrast, involves the experience of being moved by, or responding in tune with, another person.”

Emotional and Cognitive Empathy

Researchers distinguish between two types of empathy. Especially in social psychology, empathy can be categorized as an emotional or cognitive response. Emotional empathy consists of three separate components, Hodges and Myers say. “The first is feeling the same emotion as another person … The second component, personal distress, refers to one’s own feelings of distress in response to perceiving another’s plight … The third emotional component, feeling compassion for another person, is the one most frequently associated with the study of empathy in psychology,” they explain.

It is important to note that feelings of distress associated with emotional empathy don’t necessarily mirror the emotions of the other person. Hodges and Myers note that, while empathetic people feel distress when someone falls, they aren’t in the same physical pain. This type of empathy is especially relevant when it comes to discussions of compassionate human behavior. There is a positive correlation between feeling empathic concern and being willing to help others. “Many of the most noble examples of human behavior, including aiding strangers and stigmatized people, are thought to have empathic roots,” according to Hodges and Myers. Debate remains concerning whether the impulse to help is based in altruism or self-interest.

The second type of empathy is cognitive empathy. This refers to how well an individual can perceive and understand the emotions of another. Cognitive empathy, also known as empathic accuracy, involves “having more complete and accurate knowledge about the contents of another person’s mind, including how the person feels,” Hodges and Myers say. Cognitive empathy is more like a skill: Humans learn to recognize and understand others’ emotional state as a way to process emotions and behavior. While it’s not clear exactly how humans experience empathy, there is a growing body of research on the topic.

How Do We Empathize?

Experts in the field of social neuroscience have developed two theories in an attempt to gain a better understanding of empathy. The first, Simulation Theory, “proposes that empathy is possible because when we see another person experiencing an emotion, we ‘simulate’ or represent that same emotion in ourselves so we can know firsthand what it feels like,” according to Psychology Today .

There is a biological component to this theory as well. Scientists have discovered preliminary evidence of “mirror neurons” that fire when humans observe and experience emotion. There are also “parts of the brain in the medial prefrontal cortex (responsible for higher-level kinds of thought) that show overlap of activation for both self-focused and other-focused thoughts and judgments,” the same article explains.

Some experts believe the other scientific explanation of empathy is in complete opposition to Simulation Theory. It’s Theory of Mind, the ability to “understand what another person is thinking and feeling based on rules for how one should think or feel,” Psychology Today says. This theory suggests that humans can use cognitive thought processes to explain the mental state of others. By developing theories about human behavior, individuals can predict or explain others’ actions, according to this theory.

While there is no clear consensus, it’s likely that empathy involves multiple processes that incorporate both automatic, emotional responses and learned conceptual reasoning. Depending on context and situation, one or both empathetic responses may be triggered.

Cultivating Empathy

Empathy seems to arise over time as part of human development, and it also has roots in evolution. In fact, “Elementary forms of empathy have been observed in our primate relatives, in dogs, and even in rats,” the Greater Good Science Center says. From a developmental perspective, humans begin exhibiting signs of empathy in social interactions during the second and third years of life. According to Jean Decety’s article “The Neurodevelopment of Empathy in Humans ,” “There is compelling evidence that prosocial behaviors such as altruistic helping emerge early in childhood. Infants as young as 12 months of age begin to comfort victims of distress, and 14- to 18-month-old children display spontaneous, unrewarded helping behaviors.”

While both environmental and genetic influences shape a person’s ability to empathize, we tend to have the same level of empathy throughout our lives, with no age-related decline. According to “Empathy Across the Adult Lifespan: Longitudinal and Experience-Sampling Findings,” “Independent of age, empathy was associated with a positive well-being and interaction profile .”

And it’s true that we likely feel empathy due to evolutionary advantage : “Empathy probably evolved in the context of the parental care that characterizes all mammals. Signaling their state through smiling and crying, human infants urge their caregiver to take action … females who responded to their offspring’s needs out-reproduced those who were cold and distant,” according to the Greater Good Science Center. This may explain gender differences in human empathy.

This suggests we have a natural predisposition to developing empathy. However, social and cultural factors strongly influence where, how, and to whom it is expressed. Empathy is something we develop over time and in relationship to our social environment, finally becoming “such a complex response that it is hard to recognize its origin in simpler responses, such as body mimicry and emotional contagion,” the same source says.

Psychology and Empathy

In the field of psychology, empathy is a central concept. From a mental health perspective, those who have high levels of empathy are more likely to function well in society, reporting “larger social circles and more satisfying relationships,” according to Good Therapy , an online association of mental health professionals. Empathy is vital in building successful interpersonal relationships of all types, in the family unit, workplace, and beyond. Lack of empathy, therefore, is one indication of conditions like antisocial personality disorder and narcissistic personality disorder. In addition, for mental health professionals such as therapists, having empathy for clients is an important part of successful treatment. “Therapists who are highly empathetic can help people in treatment face past experiences and obtain a greater understanding of both the experience and feelings surrounding it,” Good Therapy explains.

Exploring Empathy

Empathy plays a crucial role in human, social, and psychological interaction during all stages of life. Consequently, the study of empathy is an ongoing area of major interest for psychologists and neuroscientists in many fields, with new research appearing regularly. Lesley University’s online bachelor’s degree in Psychology gives students the opportunity to study the field of human interaction within the broader spectrum of psychology.

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Declining empathy trends throughout medical curriculum and association factors of low empathy among medical students and residents: a single center study

Sethapong Lertsakulbunlue 1 na1 ,
Chutipon Kiatsrithanakorn 2 na1 ,
Pinyada Kittisarapong 2 ,
Kaophiphat Thammasoon 3 ,
Sarut Puengpreeda 4 ,
Varathpavee Bhuriveth 2 ,
Vittavat Tangdumrongvong 2 ,
Anupong Kantiwong 1 &
Chitrawina Mahagita 4

BMC Medical Education volume 24 , Article number: 951 ( 2024 ) Cite this article

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A physician’s empathy level substantially impacts clinical competence, patient relationships, and treatment outcomes. Yet, understanding empathy trends from medical students to resident doctors within a single institution is limited. This study delves into empathy trends within a single-center academic setting and identifies factors associated with low empathy.

This cross-sectional study enrolled the second—to sixth-year medical students of Phramongkutklao College of Medicine and the first—to second-year residents at Phramongkutklao Hospital. It utilized a standardized questionnaire covering demographics, family relationships, the Maudsley Personality Inventory (MPI), and the Jefferson Scale of Empathy (JSE). The relationship between variables and JSE scores was analyzed using independent t-test, one-way ANOVA, and Chi-square tests. Multivariable logistic and linear regression analyses examined associated factors and trends across educational levels. A quadratic term was incorporated to evaluate the presence of a nonlinear trend.

A total of 520 participants, comprising 189 (36.4%) preclinical students, 153 (29.4%) clinical students, and 178 (34.2%) residents, completed the survey. The JSE showed a Cronbach’s alpha of 0.83. The average empathy score was 103.8 ± 15.0, with 27.1% of low empathy levels. Specialty preference and sex-adjusted average empathy scores decreased from 114.5 (95%CI: 112.0–117.0) among second-year medical students to 95.2 (95%CI: 92.2–98.2) among second-year residents ( P non−linear <0.001). The adjusted proportion of low empathy is highest among sixth-year medical students (54.4%, 95%CI: 34.4–73.2%). Factors associated with low empathy included those preferring procedure-oriented specialties (AOR: 4.16, 95%CI: 1.54–11.18) and a higher parental income (AOR: 2.97, 95%CI: 1.09 to 8.10). Subgroup analysis revealed that residents with a GPAX above 3.5 and those in technology-oriented specialties were also associated with lower empathy (AOR: 3.46, 95%CI: 1.40–8.59 and AOR: 2.93, 95%CI: 1.05–8.12, respectively).

A declining empathy trend was observed among medical students, which then plateaued among residents. Additionally, residents in technology-oriented specialties may require empathy enhancements due to their ongoing patient consultations. Addressing these issues requires collaborative planning between students and teachers to foster empathy throughout the medical curriculum.

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Introduction

Empathy in medical professionals has been critical for clinical competence and enhanced patient satisfaction and cooperation during treatment [ 1 , 2 ]. These factors collectively contribute to improved treatment outcomes [ 3 , 4 ]. However, numerous studies indicate a consistent decline in empathy levels among medical students throughout their education and residency. This significant reduction in empathy, observed as students progress through their academic years, is a trend documented in the United States [ 2 , 5 ] and various countries worldwide, including Thailand [ 5 , 6 ].

A systematic review of seven studies also highlights a significant decrease in empathy among resident physicians throughout their residency, which may adversely affect patient care quality and medical professionalism [ 7 ]. Further findings reveal that residents exhibit lower empathy levels than early-stage medical students and specialists [ 8 , 9 ]. These might be due to workload and stress being prevalent among resident physicians [ 10 , 11 ], with studies suggesting that physicians often cope by diminishing their empathy toward patients [ 12 ].

Empathy is primarily a cognitive attribute, focusing on understanding—rather than feeling—the patient’s experiences, concerns, and perspectives, along with the ability to communicate this understanding and the intention to assist [ 13 ]. Empathy, crucial for interpersonal relationships, likely correlates with personality traits affecting these dynamics. Positive associations are expected between empathy and traits fostering relationships, like sociability, whereas negative correlations might exist with traits hindering them, such as introversion and neuroticism [ 14 , 15 ].

Preferred specialties are also one of the factors that may influence empathy levels. Personality traits, role models, market forces, societal needs, personal networks and educational experiences influence medical students’ specialty choices. Previous studies categorized specialties as “people-oriented” (e.g., internal medicine and family medicine), which focuses on initial health assessments and preventive care; “technology-oriented” (e.g., surgery and orthopedic), which involves specialized therapeutic techniques and is still oriented to the patient; and “procedure-oriented” (e.g., pathology and radiology), which involves specialized diagnostic procedures or applied basic laboratory which are patient-remote specialties [ 14 , 15 , 16 ]. Those in “people-oriented” fields are more interpersonally inclined than their counterparts, often resulting in higher empathy levels [ 14 , 15 , 17 ].

In addition, research indicates that empathy is associated with variables such as gender, personality traits, early family dynamics, and later socio-educational encounters [ 15 ]. For instance, evidence suggests that female medical students and residents exhibit higher levels of empathy than their male counterparts [ 6 , 14 , 18 ]. Nevertheless, to our knowledge, studies on empathy levels among non-binary physicians are rare despite their personality differences, such as higher positive emotions compared to binary genders. Non-binary individuals may face various forms of social exclusion, discrimination, and stigma across multiple domains in society, possibly affecting their empathy [ 6 , 19 , 20 ]. Additionally, individuals from families with either extremely high or low family function (disengaged or enmeshed) tend to demonstrate greater empathy compared to those from families with moderate dynamics [ 21 , 22 ], and closer relationships within the family may positively affect psychological well-being, thereby influencing empathy levels [ 21 , 23 ]. Moreover, a higher socioeconomic status within the family environment is linked to reduced levels of empathy [ 24 ].

Although numerous studies have investigated factors associated with empathy levels, there is limited information examining empathy across medical students and residency training within a single institution [ 6 ]. Previous studies have found that empathy often declines during medical school [ 25 , 26 ]. Still, these studies are typically restricted to either medical students or residents or compare students and residents from different institutions [ 5 , 6 ]. Similar to other hospitals here at Phramongkutklao College of Medicine (PCM) and Phramongkutklao Hospital (PMK), residents often serve as educators for medical students, and their ability to model empathy is crucial. Residents ' effective communication and teaching strategies can foster a more empathetic environment for students, enhancing their learning experience and professional attitudes [ 27 ]. On the other hand, medical students who are engaged, ask thoughtful questions, and actively participate in patient care help create a stimulating learning environment for residents [ 28 ]. Hence, understanding empathy trends within a single institution is essential for fostering a culture of empathy in healthcare.

Herein, the present study explores the level of empathy and associated factors with low empathy levels from the 2nd year medical students to 2nd year residents utilizing the data from PCM and PMK. The PCM curriculum includes two pre-clinical and three clinical years, with students transitioning from basic sciences to clinical rotations at PMK. Residents were trained at PMK, a tertiary care facility, and received training across various specialties, providing similar settings for both groups. Moreover, the present study also included non-binary gender in addition to the binary sexes. The insights from the present study would help design a tailored course to improve and maintain empathy levels across the continuum of professionality. Enabling targeted educational strategies informs curriculum development, ultimately contributing to the training of compassionate and competent healthcare professionals.

Study design and subjects

A cross-sectional study was carried out at PCM and PMK in Bangkok, Thailand, utilizing a self-administered survey. This survey included medical students from their second to sixth years, comprising 486 students and first—and second-year residents, totaling 285 residents at PMK. Whereas those who did not answer the JSE completely were excluded. The sample size calculation for a finite population of 771 was 254, using a desired precision of 0.05, a confidence interval of 0.95, and an expected prevalence of low empathy of 57% [ 29 ]. Figure 1 illustrates the flow of study participants and missing variables.

Flow of study participants

Phramongkutklao College of Medicine and Phramongkutklao Hospital educational settings

The PCM curriculum, spanning six years, is divided into one pre-medical year, two pre-clinical years focusing on basic sciences and three clinical years aimed at developing clinical experiences. Initially, first-year students, known as pre-medicals, study only basic science on other campuses with different contexts. Therefore, this study included second to sixth-year medical students. From the second to the third year, pre-clinical students begin to integrate basic science with clinical cases, primarily learning in classrooms and occasionally interacting with actual patients. Starting in the fourth year, students transition to clinical medical students, studying at PMK and rotating through various specialties and sub-specialties. In their final year, in addition to their rotation at PMK, students undertake a 4-month externship training at hospitals under the Ministry of Public Health, experiencing first contact with patients under relatively less supervision for the first time.

Regarding the residents at PMK, the hospital enrolls doctors who graduated from PMK and those who did not. As a tertiary care facility, it includes approximately 1,200 beds and offers training across various specialties and sub-specialties. These include major specialties like internal medicine, general surgery, obstetrics and gynecology, pediatrics, and minor specialties such as otolaryngology, radiology, orthopedics, pathology, etc.

Data collection

This study utilized a standardized questionnaire divided into three sections. The first section contained questions to gather demographic data, including gender, age, current year of study, cumulative grade point average (GPAX), current or preferred specialty, maternal and paternal status, education level of parents, monthly household income, and a rating scale out of 10 to assess the participant’s relationship with their current self, family, and past relationships. The second section used the Maudsley Personality Inventory (MPI) to assess introversion and extroversion personality traits. The third section featured the Jefferson Scale of Empathy (JSE), including the medical student version (S-version) for medical students and the health profession (HP-version) for resident doctors.

The survey, conducted on paper, was distributed to medical students after a monthly assembly. For residents, it was handed out after a monthly seminar. An information sheet was accessible through a QR code integrated into the survey, and participants were urged to review it carefully before proceeding. An interpretation of the MPI and JSE scores was provided on the last page of the survey. A basket was provided at the room’s exit for participants to submit the questionnaires to ensure anonymity, and no personal identification data was collected.

Participants were given multiple-choice options for categorical variables. For example, they could specify their gender as male, female, or non-binary. For family relationships, they rated their satisfaction on a scale from 1 (least satisfied) to 10 (most satisfied). Participants filled in boxes with their answers for continuous variables, such as three digits for GPAX and seven for monthly income.

The Maudsley personality inventory

Developed by Eysenck in 1959, the MPI, also known as the Eysenck Personality Inventory (EPI), is extensively utilized in the United States and the United Kingdom and adapted versions in Germany and France [ 30 ]. Its Thai adaptation [ 31 ] comprises 48 items, with 24 items each assessing Extraversion-Introversion (scale-E) and Neuroticism-Stability (scale-N) with construct validity between 0.64 and 0.78 and reliability scores of 0.91 and 0.90, respectively. Scoring differentiates positive from negative questions, with “Yes” earning 2 or 0 points, “Not sure” earning 1 point, and “No” 0 or 2 points [ 31 ]. This study focuses exclusively on the Extraversion-Introversion scale to examine introversion. Introversion was classified for individuals with MPI scores in the 1st quartile, Ambiversion for those in the 2nd and 3rd quartiles, and Extroversion for those in the 4th quartile.

The Jefferson Scale of Empathy

The Jefferson Scale of Empathy is an assessment tool used to measure empathy levels within the medical field, developed by Dr. Hojat and colleagues in 2001 for medical students [ 14 ]. It was later adapted by physicians and medical personnel [ 9 ]. The JSE features 20 questions, answered on a 7-point Likert scale, ranging from 1 (strongly disagree) to 7 (strongly agree) [ 13 ]. The JSE has been validated and published in research for validity and reliability [ 32 ]. Furthermore, the Thai version of the Jefferson Scale of Physician Empathy has been developed, demonstrating its reliability with a score of 0.76 and has undergone appropriate content and construct validity testing [ 33 ]. The JSE levels were further classified, establishing low cutoff scores at ≤ 91 for males and ≤ 97 for females [ 34 ]. While high are categorized as ≥ 126 and ≥ 128 for males and females, respectively [ 34 ].

Specialty subgroups

The participants were asked to provide their preferred specialty or current specialty, and the specialties were categorized as follows: (1) Procedure-oriented specialties involving specialized procedures or laboratory research with primary colleague interaction in hospital settings and are patient-remote (e.g., radiology, pathology). (2) Technology-oriented specialties focus on specialized therapeutic techniques and expert consultancy, mainly hospital-based, with some relatively patient-oriented office work (e.g., orthopedic surgery, neurosurgery, ophthalmology). For the people-oriented groups, including (3) Non-primary care specialties, providing episodic or long-term care for specific medical issues, combining ambulatory and hospital-based practice (e.g., cardiology, nephrology, dermatology). (4) Primary care specialties offer initial health assessments, preventive education, and comprehensive care for various conditions, primarily in office settings (e.g., family medicine, internal medicine, pediatrics) [ 14 , 15 , 16 , 35 ].

Statistical analysis

All analyses were performed using StataCorp , 2021 , Stata Statistical Software: Release 17. College Station , TX: StataCorp LLC . The study subjects were described using a frequency distribution of demographic characteristics. Categorical data were presented as percentages. Continuous variables were presented as mean and standard deviation (SD) in the case of a normal distribution and median and interquartile range (IQR) in the case of a non-normal distribution. Family relationship satisfaction was categorized using a median score of 9 as the cutoff, with scores of 9 or 10 indicating above-median satisfaction and 8 or below indicating below-median satisfaction. Cronbach’s alpha was utilized to determine the internal consistency reliability, and the construct validity of relationship satisfaction was explored using exploratory factor analysis.

The relationship between the variables and JSE scores was analyzed using an independent t-test, ANOVA, and Chi-square as appropriate. Binary logistic regression analysis determined the odds ratio (OR) with 95%CI. Multivariable analysis was performed using logistic regression and linear regression analysis, and an adjusted odds ratio (AOR) and adjusted beta coefficient were presented. Linear regression was used to calculate preferred specialty- and sex-adjusted means, while logistic regression was applied to proportions to assess the statistical significance of linear and nonlinear trends. The presence of a nonlinear trend was initially evaluated by incorporating a quadratic term into the regression model. All statistical tests were two-sided; a P -value less than 0.05 was considered statistically significant. Although the final model was adjusted for potential confounders, the risk of residual confounding effects persists. Therefore, a sensitivity analysis was performed to address unmeasured confounding, employing E-values estimated by the e-value package (Supplementary Tables 1 and 2 ) [ 36 , 37 ]. The study utilized the ggplot2 package in R software, version 4.3.3, for visualization.

Characteristics of participants

The study involved 342 medical students and 178 residents, achieving response rates of 70.4% and 62.5%, respectively. Of the participants, 56.9% were male, and 2.5% identified as non-binary gender (Table 1 ). A majority (55.1%) of medical students preferred people-oriented specialties. Among the residents, 56.1% were people-oriented, 30.4% were technology-oriented, and 13.5% were procedure-oriented specialties. Over half of the participants (54.6%) had a GPAX above 3.5. The median monthly household income was 100,000 baht (IQR: 50,000-200,000). The average empathy score was 103.8 ± 15.0, with 27.1% classified in the lower empathy group. Moreover, Cronbach’s alpha of the JSE in the present study was 0.83, revealing good internal consistency reliability.

Trends of empathy across educational years

Figure 2 illustrates the declining trends in the specialty-adjusted and sex-and-specialty-adjusted means from second-year medical students to residents, stratified by sex. The adjusted mean peaks in the second year at 114.5 and stabilizes from the sixth year of medical study into residency, with values ranging between 93.3 and 97.7 ( P non−linear <0.001). Furthermore, this decreasing trend is consistent across sexes. Figure 3 presents the adjusted proportion of participants with low empathy levels, adjusting specialty and sex or specialty-adjusted. The adjusted prevalence of low empathy progressively increases, peaking in the final year of medical study, and shows a relative decrease among residents compared to six-year medical students ( P non−linear <0.001).

Preferred specialties- and sex-adjusted mean of empathy level across the educational years

Preferred specialties- and sex-adjusted proportion of low empathy level across the educational years

Relationship between characteristics, family relationships, and empathy

Tables 2 and 3 detail the relationship between participant characteristics, family relationships, and empathy. Cronbach’s alpha of the relationship ratings within the family is 0.88, revealing a good internal consistency reliability. The unidimensionality of the relationship questionnaire was confirmed (Eigenvalue component 1: Eigenvalue component 2 = 4.34:0.98). The Kaiser–Meyer–Olkin measure of sampling adequacy was applied, yielding an overall index of 0.78, indicating sufficient data for factor analysis. Additionally, Bartlett’s test for sphericity confirmed that the intercorrelation matrix was factorable (χ² = 2604.33, p < 0.001). The factor loadings ranged from 0.35 to 0.97, all exceeding the threshold of 0.30. Significant differences in empathy were observed across various factors, including sex, educational level, specialty preference, paternal education level, and perceived family relationships, both past and present.

Logistic regression analysis for the associations factors of low empathy level

Table 4 presents the logistic regression analysis results for factors associated with low empathy levels. The model adjusted for sex, educational level, specialty preference, GPAX, household income, current family relationship, and MPI extroversion-introversion personality scores. Factors associated with lower empathy include being a resident (AOR: 3.01, 95% CI: 1.46 to 6.18), preferring a procedure-oriented specialty (AOR: 4.16, 95% CI: 1.54 to 11.18), having a household income over 200,000 baht (AOR: 2.97, 95% CI: 1.09 to 8.10), and rating the current family relationship as 8 or below (AOR: 1.79, 95% CI: 1.05 to 3.03).

Subgroup analysis was conducted to identify factors associated with lower empathy levels among residents, as shown in Table 5 . Both procedure-oriented (AOR: 12.35, 95% CI: 3.08 to 49.57) and technology-oriented specialties (AOR: 2.93, 95% CI: 1.05 to 8.12) were linked to reduced empathy. Additionally, high GPAX scores above 3.5 (AOR: 3.46, 95% CI: 1.40 to 8.59) and rating family relationships as 8 or below (AOR: 3.70, 95% CI: 1.54 to 9.09) were associated with low empathy levels. However, household incomes over 200,000 baht were not significantly associated with low empathy in this analysis.

Linear regression analysis for the association factors with empathy level

Table 6 presents a multivariable linear regression analysis, indicating that being a non-binary gender (adjusted β = − 16.12, 95% CI: − 27.17 to − 5.07), a clinical student (adjusted β = − 4.76, 95% CI: − 8.80 to − 0.73), a resident (adjusted β = − 9.07, 95% CI: − 13.06 to − 5.07), and having a preference for procedure-oriented specialties (adjusted β = − 8.69, 95% CI: − 15.00 to − 2.39) are associated with lower empathy levels, consistent with findings from the logistic regression model. A subgroup analysis by educational level and specialty preference for the association between non-binary gender and empathy level is presented in Supplementary Table 3 .

This study successfully enrolled medical students and residents from a single-center medical college to investigate empathy trends across the professional continuum. After adjusting for specialty preferences and sex, we found that empathy scores were lowest in the final year of medical education and stabilized during residency. Additionally, factors such as residency status, preference for or current engagement in non-people-oriented specialties, high household income, poorer perception of family relationships, and a high GPAX among residents were associated with lower levels of empathy.

The average empathy score among medical students in this study was notably lower than those reported in other studies involving Thai medical students (110.1 ± 10.9 among pre-clinical students and 108.5 ± 11.5 among clinical students) and dental students (114.3 ± 13.1) [ 5 , 38 ]. In contrast, a study among nurse students in Thailand revealed that empathy scores are relatively lower (89.8 ± 14.7) than in the present study [ 39 ]. This may highlight differences in empathy levels between health professionals responsible for patient management (e.g., physicians and dentists) and nurses involved in basic medical procedures and caregiving. However, further study might be needed, as previous research done in the US showed similar empathy levels between nurses and physicians [ 40 ].

To our knowledge, research on empathy among residents in Thailand is limited, making direct comparisons difficult. Among residents in this study, the average empathy score was 99.4 ± 15.0, with 37.1% classified as having low empathy. In contrast, a nationwide survey of 824 residents in Japan found an average JSE score of 103.6, slightly higher than the scores found in our study [ 17 ]. This highlights the need to maintain empathy among both medical students and resident groups in the population. Furthermore, a nationwide study among medical students in the United States revealed a relatively high average JSE score of 116.5 ± 10.9. In contrast, a study among medical students in the United Kingdom reported a JSE score of approximately 81, indicating possible differences in empathy levels across cultures [ 32 , 41 ].

Consistent with prior research, our study observed a declining trend in empathy levels through the years of medical education [ 6 , 7 ]. A key strength of our study is the inclusion of participants from second-year medical students to second-year residents, facilitating comparison across these groups from a single center. Empathy levels were found to be lowest among sixth-year medical students, stabilizing thereafter in residents. This decline may be attributed to factors such as high workload, mistreatment, unsuitable learning environments, and stress, which are known to reduce empathy levels [ 7 ]. Particularly, sixth-year medical students face a challenging 4-month externship in hospitals under the Ministry of Public Health, where they encounter first-hand patient care with minimal supervision by physicians they are not familiar with. The inability to adapt to increased stress and workload, especially in hospitals with a higher patient-to-doctor ratio in different provinces, may contribute to this trend [ 42 ].

Overall, procedure-oriented specialties are associated with lower empathy levels. Subgroup analysis further revealed that both procedure- and technology-oriented specialties correlate with lower empathy levels among residents. These findings are consistent with prior research indicating lower empathy levels among individuals in non-people-oriented specialties [ 14 , 15 , 17 ]. Although individuals in procedure-oriented specialties may not frequently interact with patients, those in technology-oriented fields often engage in patient contact. This includes tasks such as delivering bad news, taking histories, and giving treatment, where empathy is crucial in enhancing patient care [ 1 ]. Hence, strategies are needed to increase empathy among individuals in technology-oriented specialties. For example, Iramaneerat et al. have reported that dialogue workshops can improve understanding and empathy among the first-year residents of this institute [ 43 ]. Nevertheless, the preservation of increased empathy may be a significant challenge.

A good family relationship was also important to a higher empathy level [ 14 , 15 ]. Parents may significantly influence their children’s empathy development by discussing emotions, rewarding caring behaviors, and modeling empathy [ 44 ]. However, higher-income families might exhibit lower empathy levels due to the independence wealth provides [ 45 ]. This independence can result in less concern for other’s feelings and a more self-centered outlook [ 45 ]. To counteract this, students could engage in empathetic leadership, genuinely connecting with and showing interest in others’ lives. This can be done by initiating a task for the student to ask employees about their lives and show genuine interest in their well-being. This might lead to increased empathy and a stronger emotional connection between students and faculty employees, leading to increased productivity and creativity [ 46 ].

A high GPAX was also associated with lower empathy among residents. The relationship between empathy and academic performance in medical students is complex and multifaceted. While some studies have identified a positive correlation between empathy and academic success, others have found no significant link [ 47 ]. This discrepancy may stem from the predominant focus on cognitive aspects among medical students, especially those with high grades [ 48 ]. In contrast, empathy is more closely aligned with soft skills in the affective domain, which are notably more challenging to assess [ 49 , 50 ]. Therefore, placing greater emphasis on assessing affective domains may contribute to the long-term maintenance of empathy among medical students.

Enhancing empathy in the medical curriculum can involve several strategies. This includes hands-on learning through workshops and sharing patient stories, along with precise teaching methods like “Invite, listen, and summarize” [ 51 ]. Integrating empathy improving class into the curriculum by integrating subjects like Health Systems Science with varied activities and challenges can also be effective [ 51 , 52 ]. It’s also important to reflect on these sessions afterward to process emotions and learn from them. Working together, students and staff can create relevant and engaging content [ 53 ]. Furthermore, emphasizing empathy as an intrinsic value, promoting cultural understanding and diverse interests, and teaching “deep acting” can cultivate authentic empathic connections [ 52 ]. Addressing any obstacles to empathy, especially in residency programs, is vital to prevent a decrease in empathy as students progress through their medical training.

Several factors associated with low empathy levels have been identified, but a constructive plan to address these factors is still lacking. Tavakol et al. have further reported that the barriers to empathy among medical students include a lack of role models, a high workload, and an emphasis on cognitive assessment in the medical curriculum [ 48 ]. Additionally, any plan to improve empathy should be customized to the specific context of each university. For behavioral change to occur, learners must be motivated and hold positive attitudes toward the desired change, recognizing its significant benefits [ 54 , 55 ]. Behavioral theories emphasize the importance of a strong sense of belonging and autonomy for learners to adopt sustainable changes. Thus, strategy development should involve learners in co-creation processes [ 53 ].

The present study faced several limitations. First, it exclusively targeted medical students and residents from PCM and PMK, potentially limiting the generalizability of its findings to other medical colleges with different curricula. Second, the cross-sectional design precludes the determination of causality, and the paper-based data collection may result in some missing data, leading to the final regression model accounting for 332 (63.85%) participants. This may introduce potential volunteer bias. Nevertheless, the number of participants in the final model still exceeds the calculated sample size of 254. Third, the study did not account for other possible confounding factors, such as stress, anxiety, and burnout. Despite these limitations, a sensitivity analysis for unmeasured confounders demonstrated a relatively high E-value, suggesting a robust association between the variables of interest and empathy levels, as detailed in Supplementary Tables 1 and 2 . Fourth, the ratings of family relationships are simplistic and may not fully capture the complexities of family function. Thus, further research might be needed to verify the association between family function and empathy. Fifth, the present questionnaire is subjective and self-perceived, which may lead to potential inaccuracies [ 56 ]. However, self-perception and self-awareness could also affect empathy, which is worth exploring [ 57 ].

Finally, the relatively low number of non-binary gender participants may lead to inconclusive findings regarding the relationship between non-binary gender and low empathy levels. To the best of our knowledge, data on this relationship is limited. Additionally, the results of the subgroup analyses may reflect the small sample size rather than the actual effect of an effect modifier. Moreover, the prevalence of non-binary individuals may be underestimated, and interpretations should be made with caution, given that non-binary participants in the present study accounted for only 13 individuals (2.5%), whereas a survey in Thailand suggests that non-binary individuals might comprise up to 9% of the population [ 58 , 59 ]. This discrepancy highlights the potential for an inconclusive relationship and underestimates the true prevalence. This limitation underscores the necessity for further quantitative and qualitative research to validate the present study’s findings externally.

The present study successfully enrolled medical students and residents from a single institute, providing valuable insights into factors associated with low empathy. These include residency status, preference for non-people-oriented specialties, high household income, poorer family relationships, and a higher GPAX among residents. Despite non-binary individuals showing relatively lower empathy compared to binary genders, the small sample size and possible underestimation render this finding inconclusive, requiring further studies for confirmation. Additionally, empathy scores were lowest among sixth-year medical students. To address these factors, further planning should involve collaboration between students and teachers to maintain a high level of empathy throughout the medical curriculum.

Data availability

The datasets used and/or analyzed during the current study are available from the author upon reasonable request (contact Sethapong Lertsakulbunlue via [email protected]).

Abbreviations

Cumulative grade point average

Jefferson Scale of Empathy

Maudsley Personality Inventory

Phramongkutklao College of Medicine

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Acknowledgements

We express our gratitude to the Phramongkutklao College of Medicine and its esteemed academic leaders, whose active support was vital for completing this work. Their names are too numerous to mention individually, but their involvement was instrumental in making this project possible. We express our gratitude to Asst. Prof. Somsong Suwanlert and Ms. Supavadee Nuanmanee, President of The Thai Clinical Psychologist Association, thank you for allowing us to use the Thai version of the Maudsley Personality Inventory.

The author(s) reported funding from the Phramongkutklao College of Medicine.

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Sethapong Lertsakulbunlue and Chutipon Kiatsrithanakorn contributed equally to this work.

Authors and Affiliations

Department of Pharmacology, Phramongkutklao College of Medicine, Bangkok, 10400, Thailand

Sethapong Lertsakulbunlue & Anupong Kantiwong

Phramongkutklao College of Medicine, Bangkok, 10400, Thailand

Chutipon Kiatsrithanakorn, Pinyada Kittisarapong, Varathpavee Bhuriveth & Vittavat Tangdumrongvong

Department of Personnel Administration Division, Phramongkutklao College of Medicine, Bangkok, 10400, Thailand

Kaophiphat Thammasoon

Department of Physiology, Phramongkutklao College of Medicine, Bangkok, 10400, Thailand

Sarut Puengpreeda & Chitrawina Mahagita

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The concept for the study was developed by SL, CK, PK, KT, SP, VB, VT, AK and CM. SL, CK, PK, KT, VB, VT and CM collected the data, SL and AK analyzed the data, and SL, CK and PK wrote the first draft. All authors contributed and approved the final version.

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Correspondence to Chitrawina Mahagita .

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This study was approved by the Medical Department Ethics Review Committee for Research in Human Subjects, Institutional Review Board, Royal Thai Army (RTA) (Approval no. S024q/66), following international guidelines such as the Declaration of Helsinki, the Belmont Report, CIOMS Guidelines, and the International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use - Good Clinical Practice. Informed consent was obtained from all subjects with permission from the Institutional Review Board, RTA Medical Department.

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Lertsakulbunlue, S., Kiatsrithanakorn, C., Kittisarapong, P. et al. Declining empathy trends throughout medical curriculum and association factors of low empathy among medical students and residents: a single center study. BMC Med Educ 24 , 951 (2024). https://doi.org/10.1186/s12909-024-05962-6

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DOI : https://doi.org/10.1186/s12909-024-05962-6

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A 25-Year Study Reveals How Empathy is Passed from Generation to Generation

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Our new research shows that parents who express empathy toward their teenagers may give teens a head start in developing the skill themselves. In addition, adolescents who show empathy and support toward their friends are more likely to become supportive parents, which may foster empathy in their own offspring.

How we did our work

The KLIFF/VIDA study at the University of Virginia has tracked 184 adolescents for more than 25 years: from age 13 well into their 30s.

Starting in 1998, teens came to the university every year with their parents and closest friend, and a team of researchers recorded videos of their conversations. Researchers observed how much empathy the mother showed to her 13-year-old when her teen needed help with a problem. We measured empathy by rating how present and engaged mothers were in the conversation, whether they had an accurate understanding of their teen’s problem, and how much help and emotional support they offered.

Then, each year until teens were 19 years old, we observed whether teens showed those same types of empathic behaviors toward their close friends .

A decade later, when some of those same teens were starting to have children of their own, we surveyed them about their own parenting. We also asked them about their young children’s empathy. For example, parents rated how often their child “tries to understand how others feel” and “tries to comfort others.”

We found that the more empathic a mother was toward her teenager at age 13, the more empathic the teen was toward their close friends across the adolescent years. Among teens who later had kids themselves, the ones who had shown more empathy for close friends as adolescents became more supportive parents as adults. In turn, these parents’ supportive responses to their children’s distress were associated with reports of their young children’s empathy.

Why it matters

The ability to empathize with other people in adolescence is a critical skill for maintaining good relationships , resolving conflict , preventing violent crime and having good communication skills and more satisfying relationships as an adult .

Adults want teens to develop good social skills and moral character, but simply telling them to be kind doesn’t always work. Our findings suggest that if parents hope to raise empathic teens, it may be helpful to give them firsthand experiences of being understood and supported.

But teens also need opportunities to practice and refine these skills with their peers. Adolescent friendships may be an essential “training ground” for teens to learn social skills such as empathy, how to respond effectively to other people’s suffering, and supportive caregiving abilities that they can put to use as parents. Our lab’s most recent paper presents some of the first evidence that having supportive teenage friendships matters for future parenting.

What’s next

We’re continuing to follow these participants to understand how their experiences with parents and peers during adolescence might play a role in how the next generation develops. We’re also curious to understand what factors might interrupt intergenerational cycles of low empathy, aggression and harsh parenting. For example, it’s possible that having supportive friends could compensate for a lack of empathy experienced from one’s family.

While it’s true that you can’t choose your family, you can choose your friends. Empowering teens to choose friendships characterized by mutual understanding and support could have long-term ripple effects for the next generation.

This article is republished from The Conversation under a Creative Commons license. Read the original article .

Jessica A. Stern is a research scientist of psychology at The University of Virginia

Joseph P. Allen is a professor of psychology at The University of Virginia

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Meditation and Mindfulness: Effectiveness and Safety

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} What are meditation and mindfulness?

Meditation has a history that goes back thousands of years, and many meditative techniques began in Eastern traditions. The term “meditation” refers to a variety of practices that focus on mind and body integration and are used to calm the mind and enhance overall well-being. Some types of meditation involve maintaining mental focus on a particular sensation, such as breathing, a sound, a visual image, or a mantra, which is a repeated word or phrase. Other forms of meditation include the practice of mindfulness, which involves maintaining attention or awareness on the present moment without making judgments.

Programs that teach meditation or mindfulness may combine the practices with other activities. For example, mindfulness-based stress reduction is a program that teaches mindful meditation, but it also includes discussion sessions and other strategies to help people apply what they have learned to stressful experiences. Mindfulness-based cognitive therapy integrates mindfulness practices with aspects of cognitive behavioral therapy.

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Meditation and mindfulness practices usually are considered to have few risks. However, few studies have examined these practices for potentially harmful effects, so it isn’t possible to make definite statements about safety.

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} More

A 2020 review examined 83 studies (a total of 6,703 participants) and found that 55 of those studies reported negative experiences related to meditation practices. The researchers concluded that about 8 percent of participants had a negative effect from practicing meditation, which is similar to the percentage reported for psychological therapies. The most commonly reported negative effects were anxiety and depression. In an analysis limited to 3 studies (521 participants) of mindfulness-based stress reduction programs, investigators found that the mindfulness practices were not more harmful than receiving no treatment.

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} How popular are meditation and mindfulness?

According to the National Health Interview Survey, an annual nationally representative survey, the percentage of U.S. adults who practiced meditation more than doubled between 2002 and 2022, from 7.5 to 17.3 percent. Of seven complementary health approaches for which data were collected in the 2022 survey, meditation was the most popular, beating out yoga (used by 15.8 percent of adults), chiropractic care (11.0 percent), massage therapy (10.9 percent), guided imagery/progressive muscle relaxation (6.4 percent), acupuncture (2.2 percent), and naturopathy (1.3 percent).

For children aged 4 to 17 years, data are available for 2017; in that year, 5.4 percent of U.S. children used meditation.

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In a 2012 U.S. survey, 1.9 percent of 34,525 adults reported that they had practiced mindfulness meditation in the past 12 months. Among those responders who practiced mindfulness meditation exclusively, 73 percent reported that they meditated for their general wellness and to prevent diseases, and most of them (approximately 92 percent) reported that they meditated to relax or reduce stress. In more than half of the responses, a desire for better sleep was a reason for practicing mindfulness meditation.

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Meditation and mindfulness practices may have a variety of health benefits and may help people improve the quality of their lives. Recent studies have investigated if meditation or mindfulness helps people manage anxiety, stress, depression, pain, or symptoms related to withdrawal from nicotine, alcohol, or opioids.

Other studies have looked at the effects of meditation or mindfulness on weight control or sleep quality.

However, much of the research on these topics has been preliminary or not scientifically rigorous. Because the studies examined many different types of meditation and mindfulness practices, and the effects of those practices are hard to measure, results from the studies have been difficult to analyze and may have been interpreted too optimistically.

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A 2018 NCCIH-supported analysis of 142 groups of participants with diagnosed psychiatric disorders such as anxiety or depression examined mindfulness meditation approaches compared with no treatment and with established evidence-based treatments such as cognitive behavioral therapy and antidepressant medications. The analysis included more than 12,000 participants, and the researchers found that for treating anxiety and depression, mindfulness-based approaches were better than no treatment at all, and they worked as well as the evidence-based therapies.
A 2021 analysis of 23 studies (1,815 participants) examined mindfulness-based practices used as treatment for adults with diagnosed anxiety disorders. The studies included in the analysis compared the mindfulness-based interventions (alone or in combination with usual treatments) with other treatments such cognitive behavioral therapy, psychoeducation, and relaxation. The analysis showed mixed results for the short-term effectiveness of the different mindfulness-based approaches. Overall, they were more effective than the usual treatments at reducing the severity of anxiety and depression symptoms, but only some types of mindfulness approaches were as effective as cognitive behavioral therapy. However, these results should be interpreted with caution because the risk of bias for all of the studies was unclear. Also, the few studies that followed up with participants for periods longer than 2 months found no long-term effects of the mindfulness-based practices.
A 2019 analysis of 23 studies that included a total of 1,373 college and university students looked at the effects of yoga, mindfulness, and meditation practices on symptoms of stress, anxiety, and depression. Although the results showed that all the practices had some effect, most of the studies included in the review were of poor quality and had a high risk of bias.

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Few high-quality studies have examined the effects of meditation and mindfulness on blood pressure. According to a 2017 statement from the American Heart Association, the practice of meditation may have a possible benefit, but its specific effects on blood pressure have not been determined.

A 2020 review of 14 studies (including more than 1,100 participants) examined the effects of mindfulness practices on the blood pressure of people who had health conditions such as hypertension, diabetes, or cancer. The analysis showed that for people with these health conditions, practicing mindfulness-based stress reduction was associated with a significant reduction in blood pressure.

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Studies examining the effects of mindfulness or meditation on acute and chronic pain have produced mixed results.

A 2020 report by the Agency for Healthcare Research and Quality concluded that mindfulness-based stress reduction was associated with short-term (less than 6 months) improvement in low-back pain but not fibromyalgia pain.
A 2020 NCCIH-supported analysis of five studies of adults using opioids for acute or chronic pain (with a total of 514 participants) found that meditation practices were strongly associated with pain reduction.
Acute pain, such as pain from surgery, traumatic injuries, or childbirth, occurs suddenly and lasts only a short time. A 2020 analysis of 19 studies examined the effects of mindfulness-based therapies for acute pain and found no evidence of reduced pain severity. However, the same analysis found some evidence that the therapies could improve a person’s tolerance for pain.
A 2017 analysis of 30 studies (2,561 participants) found that mindfulness meditation was more effective at decreasing chronic pain than several other forms of treatment. However, the studies examined were of low quality.
A 2019 comparison of treatments for chronic pain did an overall analysis of 11 studies (697 participants) that evaluated cognitive behavioral therapy, which is the usual psychological intervention for chronic pain; 4 studies (280 participants) that evaluated mindfulness-based stress reduction; and 1 study (341 participants) of both therapies. The comparison found that both approaches were more effective at reducing pain intensity than no treatment, but there was no evidence of any important difference between the two approaches.
A 2019 review found that mindfulness-based approaches did not reduce the frequency, length, or pain intensity of headaches. However, the authors of this review noted that their results are likely imprecise because only five studies (a total of 185 participants) were included in the analysis, and any conclusions made from the analysis should be considered preliminary.

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Mindfulness meditation practices may help reduce insomnia and improve sleep quality.

A 2019 analysis of 18 studies (1,654 total participants) found that mindfulness meditation practices improved sleep quality more than education-based treatments. However, the effects of mindfulness meditation approaches on sleep quality were no different than those of evidence-based treatments such as cognitive behavioral therapy and exercise.

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Several clinical trials have investigated if mindfulness-based approaches such as mindfulness-based relapse prevention (MBRP) might help people recover from substance use disorders. These approaches have been used to help people increase their awareness of the thoughts and feelings that trigger cravings and learn ways to reduce their automatic reactions to those cravings.

A 2018 review of 37 studies (3,531 total participants) evaluated the effectiveness of several mindfulness-based approaches to substance use disorder treatment and found that they significantly decreased participants’ craving levels. The mindfulness-based practices were slightly better than other therapies at promoting abstinence from substance use.
A 2017 analysis specifically focused on MBRP examined 9 studies (901 total participants) of this approach. The analysis concluded that MBRP was not more effective at preventing substance use relapses than other treatments such as health education and cognitive behavioral therapy. However, MBRP did slightly reduce cravings and symptoms of withdrawal associated with alcohol use disorders.

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Studies have suggested that meditation and mindfulness may help reduce symptoms of post-traumatic stress disorder (PTSD).

A 2018 review supported by NCCIH examined the effects of meditation (in 2 studies, 179 total participants) and other mindfulness-based practices (in 6 studies, 332 total participants) on symptoms of PTSD. Study participants included veterans, nurses, and people who experienced interpersonal violence. Six of the eight studies reported that participants had a reduction of PTSD symptoms after receiving some form of mindfulness-based treatment.
A 2018 clinical trial funded by the U.S. Department of Defense compared the effectiveness of meditation, health education, and prolonged exposure therapy, a widely accepted treatment for PTSD recommended by the American Psychological Association. Prolonged exposure therapy helps people reduce their PTSD symptoms by teaching them to gradually remember traumatic memories, feelings, and situations. The study included 203 veterans with PTSD as a result of their active military service. The results of the study showed that meditation was as effective as prolonged exposure therapy at reducing PTSD symptoms and depression, and it was more effective than PTSD health education. The veterans who used meditation also showed improvement in mood and overall quality of life.

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Mindfulness-based approaches may improve the mental health of people with cancer.

A 2019 analysis of 29 studies (3,274 total participants) of mindfulness-based practices showed that use of mindfulness practices among people with cancer significantly reduced psychological distress, fatigue, sleep disturbance, pain, and symptoms of anxiety and depression. However, most of the participants were women with breast cancer, so the effects may not be similar for other populations or other types of cancer.

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Studies have suggested possible benefits of meditation and mindfulness programs for losing weight and managing eating behaviors.

A 2017 review of 15 studies (560 total participants) looked at the effects of mindfulness-based practices on the mental and physical health of adults with obesity or who were overweight. The review found that these practices were very effective methods for managing eating behaviors but less effective at helping people lose weight. Mindfulness-based approaches also helped participants manage symptoms of anxiety and depression.
A 2018 analysis of 19 studies (1,160 total participants) found that mindfulness programs helped people lose weight and manage eating-related behaviors such as binge, emotional, and restrained eating. The results of the analysis showed that treatment programs, such as mindfulness-based stress reduction and mindfulness-based cognitive therapy, that combine formal meditation and mindfulness practices with informal mindfulness exercises were especially effective methods for losing weight and managing eating.

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Several studies have been done on using meditation and mindfulness practices to improve symptoms of attention-deficit hyperactivity disorder (ADHD). However, the studies have not been of high quality and the results have been mixed, so evidence that meditation or mindfulness approaches will help people manage symptoms of ADHD is not conclusive.

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Some research suggests that meditation and mindfulness practices may affect the functioning or structure of the brain. Studies have used various methods of measuring brain activity to look for measurable differences in the brains of people engaged in mindfulness-based practices. Other studies have theorized that training in meditation and mindfulness practices can change brain activity. However, the results of these studies are difficult to interpret, and the practical implications are not clear.

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NCCIH supports a variety of meditation and mindfulness studies, including:

An evaluation of how the brain responds to the use of mindfulness meditation as part of a combined treatment for migraine pain.
A study of the effectiveness of mindfulness therapy and medication (buprenorphine) as a treatment for opioid use disorder.
A study of a mindfulness training program designed to help law enforcement officers improve their mental health by managing stress and increasing resilience.

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Don’t use meditation or mindfulness to replace conventional care or as a reason to postpone seeing a health care provider about a medical problem.
Ask about the training and experience of the instructor of the meditation or mindfulness practice you are considering.
Take charge of your health—talk with your health care providers about any complementary health approaches you use. Together, you can make shared, well-informed decisions

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Nccih clearinghouse.

The NCCIH Clearinghouse provides information on NCCIH and complementary and integrative health approaches, including publications and searches of Federal databases of scientific and medical literature. The Clearinghouse does not provide medical advice, treatment recommendations, or referrals to practitioners.

Toll-free in the U.S.: 1-888-644-6226

Telecommunications relay service (TRS): 7-1-1

Website: https://www.nccih.nih.gov

Email: [email protected] (link sends email)

Know the Science

NCCIH and the National Institutes of Health (NIH) provide tools to help you understand the basics and terminology of scientific research so you can make well-informed decisions about your health. Know the Science features a variety of materials, including interactive modules, quizzes, and videos, as well as links to informative content from Federal resources designed to help consumers make sense of health information.

Explaining How Research Works (NIH)

Know the Science: How To Make Sense of a Scientific Journal Article

Understanding Clinical Studies (NIH)

A service of the National Library of Medicine, PubMed® contains publication information and (in most cases) brief summaries of articles from scientific and medical journals. For guidance from NCCIH on using PubMed, see How To Find Information About Complementary Health Approaches on PubMed .

Website: https://pubmed.ncbi.nlm.nih.gov/

NIH Clinical Research Trials and You

The National Institutes of Health (NIH) has created a website, NIH Clinical Research Trials and You, to help people learn about clinical trials, why they matter, and how to participate. The site includes questions and answers about clinical trials, guidance on how to find clinical trials through ClinicalTrials.gov and other resources, and stories about the personal experiences of clinical trial participants. Clinical trials are necessary to find better ways to prevent, diagnose, and treat diseases.

Website: https://www.nih.gov/health-information/nih-clinical-research-trials-you

Research Portfolio Online Reporting Tools Expenditures & Results (RePORTER)

RePORTER is a database of information on federally funded scientific and medical research projects being conducted at research institutions.

Website: https://reporter.nih.gov

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Anheyer D, Leach MJ, Klose P, et al. Mindfulness-based stress reduction for treating chronic headache: a systematic review and meta-analysis . Cephalalgia . 2019;39(4):544-555.
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Acknowledgments

Thanks to Elizabeth Ginexi, Ph.D., Erin Burke Quinlan, Ph.D., and David Shurtleff, Ph.D., NCCIH, for their review of this 2022 publication.

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Preventing White supremacy: an applied conceptualization for the helping professions

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Published: 01 September 2024
Volume 2 , article number 52 , ( 2024 )

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Loran Grishow-Schade ORCID: orcid.org/0009-0003-6246-1195 1

This perspective paper synthesizes insights from social work research, Critical Race Theory (CRT), and Critical Whiteness Studies (CWS) to develop a strategy for preventing White supremacy and promoting racial justice. It examines the intricate feelings of White guilt and shame, advocating for introspection, comprehension, and active engagement by White individuals toward systemic reform. The paper underscores CRT principles like Interest Convergence and Critique of Liberalism to examine concepts such as Moral Injury, Perpetration-Induced Traumatic Stress, and White Shame Culture. Three main obstacles to racial justice are identified: perceptions of power, funding dynamics, and attitudes toward White identity. The paper argues that racial healing should not be solely the responsibility of people of color, emphasizing the crucial role of White people in anti-racism work within supportive settings that foster growth rather than stress and humiliation. Focusing on prevention, the paper argues for social work practices that eliminate conditions obstructing optimal social functioning while challenging oppressive systems. This includes implementing trauma-informed approaches and fostering group work centered on empathy, relationship-building, and reflection. Advocating a strategy that champions our collective liberation, it suggests social work praxis as central to applying interpersonal and group solutions to systemic racism. The paper stresses the need for preventative funding in social services—highlighting tangible action steps and reforming funding strategies to support long-term engagement and address root causes of marginalization and oppression. This integral strategy calls for a collective push toward an equitable society, significantly enriching the discourse on CRT and CWS within social work.

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The foundations of Critical Whiteness Studies (CWS), an interdisciplinary field—were laid in the previous century through the works of eminent thinkers such as W.E.B. Du Bois [ 1 ], James Baldwin [ 2 ], Zora Neal Hurston [ 3 ], Gloria Anzaldúa [ 4 ], and Vine Deloria Jr. [ 5 ] among others. These authors challenged 'Whiteness' as an unseen status quo, emphasizing its recognition to dismantle racialized oppression. CWS, a product of Critical Race Theory (CRT), builds on the work of these influential thinkers and scrutinizes White culture and its role in perpetuating systems of White supremacy, emphasizing the need to explore the thoughts, feelings, and behaviors of White people [ 6 ].

Recent scholars have applied CWS principles specifically to social work. Scholars such as Nylund [ 7 ], Jeyasingham [ 8 ], and Hafen [ 9 ] have shown how entrenched White perspectives in social work hinder social justice. Their work advocates for deeper analysis of Whiteness and Whitenormativity, formal anti-racism education, and encourages White social workers to confront White supremacy culture. These studies highlight the importance of incorporating CWS into social work to combat systemic racism.

As social work strives to stay relevant and adaptive, by integrating CWS into our knowledge, skills, and abilities, as our sibling fields of psychology [ 10 ] and education [ 11 ] began more explicitly over a decade ago, we can advance our understanding of how to prevent White supremacy. This paper explores key barriers—how we think about power, funding, and attitudes toward race and racism among White practitioners—that hinder the adoption of CWS in North American social work.

The predominantly White (68.8%) and politically liberal (55%) social work field in the US presents a unique backdrop for exploring its racist history and White supremacy [ 12 , 13 , 14 , 15 ]. This demographic implies a majority of White liberals, grouped under the term “liberal” for this paper.

Social work has a long-standing history of racism, acknowledged and apologized for by the National Association of Social Workers (NASW) in a 2021 press release [ 16 ]. CRT shows racism is entrenched in societal structures and daily interactions, often unnoticed by those with privilege [ 17 ]. CRT redefines racism as systemic inequities, not just isolated acts of discrimination. CRT and the Racial Contract expose the historical roots of racism within societal norms, perpetuating systemic inequities [ 18 ]. CRT calls for deconstructing racial categories and confronting systemic injustices for significant change. Social work’s connection to White supremacy has been examined through CRT [ 19 , 20 , 21 ]. However, the reluctant adoption of CWS in social work raises questions, given the critical role of race and racism in the US. This situation suggests a deeper issue.

1 Positionality

In social work research, acknowledging our 'positionality'—our unique perspective shaped by personal experiences—is crucial [ 22 ]. This self-awareness helps us manage biases and understand how our backgrounds influence our research. Holding a license in social work and being a White, non-binary, queer, neurodivergent, HIV-positive millennial renting in a mid-Atlantic city while juggling three jobs and a marketplace insurance plan distinctly influences my approach to social work. As a White social worker, I use “we,” “us,” and “our” pronouns when discussing White social workers to avoid any real or perceived allusions to expertise, elitism, or an us-versus-them mentality.

In this paper, “Whiteness” is shorthand for White Culture. In the tradition of queer and feminist theories, which critiques the normalization of heterosexuality and cisgender identities through the study of heteronormativity and cisnormativity, I find “Whitenormativity” to be more precise, parallel, and streamlined to other social movements pointed toward our collective liberation from systems of oppression.

This paper speaks specifically to White practitioners, acknowledging our shared experience. In the context of the social construction of Whiteness, I find myself having this conversation with a diverse spectrum of people who have internalized this experience. This includes those who are biologically White and those who are culturally White—people who are often mis/read as biologically White. We are all part of this conversation, seeking healing and understanding. “White people” refers to individuals who are biologically or culturally White.

Lastly, I employ the term "collective liberation" instead of "anti-racism" as our end goal because it highlights that everyone's freedom is interconnected. "Collective liberation" addresses not just racism, but also other forms of oppression like sexism and classism. This term helps readers understand that dismantling White supremacy benefits the entire community, emphasizing solidarity and the well-being of all.

3 The (myth of a) White monolith

CWS critiques and examines the dynamics of race, Whiteness, and Whitenormativity [ 23 ]. These concepts can be large and opaque, so let us start by remembering that race and Whiteness do not exist in a social vacuum. Our relationships with gender, class, ability, sexuality, religion, immigration status, and age impact our relationship to race. As Lorde said, “There is no such thing as a single-issue struggle because we do not live single-issue lives” [ 24 ].

Generalizations about White people fail to honor the diverse White experience. We must consider the spectrum of identities that exist simultaneously to being raced: we are gendered, aged, classed, sexed, abled, and our ethnicities determined. Our social positioning may simultaneously grant us social privileges and disadvantages. A single father on welfare in Elko, Nevada, who is White, has a different—better and worse—social experience than a mother with an au pair in Baldwin Hills, California, who is Black. Socially, we have a range of experiences within races. Being White is no different.

For example, within the White community, there is significant diversity in terms of ethnicity and experiences. Recognizing this diversity is crucial for a nuanced discussion on race and Whiteness. Nearly two-thirds of Romani Americans report feeling discriminated against due to their heritage, with close to 80% agreeing that Americans treat Roma people differently from other minority groups [ 25 ]. Similarly, Jewish people face ongoing challenges, particularly due to the current conflict in Palestine, impacting perceptions and experiences of discrimination globally [ 26 ]. These examples underscore the importance of recognizing the diverse and intersectional experiences within the White community, emphasizing the need for a nuanced discussion on race and Whiteness in social work.

Now we have a shared language and context; let’s dive in.

4 Critical Race Theory

Critical Race Theory (CRT) emerged from students of color at Ivy League institutions in the 1970s and '80s [ 27 ]. It aimed to challenge entrenched White supremacist narratives in academia and the legal field. Delgado and Stefancic identified its core principles: Interest Convergence, Revisionist History, Critiquing Liberalism, and Structural Determinism [ 28 ].

4.1 Core principles of CRT

Interest Convergence : Civil rights gains for communities of color often align with White self-interest. This challenges the idea that progress is purely driven by altruism.

Revisionist History : CRT reexamines America’s history, challenging majoritarian views and presenting marginalized perspectives.

Critique of Liberalism : Critical race theorists argue that liberal concepts like color blindness and neutral constitutional principles fail to address systemic racial issues.

Structural Determinism : The idea that the societal structure and its inherent vocabulary are fundamentally ill-equipped to redress certain systemic wrongs.

This paper will focus on the principles of Interest Convergence and Critique of Liberalism. Future research should explore White social workers' relationship with Revisionist History and Structural Determinism.

4.2 Focus on interest convergence

Introduced by Derrick Bell in 1980, Interest Convergence examines power dynamics and the limitations of zero-sum thinking in racial equity and justice [ 29 ]. There are many examples, and history is more complex than a summary can capture:

During the Civil War, President Abraham Lincoln issued the Emancipation Proclamation, which freed enslaved people in the Confederacy. This act was not only driven by moral considerations but also by the Union's strategic interests in undermining the Confederate war effort and bolstering its own military forces [ 29 ].

The US Civil Rights Act of 1964 was influenced by the emotional impact of President Kennedy's assassination, generating sympathy among White Americans and a shared interest in honoring his legacy by ending discrimination [ 30 ].

In Canada, establishing the Royal Commission on Aboriginal Peoples (RCAP) following the Oka Crisis in 1990 demonstrates Interest Convergence [ 31 ]. The federal government's interests in political stability and maintaining its international human rights image aligned with and benefited from Indigenous demands for recognition and justice.

Understanding how White interests intersect with those of minoritized racial groups is key to advancing collective liberation. This shared liberation comes from meeting the interests of White people with Indigenous, Black, Latin@, and Asian populations. We must do both; we cannot do either/or. We must not de-center but co-center. This argument relies on resolving contradictions like de-centering White people in CRT and how our approaches can create reinforce White supremacy [ 32 ]. This leads us to examine the ideologies guiding our understanding of racial dynamics and their impact on professional practices.

4.3 Zero-Sum ideologies and its implications

In understanding equality and justice, we encounter the zero-sum paradigm of social progress. In economic or game theory, a zero-sum scenario is where one participant's gain or loss is balanced by the other's. Both groups cannot win. Both participants cannot lose: a competition. In discussions on racism and equality, a zero-sum viewpoint implies that advancements for marginalized groups result in losses for the dominant group. For example, opportunities for people of color through affirmative action or fair hiring practices are seen as reducing opportunities for White individuals. With limited resources or one job posting, there can be only one “winner,” making everyone else a “loser.”

In social work, zero-sum thinking is often applied to power. Abrams defines power as the ability to acquire what one needs and persuade others to help; essentially, it revolves around winning [ 33 ]. Discussions on power frequently suggest that it must be "taken" [ 34 ] or taken "away from" [ 35 ] dominant populations (re: White, straight, able, men)—and redistributed [ 36 ]—implying that non-dominant populations (re: people of color, queer, disabled, women and gender nonconforming, nonbinary, and trans people) cannot persuade others to assist them in securing what they need. This binary model fosters a harmful either/or mindset: one either has power or does not.

Seeing power as socially constructed allows us to view it as expandable and shareable. Community organizing and coalition-building can create new, collaborative forms of power, promoting social justice for all. Interest Convergence shows that aligning the interests of dominant and marginalized groups can expand and equitably distribute power. This framework challenges zero-sum thinking by showing that progress for marginalized groups does not come at the expense of dominant groups.

Because of the perils of the illusory truth effect—where we begin to believe false information is correct merely because it is repeated—we can start to construct a reality of power that portrays social justice as a competition. This method maintains social inequity by competing for power, bypassing the need for collaboration or communal power [ 33 , 37 ]. We neglect the tools and trainings—power mapping, community organizing, strategic alliances and partnerships, social media campaigns, narrative and framing techniques, crowdfunding and resource mobilization, volunteer networks, digital advocacy, grassroots lobbying, and coalition building—that instruct us on how to achieve this, which demonstrate the evidence and legacy of how to build power out of nothing [ 38 , 39 , 40 ]. We forfeit power by adopting a scarcity mindset, overlooking our social work education.

4.5 Zero-sum implications

For example, many White liberal social workers adhere to biological essentialism, which asserts that racial identities dictate behaviors and capabilities [ 41 ]. This philosophy suggests White individuals are inherently racist and are therefore intrinsically incapable of addressing race and racism. This makes change or justice seem unattainable [ 42 , 43 , 44 ]. White people will always win: zero-sum. Such a stance not only simplifies complex racial dynamics but also ignores the diversity within White communities. Casting racial dynamics as a rigid power battle, where White people monopolize authority, cultivates zero-sum ideologies. This view ignores Interest Convergence and sees power as a limited resource to be reallocated, rather than a socially constructed concept that can be expanded and equitably distributed.

4.6 Misconceptions

Table 1 catalogs how zero-sum thinking and distorted views of power have created a wide array of biases, assumptions, and misconceptions within anti-racism work. It shows us how far we have strayed from recognizing the power of Interest Convergence to creating social change.

The Table begins with the prevalent assumption (#1) that all White individuals are inherently racist or uniformly benefit from racial privilege. This view ignores individual complexities like socioeconomic status, education, and personal values. Additionally, it challenges the way of thinking (#2) that White people cannot comprehend or tackle racism by ourselves, highlighting the significance of both individual efforts and collective action in addressing racism. The table also draws attention to the diversity within White communities, revealing a wide spectrum of (#4) awareness and engagement with racial issues. It demonstrates that White individuals can make significant contributions to collective liberation efforts (#5), countering the myth of our ineffectiveness or non-involvement. By questioning the assumption that White people are excluded from responsibility (#3) and the one-directional impact of racism (#7), Table 1 advocates for the possibility of change and fluid power dynamics inherent in CRT’s social construction thesis [ 27 ].

Table 1 examines misconceptions about White individuals and clarifies how these perceptions impact social workers' actions and inactions. By adhering to the flawed zero-sum paradigm, we overly focus on interventions, often neglecting a holistic approach to prevent White supremacy.

4.7 Reverse racism

For many White people, zero-sum thinking aligns with 'reverse racism'—power being taken from and redistributed from White people [ 42 , 43 , 56 , 57 ]. Many scholars in the helping professions maintain that reverse racism does not—and cannot—exist. This stance is supported by key arguments: (1) reverse racism misunderstands discrimination and racism, (2) ignores historical context and power dynamics, (3) misinterprets discrimination dynamics, (4) denies racial privileges, (5) misunderstands affirmative action, and (6) neglects evidence of White advantages. [ 58 , 59 ].

However, a 2017 report revealed that 55% of White respondents believed that racism against White people exists [ 60 ]. In 2020, data from FiveThirtyEight showed that 73% of Republicans, 38% of independents, and 22% of Democrats shared this belief [ 61 ]. Public figures like Elon Musk and Scott Adams have propagated these narratives, indicating growing acceptance of reverse racism among White individuals [ 62 ]. This data shows an interest by White people to acknowledge racism against White people in contemporary American culture despite the key arguments that maintain it cannot exist.

While some White people fear that systemic racism against White people is emerging as we become a racial minority, it is important to focus on creating equitable systems that prevent any form of systemic oppression. This demographic shift is part of the natural progression of society in the US and is projected to occur within the next two decades. However, this change will not happen suddenly; we are already in the transitional phase. White nationalist groups have weaponized this notion and propagated The Great Replacement Theory, suggesting that White individuals in the US are experiencing systematic displacement and eradication [ 63 ]. This conspiracy has been cited in the manifestos of mass shootings at the Christchurch Mosque in New Zealand and Walmart in El Paso, Texas, in 2019; the Squirrel Hill synagogue shooting in Pittsburgh, Pennsylvania, in 2018; and the Tops Supermarket shooting in Buffalo, New York, in 2022 [ 64 ].

Even if textbook definitions do not support the existence of reverse racism, many White people believe it exists. Ignoring this belief can have deadly consequences, as evidenced by these violent acts. We must also recognize our unintentional role in fostering dangerous narratives due to a disconnect between our theory and practice concerning White people. For instance, children born between 2008 and 2016, who grew up during Barack Obama's presidency, will experience Donald Trump as their first president who is White. This shift in experience underscores the evolving nature of our language, demographics, societal experiences, and the importance of updating our social definitions accordingly. As social workers, it is imperative that our practices reflect these changes to effectively serve our communities.

4.8 The intervention vs. prevention binary

A second oversight in social work's fight against White supremacy is the false dichotomy between intervention and prevention. Effectively addressing systemic racism in social work requires a nuanced understanding of intervention and prevention strategies. Balancing intervention—challenging oppressive systems [ 65 , 66 ]—with prevention—eliminating conditions that obstruct optimal social functioning [ 67 , 68 , 69 ]—is essential. CRT’s principle of Interest Convergence can guide this balance by identifying common interests supporting immediate interventions and long-term preventive measures. We must see these approaches as complementary, with a focus on preventive measures. Like addressing a flood, we need to aid survivors and construct a dam to stop future occurrences.

However, efforts to shift social work culture toward prevention often go unheeded [ 70 ]. If we understand White supremacy as a problem White people have created, then preventing White supremacy means working with White people. As reported by Guidestar, the database of registered nonprofits in the US, the majority of organizations working within community and economic development, education, human rights, and human services are explicitly working with Black (29%), Latin@ (20.6%), Native (16.1%), Multi-Racial (15.4%), and Asian (11.2%) populations [ 71 ]. While these organizations play a crucial role in supporting marginalized communities, the limited focus of nonprofits working explicitly with White people—only 3.7%—highlights a significant gap. Without addressing the population that perpetuates White supremacy, it can feel unpreventable, leading to misconceptions about its inevitability.

Effectively combating White supremacy in social work requires a balanced approach that integrates both intervention and prevention strategies. Viewing these methods as complementary enables us to address immediate harms while eliminating the conditions that allow systemic racism to persist. While prioritizing preventive measures is essential, we must also recognize the necessity of immediate interventions to challenge oppressive systems and support those affected. Currently, many efforts overlook the principle of Interest Convergence, focusing more on harm reduction than on reducing harm itself. By aligning our strategies, we can more properly attune our praxis.

4.9 Example: “de-centering Whiteness”

The phrase and practice of “de-centering Whiteness” has become common in the US [ 32 , 72 , 73 , 74 , 75 ]. De-centering is generally known as the process of moving away from treating White cultural norms, values, and perspectives as the default or standard in our literature, classrooms, and staff meetings throughout the helping professions. However, based on the misconceptions we hold around race and racism (see Table 1 ) White people might feel hesitant to engage in spaces focused on decentering Whiteness due to fears of being labeled or judged, self-doubt about our understanding of racism, and feelings of exclusion from responsibility. Additionally, we may perceive that our contributions are undervalued or that their unique perspectives and experiences are not considered relevant. “De-centering” then becomes internalized as code for shutting down or tuning out White people. People of color are centered; White people are de-centered: zero-sum. There is no talk of co-centering. Often, it’s these spaces that profess to support CRT who are suddenly fumbling one of its core principles (re: Interest Convergence). Ironically, by getting White people to stop talking about Whiteness the interests of Republicans and conservative movements to stifle race-related conversations are inadvertently supported in liberal spaces [ 76 , 77 , 78 ].

Centering leadership from marginalized groups while holding White individuals accountable for most of the work can be seen as an attempt to manufacture Interest Convergence. This well-intentioned strategy risks reducing White individuals' agency to mere compliance rather than active participation, leading to superficial engagement that lacks genuine understanding and long-term commitment to racial justice. Moreover, this approach can inadvertently reinforce zero-sum thinking by implying that the empowerment of people of color necessitates the disempowerment of White individuals. Instead, a more effective strategy would involve co-creating spaces where White people and people of color can lead and collaborate, recognizing the unique contributions and responsibilities of each group. This balanced approach aligns with the principles of Interest Convergence by ensuring that the interests of all parties are considered and integrated into the collective effort to dismantle systemic racism.

Over the past decade, many North American classrooms, conferences, and social service providers have shifted toward 'De-Centering Whiteness.' While the goal is to de-center Whitenormativity, current literature suggests removing White people from these conversations [ 32 ]. Literature shows that when White people enter race and racism conversations, we often feel poorly informed, miseducated, or uneasy. Our involvement decreases, and we anticipate that Indigenous, Latin@, Black, and Asian people will fill the silence, teach, and lead [ 48 , 72 , 74 ]. This often places an undue burden on people of color to lead and educate. This dynamic creates an escape for White people from engaging meaningfully in intergroup dialogues [ 75 ].

In social work, misinterpreting 'de-centering' Whiteness fosters a belief in zero-sum equity—that making space for marginalized groups means taking space from White individuals [ 56 ]. A recent journal example illustrates this by advocating for inclusivity while suggesting the education system 'de-emphasize' Whiteness, reflecting a counterproductive shift toward zero-sum thinking. What is more: White people do not have to internally stop ourselves from showing up, because other well-intentioned White people are already telling us to sit down and not speak.

The flawed approach that elevating marginalized voices requires silencing White voices reinforces the erroneous belief that White perspectives on racism are fixed, ignoring the fluid nature of racial interactions. This, coupled with increasing societal segregation, raises vital questions about our collective liberation and the importance of mutual accountability among all racial demographics [ 79 , 80 ].

Interest Convergence suggests that efforts to prevent White supremacist structures—like de-centering Whiteness or avoiding race discussions—hinder collective progress. Instead of removing White voices from the conversation, Interest Convergence advocates for a balanced approach where the interests of both White individuals and marginalized groups are aligned. Involving White people in race-based initiatives can bridge understanding and foster collective action toward systemic change. Overlooking the role of White individuals in addressing systemic racism by failing to acknowledge the impact of race only serves to preserve the structures we are seeking to change.

This oversight underscores the need for careful integration of CWS and CRT within social work.

Implementing Interest Convergence in social work invites us to collaboratively confront and address systemic racism. This collaboration is central to both CRT and effective social work practice, challenging us to move beyond binary perspectives of intervention and prevention toward true inclusivity and accountability.

5 Critical Whiteness Studies

Critical Whiteness Studies (CWS) explores Whiteness as a social construct and its implications across cultural, historical, and institutional contexts [ 6 , 81 ]. Scholars from various disciplines contribute to CWS by examining the origins, manifestations, and privileges of White people. It is crucial to examine Whiteness itself, rather than taking it for granted. This involves questioning how Whiteness is constructed, maintained, and contested, and understanding its role in systemic racism. CWS's mission is evident in its engagement with CRT, aiming to prevent oppressive systems and encourage ethical practices that address race and power complexities. By understanding how Whiteness operates within social work and other fields, we can identify and address the unique stresses, such as Perpetration-Induced Traumatic Stress (PITS) and moral injury, thereby facilitating more authentic engagement for our collective liberation.

5.1 Liberalism and CWS

Since 68.8% of social workers in the US are White and operate within Western Liberalism's political and moral framework, this paper uses Critical Race Theory's Critique of Liberalism along with CWS [ 28 ]. The Critique of Liberalism argues that the ideas of individualism, equality, and freedom in classical liberalism can hide systemic racial injustices [ 82 ]. For decades, the anti-racism movement has relied on the narrative that education is the answer to injustice: if we know better, we do better. However, recent data shows that support for Black Lives Matter has declined, and many believe race relations have not improved [ 83 ]. Addressing these issues through CWS is essential for social work. It underscores the need for something deeper with concrete actions to prevent systemic injustices, moving beyond mere education and awareness.

5.2 Mental health needs of White liberals

When White people realize that our beliefs in liberalism clash with systemic racial injustices, we have a spectrum of emotional responses, including cognitive dissonance, guilt, shame, emotional exhaustion, and identity crises. In 2020, at the height of the dual pandemics of COVID-19 and systemic racism, only 11.2% of White people received counseling or therapy at least once from a mental health professional [ 84 ]. This suggests that seeking mental health support was not a widespread response—or financially viable—among White people, even amidst a global health crisis and civil unrest. Stigmas around mental health are still quite high [ 85 ], which may contribute to this low percentage. Therefore, when White people do seek mental health support, it is crucial to use skilled interventions to address these emotional responses and prevent these responses from reinforcing White supremacy.

This paper advocates addressing the mental health needs of White liberals as a strategy to prevent the perpetuation of White supremacy. This argument is supported by the works of Baldwin [ 2 ], Morrison [ 86 ], and Menakem [ 87 ], who highlight racism as a manifestation of White people’s troubled relationship with mental health. Central to this discussion is exploring guilt and shame among White social work students, a common thread in recent studies [ 88 , 89 , 90 ]. By addressing these mental health challenges, we can better equip White people to engage in collective liberation work without being hindered by emotional barriers, ultimately contributing to the prevention of systemic racism.

5.3 Guilt and shame

Guilt and shame, while related, influence self-concept and self-esteem differently. Guilt is transient, triggered by wrongdoing (re: 'I did something bad'), offering a pathway to rectification [ 91 , 92 ]. Shame, however, is more enduring, entailing a deeper internalization of fault (re: 'I am bad'), which can significantly hinder personal and professional growth. As White people become more aware of racial privilege and systemic racism, we often experience these emotions. Understanding these emotions through lived experiences is essential for navigating discussions on race and racism. However, color-blind and post-racial approaches can exacerbate or dismiss these feelings, denying the need for systemic reform. Therefore, developing a positive White racial identity requires acknowledging the emotional landscape of being White [ 93 , 94 , 95 , 96 ], particularly in the dynamics between guilt and shame.

5.4 White guilt

White guilt, emerging from the 1960s liberation movements, has evolved, resulting in diverse viewpoints on preventing racism today [ 50 , 97 ]. White guilt is the remorse some White people feel when we recognize racial injustices and how our race protects us from these injustices. Research around trust and self-worth offers valuable insight into White guilt. While cultivating a robust moral compass is beneficial [ 98 , 99 ]—particularly for middle-class White people—feelings of White guilt can hinder our ability to trust ourselves and have positive self-worth. This highlights the importance of addressing White guilt for societal progress and individual well-being [ 100 , 101 ].

Moreover, this overwhelming sense of guilt can lead White individuals to believe that we are incapable of leading or co-leading anti-racism work. Current social justice narratives suggest that White individuals cannot prevent White supremacy without the leadership of people of color [ 102 , 103 , 104 ]. This perspective emphasizes the importance of centering the experiences and leadership of people of color in anti-racism initiatives. However, it is sometimes misinterpreted as suggesting that only people of color should lead these efforts [ 49 , 105 ] (See Table 1 , misconceptions 8 through 10). Such misinterpretations can lead to the simplistic belief that White people are always guilty of wanting to maintain White supremacy, which makes it hard to believe we can fight against it effectively.

High-profile incidents like the deaths of Trayvon Martin, Michael Brown, and Breonna Taylor have ignited a racial awakening among many White people, with the Black Lives Matter movement keeping this dialogue at the forefront [ 106 , 107 , 108 ]. The enduring presence of the Black Lives Matter movement, highlighting police brutality, has made it difficult for many White people to ignore these issues. From 2016 to 2019, the Pew Research Center observed a 50% increase in White people recognizing racial discrimination [ 109 ]. By the decade’s end, a majority of White Americans (55%) acknowledged that racial discrimination was occurring in the US. The escalation of conversations surrounding race, racism, Whitenormativity, and White supremacy across various platforms, including the Super Bowl Halftime Show [ 110 ], housekeeping magazines aimed at suburban mothers [ 111 ], and children's networks like Nickelodeon, which aired an eight-minute and forty-six-second tribute to George Floyd [ 112 ], has brought racism, from interpersonal to systemic, into the limelight of national discourse.

This widespread exposure to discussions of racism has influenced White American culture and profoundly affected our collective consciousness. Against this backdrop, White Americans' understanding of our role in a racially structured society has begun to unravel. This confrontation with explicit racism and the realization of complicity in systemic injustice has led to what some describe as “moral injury” among White liberals, affecting deeply held moral values and beliefs.

5.5 Moral injury and perpetration-induced traumatic stress

Moral injury, initially associated with traumatic experiences like warfare, has found increasing relevance in racial discourse [ 48 , 113 , 114 ]. It arises when individuals experience, witness, or fail to prevent actions that contradict their moral beliefs and expectations. This contradiction leads to profound psychological distress, characterized by guilt, shame, disgust, anger, struggles with self-forgiveness, and changes in behavior, relationships, and spirituality. It may also include feelings of betrayal by leaders or peers [ 115 , 116 ]. This construct can emerge as White people confront our involvement in a racist system, particularly when viewed through the Critique of Liberalism [ 42 , 45 , 49 ]. Depending on the perceived severity of the racist act, moral injury often manifests as feelings associated with White guilt [ 113 , 114 ]. Prolonged engagement with guilt-like thoughts can exacerbate stress, potentially leading to a state of emotional paralysis; being stuck.

Research on perpetration-induced traumatic stress (PITS), initially applied to combat veterans and executioners [ 117 , 118 ], now extends to White populations grappling with this emotional paralysis or "stuckness" [ 48 , 113 ]. At the heart of PITS is the struggle to transcend the discomfort of moral injury, marked by continuous distressing memories and psychological distress [ 119 ]. This traumatic stress is characterized by persistent avoidance of trauma-associated stimuli and negative changes in cognition and mood. PITS takes the concept of moral injury one step further by internalizing the conflict—transitioning from "I have done something bad" to "I am bad," which reflects the shift from guilt to shame.

Given the recent emergence of PITS, moral injury, White shame, and White guilt in both academic and public discourse [ 48 , 90 , 120 ], it is important to clarify that these terms are often used interchangeably. However, moral injury is more closely related to White guilt, while PITS is more aligned with White shame. Each term represents a deeper psychological impact, compounding the initial trauma with self-condemnation.

5.6 Emotional impact of White shame and guilt on anti-racist efforts

Two recent studies have examined the issue of White shame's impact on our collective liberation from White supremacy, yielding insightful findings. The first study, conducted in 2019 by Grzanka, Frantell, and Fassinger [ 120 ], explore the relationship between emotions and attitudes toward racism among White people. It found that White shame was weakly and negatively correlated with racist attitudes, suggesting that higher levels of such shame do not inherently lead to reduced racist views. In contrast, White guilt was strongly associated with rejecting racist attitudes, indicating that guilt might be a more effective motivator for White individuals to adopt anti-racist perspectives. The study suggests that emotional responses to racism, particularly guilt, can be leveraged in educational and social initiatives to encourage deeper anti-racist commitments. This insight suggests focusing on guilt rather than inducing shame to interrupt and interrogate racist attitudes within White communities.

The second study by Brock-Petroshius, Garcia-Perez, Gross, and Abrams found that shame was significantly linked with fewer anti-racist behaviors than colorblind attitudes [ 90 ]. This finding suggests that White shame acts as a considerable obstacle to engaging in anti-racist actions. Although the research team did not identify a significant relationship between guilt and anti-racist behaviors, they acknowledged the existence of a positive relationship. This underlines the need for interventions to help White MSW students manage feelings of shame or guilt from reduced colorblind attitudes and highlights the importance of reducing White shame and promoting anti-racist actions. Shame can inhibit anti-racist activities despite a deeper understanding of racism and a solid intent to engage in anti-racist actions. Interestingly, more respondents said they felt higher levels of shame compared to empathy or guilt, even though the average score for shame was similar to that of guilt. The self-perception of shame among respondents is notably higher than that of empathy or guilt. This discrepancy highlights the personal impact and potentially more profound experience of shame, suggesting it may significantly influence behaviors or attitudes.

These studies suggest that while White guilt might motivate anti-racist perspectives, without careful management, White guilt could potentially lead to White shame, which does not inherently reduce racist views [ 90 , 120 ]. These findings highlight the need for interventions to guide White individuals through guilt-related experiences and away from the paralyzing effects of shame, enabling meaningful actions towards our collective liberation.

5.7 White Shame Culture

White Shame Culture, a feature of contemporary White liberalism, arises from the acknowledgment of racial privilege and the perpetuation of White supremacy. It is characterized by pervasive feelings of shame related to racial identity, fueled by social justice discourses that often frame racial equity as a zero-sum competition. This culture is marked by a lack of positive White racial identity formation and resistance to transformative practices aimed at achieving collective liberation. White Shame Culture is rampant with untreated moral injury and Perpetration-Induced Traumatic Stress (PITS), often disguised as the "Good White Person" complex [ 44 ], where individuals strive to be seen as morally superior without addressing underlying issues. Understanding White Shame Culture involves examining its systemic manifestations, which extend beyond individual anxieties to influence group norms, values, and traditions. Addressing this culture requires proactive racial justice measures and educational initiatives that transform shame into constructive action, fostering a positive and equitable racial identity.

For example, the term "Karen" exemplifies societal entitlements and racial insensitivity [ 121 ], causing anxiety among White women about public shaming and social ostracization [ 122 , 123 , 124 ]. While some women do exhibit 'Karen' behaviors (re: entitled, often territorial policing, racially insensitive), the misappropriation of the term outside of these behaviors helps to perpetuate White Shame Culture, making it difficult for White women to build a positive identity around their Whiteness. CRT and CWS stress introspection and fostering positive White identities as key steps toward equity [ 27 , 81 , 87 ].

Furthermore, social justice literature advises White individuals to brace for potential isolation from other White people and possible rejection from communities of color, contributing to heightened internalized guilt among White liberals [ 42 , 125 , 126 , 127 ]. Public shaming and social ostracization, intertwined with the fear of isolation, underscore pervasive anxiety among White individuals as we confront our racial identities, transforming personal guilt into communal and internal shame.

To mitigate this shame, some White individuals downplay or conceal our racial identity, adopt cultural markers of other groups, sidestep discussions on White-specific topics, or use pseudonyms and avatars online [ 128 , 129 ]. This effect, distinct from cultural appropriation, often results in White individuals tokenizing academics and artists of color, frequently out of context, as a performative act of anti-racism [ 130 ]. This can also look like White people having a pronounced lack of patience and empathy for other White people or claiming expertise on the experiences of people of color. These behaviors, a form of credentialing to be received as a “Good White Person” [ 131 ], mirror the chameleon effect, critiqued by CRT and CWS as performative, indicating a need for authentic engagement with racial matters beyond superficial actions.

Paradoxically, these external stressors, expectations of rejection, internalized stigma, and identity concealment align with Minority Stress Theory (MST), initially designed to understand stressors faced by marginalized groups [ 132 ]. Increasingly prevalent among White liberals, these characteristics underscore the emergence of MST-like experiences, signaling a need for understanding and supportive mental-health measures for White people struggling with PITS.

Exploring these emotional dynamics and behavioral patterns through CRT and CWS unveils the intricate web of White guilt and shame and emphasizes moving beyond performative gestures toward our collective liberation. This deep-seated anxiety, shared across the political spectrum, highlights the reach of White supremacy and shame—and the need to transform the norms, values, and traditions that maintain it within liberal settings. Addressing the psychological impact of these dynamics is paramount in preventing White supremacy and fostering environments conducive to introspection and meaningful action.

While anti-racism work has traditionally focused on the implications of White supremacy for populations of color [ 133 , 134 , 135 ], it is equally critical to address the escalating racialized anxiety within White populations. As Charles notes, "White America could not perpetrate five hundred years of dehumanizing injustice without traumatizing itself” [ 113 ]. By integrating insights from the Critique of Liberalism, CWS, moral injury, and PITS, we achieve a nuanced understanding of White Shame Culture and its ramifications, advocating for informed dialogues and collective efforts toward racial equity and the work necessary to prevent White supremacy at individual and systemic levels.

6 Applications for social work

The application of CWS and CRT in social work is crucial to effectively address systemic racism. Group work is a pivotal strategy in this endeavor [ 136 ], highlighting the importance of interpersonal relationships and individual commitments in shaping and transforming the systems and institutions we navigate. Reflective and transformative approaches, which involve continuous self-assessment and adaptation in practice, are essential in social work education and practice. These approaches enable the identification and correction of ingrained prejudices, fostering genuine understanding and collective liberation.

White social work practitioners face unique challenges, including negative emotions and mistrust towards our coworkers, which can hinder collaborative efforts. Addressing anti-White bias, alongside other forms of bias, and promoting empathy are vital steps in cultivating an inclusive environment where all individuals can contribute meaningfully to the fight against White supremacy. By integrating these insights and acknowledging the diverse perspectives within the field, social workers can play an instrumental role in leading our collective liberation.

6.1 Group work

A significant tool to prevent White supremacy lies in our ability to work with groups. Intergroup dialogue, as outlined by Bohm [ 137 ], is an exceptionally well-crafted tool to meet this moment. Bohm explains that dialogue involves participants openly sharing their thoughts and experiences, which helps everyone gain a clearer understanding and work together more effectively. Dialogue is not merely a conversation where we wait for our turn to speak; it requires us to actively listen and truly understand the other person's perspective before considering how our own views align or differ. In a dialogue, there is no attempt to win. The zero-sum mindset is avoided. Instead, everybody wins if anybody wins. This collective spirit is vital for genuine collaboration and preventing systemic issues like White supremacy.

Combating White supremacy relies on group work that improves interpersonal relationships and acknowledges individual contributions. As Toseland and Rivas find [ 136 ], group work nurtures the socio-emotional needs of individuals and the group. Since group work is mandated by the Council on Social Work Education [ 138 ], we must hold ourselves accountable for not fully utilizing this powerful tool effectively in the fight against White supremacy. By critically examining and reflecting on our group work practices, we can identify and correct ingrained prejudices, fostering genuine understanding and actions toward our collective liberation.

While some perspectives in social work focus on racism as a macro-level problem inherent in systemic and institutional discrimination, it is crucial to consider the influence of individual and collective values and morals in shaping these systems and institutions. We must stop thinking of systems and institutions as amorphous, wandering behemoths. Policies and laws are simply the morals and values of a group of people.

Interpersonal relationships and individual commitments are crucial for group work in preventing White supremacy. However, some White social work practitioners may harbor negative emotions toward our White counterparts, including frustration and mistrust, as observed in certain contexts. These feelings are often borne out in classrooms [ 139 ], professional forums [ 140 ], and social media comment sections of many social work organizations. Many social workers recognize that historical contributions by White individuals have played a significant role in shaping contemporary societal issues. Contributions to oppressive ideologies in the sixteenth and seventeenth centuries can still shape contemporary dynamics, fueling mistrust toward White colleagues, especially White, straight, cisgender men [ 121 , 141 , 142 ].

6.2 Addressing anti-White bias

Despite social work’s efforts to address racism and White supremacy over the past fifty years [ 143 , 144 , 145 ], some White people feel devalued and discriminated against in social work curricula [ 88 , 146 ]. As of 2017, White students are now underrepresented in higher education, with significant decreases in Ivy League schools, the University of California system, and a 31.49% decrease of enrollment at major institutions since 1980 [ 147 ]. Within classrooms, many White students argue that coursework overlooks anti-White bias and induces guilt or discomfort about our racial identity [ 88 ]. Cases like the Ontario school principal who took his own life after being accused of White supremacist behavior during a training session—led by a social worker—for public educators highlight the emotional toll such discussions can take, notably when adequate support is lacking [ 148 , 149 ]. These practices highlight how disconnected social work has become from our best practices for social change and adherence to the NASW Code of Ethics in our anti-racism work [ 150 ].

Many articles, publications, and media on White supremacy for White audiences emphasize White privilege. While this is an important aspect, it creates a single-story narrative of Whiteness. Very little is said about the ways White people are negatively impacted—directly and indirectly—by White supremacy. However, the work of scholars like Todd Jealous and Haskell [ 47 ], Brock-Petroshius [ 90 ], Grzanka [ 120 ], Lensmire [ 52 ], Spanierman [ 151 ], Burnett [ 50 ], Charles [ 113 ], and Grishow-Schade [ 114 ], and the insights from the Spillway [ 48 ], highlight the importance of our collective role in understanding this issue. These authors reveal the paradox of being White in contemporary U.S. culture, where we are both perpetrators and victims of White supremacy. This perspective calls for active involvement, stressing the need to complicate the narrative that White people only have positive and privileged racialized experiences.

Even though research shows the inefficacy of inducing guilt, shame, and discomfort about racial identity [ 90 , 120 ], social workers have continued to use these approaches. However, in a profession built on values of service, social justice, dignity, and integrity [ 143 ], we must question whether these methods truly benefit White racial identity development and strengthen the relationships needed for group work. Sustainable growth is challenging amidst emotional dysregulation [ 152 ], as it can hinder our ability to adhere to our Code of Ethics. Therefore, fostering emotional attunement and empathy is essential for constructive dialogue and ethical practice. Change needs empathy.

Feelings of hostility or mistrust toward White people from various racialized communities can be understood from a psychological, emotional, and somatic perspective [ 153 , 154 ]. These communities have borne the brunt of racism, impacting their relationship to White culture and White people. However, similar emotional responses among White social workers toward other White people need a different analytical lens. By adopting the CWS framework, we can gain a deeper understanding of the complexities surrounding the presumption of guilt among White social workers by White social workers. It also provides tools to navigate and mitigate these feelings, enhancing the effectiveness of social work across diverse racial and ethnic contexts and preventing White supremacy. This dynamic of White people harboring negative feelings toward other White people can also be seen as profitable within the context of the Nonprofit Industrial Complex (NPIC), which underscores the financial motivations behind these emotional responses.

6.3 The Nonprofit Industrial Complex

Financial sustainability in social service nonprofits often depends on external funding rather than clients paying for services. The NPIC highlights the dynamics among nonprofit organizations, government agencies, and private funders, showing how reliance on external funding can divert social movements from their core objectives and create caution in confronting harmful practices by funders due to fear of losing financial support [ 155 ].

The NPIC tends to fund intervention services over preventative measures, showing a bias for immediate solutions over addressing root causes. This bias is evident in child welfare, where only 11 percent of funds are directed toward preventative efforts, underscoring the constraints of the current funding landscape [ 156 ].

Smith critiques the 501(c)(3) model [ 157 ], which many social justice organizations adopt to secure tax-deductible donations and foundation grants. This model can co-opt movements, forcing them to conform to the priorities of funders rather than their communities. The NPIC promotes a social movement culture that is non-collaborative, narrowly focused, and competitive—re: zero-sum, Liberalism—often stifling genuine activism and innovation.

The NPIC's competitive nature forces groups to vie for limited resources, often promoting their work at the expense of broader coalition-building. This competition can dilute the focus on systemic change and maintain the status quo. This liberal approach often prioritizes incremental change and personal achievements rather than addressing systemic inequalities through group efforts. By focusing on individual success, the NPIC undermines the power of collective action and solidarity, which are essential for achieving true social justice. Foundations, while providing temporary relief, can mask underlying issues like White supremacy, as they often prefer funding projects that do not challenge systemic inequalities.

Spade advocates for a paradigm shift in the NPIC toward prevention-focused strategies that address the root causes of marginalization and oppression [ 158 ]. Drawing inspiration from public health successes like anti-smoking campaigns, Spade emphasizes that balancing immediate interventions with long-term preventative measures is crucial. Combining insights from INCITE! Women of Color Against Violence—who wrote the seminal guide to the NPIC [ 155 ]—with Spade there exists a profound transformation required in funding strategies centered on racial equity. This reform aims to support individual and group efforts necessary for systemic change, ensuring a fairer distribution of financial resources and promoting sustainable change [ 155 , 156 , 159 ].

Recent research from the Philanthropic Initiative for Racial Equity reveals that nonprofits received $4.47 billion in race-related funding in 2020 alone [ 160 ]. Further analysis shows that foundations, funds, and trusts provided $111.58 billion for race-focused initiatives in education, health, human rights, and social rights from 2003 to 2021. Of this, only 0.49% ($557 million) was allocated for initiatives serving "people of European descent." Through the lens of CRT and CWS, this is less than half a cent of every dollar spent on race-related funding for preventative actions.

Thus, how we think about our work—considering power dynamics, Liberalism, zero-sum thinking, and the balance between prevention and intervention—greatly influences our funding strategies. To address these challenges, it is crucial to explore alternative resources and strategies that prioritize prevention over short-term interventions. Informed by CRT and CWS praxis, this shift toward preventative paradigms is vital for our funding streams. By focusing on preventive measures, we can better address the root causes of social issues, ensuring our efforts lead to sustainable change. This strategy aligns with our mission to promote social justice, challenges the systemic constraints of the NPIC, and advocates for a more equitable distribution of financial resources, ultimately reimagining how social work can meet the needs of all communities.

7 Preventing systemic racism

Integrating CWS and CRT within social work is fundamental to effectively addressing systemic racism. Group work is a pivotal strategy, emphasizing the importance of interpersonal relationships and individual commitments in transforming our systems and institutions. Reflective and transformative approaches enable the identification and correction of ingrained prejudices, fostering genuine understanding and collective liberation. Intergroup dialogue and critical examination of group work practices can enhance collaboration and mitigate systemic issues like White supremacy.

Secondly, White social work practitioners face unique challenges, including anti-White bias, negative emotions, and White Shame Culture that can hinder collaboration. Addressing these biases and promoting empathy, an essential quality in our work, are vital for creating an inclusive environment.

Lastly, the Nonprofit Industrial Complex (NPIC) presents additional challenges, often prioritizing intervention over prevention. However, a shift towards prevention-focused strategies that address root causes, informed by CRT and CWS, is beneficial and urgent for sustainable change and social justice.

Maintaining momentum in these efforts can be challenging. As Mondros and Wilson observed [ 161 ], participation often declines after initial enthusiasm peaks. To counter this, it is crucial to focus on factors that encourage long-term engagement, such as emphasizing the group's impact, building a supportive community, maintaining a strong interest in tasks, and recognizing every member's contribution.

By focusing on these aspects, especially within the context of White social workers, we enhance individual accountability and strengthen interpersonal relationships. This approach fosters a resilient and committed community ready to tackle and prevent systemic racism through evidence-based practices in group work, aiming to root out deep-seated prejudices that fuel racial inequities.

Ultimately, embracing reflective, group-based efforts and shifting towards collective, community-focused liberation will pave the way for a social justice environment where ideals are actively pursued and realized. Social workers must adopt these principles to foster a more equitable and just profession, ensuring that our efforts lead to meaningful and sustainable change.

7.1 How we start

The transformation toward preventative work in social services requires social workers across nonprofit organizations, academic institutions, and funding bodies to address pivotal areas. This task necessitates a profound understanding of the intersection of racism and mental health, specifically among White individuals.

First and foremost, it is essential to recognize the diversity within White populations. Being White does not equate to uniform experiences or perspectives. Social workers must comprehend the unique racial experiences and perceptions of White individuals, debunking common misconceptions about homogeneity within this group. By acknowledging this diversity, we can tailor our approaches to be more effective and sensitive to individual experiences.

Facilitating intergroup dialogue is another critical aspect. Dialogues about systemic racism often stir feelings of guilt and shame. Social workers can provide spaces for constructive intergroup dialogue, mitigating feelings of isolation and potential radicalization. These dialogues can help bridge gaps in understanding and foster a sense of community and shared responsibility in addressing racism.

Implementing trauma-informed approaches is integral to promoting understanding and preventing racism. Social workers need to acknowledge the unique stresses that White individuals might experience like PITS, moral injury, and MST. Trauma-informed approaches can support these individuals in their journey toward healing, helping us understand and combat the roots of racism within ourselves and our communities.

Debunking misconceptions about race, racism, and White supremacy is a critical role for social workers (See Table 1 ). Challenging harmful stereotypes and assumptions fosters a nuanced understanding of these complex issues. By promoting accurate and comprehensive views of these topics, we can dismantle the biases that perpetuate systemic racism.

Promoting and building leadership among White individuals in collective liberation work shifts the responsibility of preventing White supremacy away from marginalized populations who are most impacted by it. Encouraging White people to take initiative allows for respect for each group's unique healing and restoration paths from a place of lived experience. This shift is essential for fostering a collective commitment to social justice.

Advocating for transparency through open and honest discussions about racialized harm and trauma is necessary for healing. Social workers should offer resources to help White individuals understand our role in systemic racism and White Shame Culture. These discussions can pave the way for greater awareness and responsibility in addressing racial harm.

Practicing empathy is crucial in these efforts. Understanding that everyone is at different stages in comprehending race and racism can facilitate more productive interventions. Some White individuals are firmly rooted in White Shame Culture, some traverse between Shame and Supremacy Cultures depending on their context, and others actively seek a return to explicit forms of White supremacy. By meeting individuals where they are, social workers can guide ourselves and other White people more effectively toward greater awareness and action.

Group work plays a significant role in addressing contemporary systemic and institutional racism. Often, the failure to tackle the policies, practices, and values of groups and organizations perpetuates these issues. The key to systems change is merely group work. Even the largest companies in the world do not have more than 12 people on their board of directors. Collaborative efforts are essential for driving significant change.

Lastly, reforming funding strategies to prioritize preventive measures over short-term interventions is critical. By addressing the root causes of societal issues and promoting sustainable, equitable social change within the NPIC framework, we can create long-lasting impacts. Investing in prevention work is essential for fostering a more just and equitable society.

7.2 Action steps

Provide immediate resources and build emotional resilience : offer accessible resources that support immediate needs, such as crisis hotlines, counseling services, and support groups. Build emotional resilience by creating spaces for emotional expression and open discussions without fear of judgment, such as community workshops and peer support circles.

Promote anti-racist actions : engage in meaningful conversations about race and racism, especially with those who may not share your views. If everyone in the room has the same definition of justice, it’s not a diverse space [ 162 ]. Approach these conversations with compassion, patience, empathy, and understanding. For example, organize intergroup dialogues that foster new relationships.

Create healing affinity spaces : develop and maintain healing spaces that allow for personal growth and deeper understanding within affinity groups. Examples include dedicated rooms in community centers for reflective practices, online support groups, and retreats focused on racial healing and identity exploration.

Encourage reflective practices : promote introspective activities such as reflective journaling, meditation, or self-assessment exercises. These practices help individuals organize and deeply understand our thoughts and experiences, fostering personal growth. Provide resources like guided journals, online meditation sessions, and self-assessment tools while being mindful to reflect on more than only our privileges.

Leverage technology for engagement : utilize online platforms and social media to facilitate the exploration of racial identity and intergroup dynamics. Choose the medium that best supports individual learning and engagement styles. Examples include virtual discussion groups, webinars, and interactive educational platforms.

Shift accountability to include all parties : ensure accountability mechanisms consider the needs of those harmed, those who caused harm, and their communities. Accountability should validate humanity while enabling behavior correction. Implement restorative justice practices that involve all parties in the accountability process.

Build community support : foster community building through local meetups, online forums, or social media groups. These communities offer support and foster meaningful relationships grounded in compassion and empathy. Examples include organizing neighborhood potlucks, creating online discussion groups, and hosting community-building events. Consider a support group for people in White Shame Culture.

Understand the difference between shame and guilt : educate individuals on the difference between shame ("I am bad") and guilt ("I did something bad"). Effective accountability should avoid reinforcing White Shame Culture. Provide educational workshops and resources that focus on understanding and applying this distinction.

Proactive and reactive approaches : implement both proactive and reactive strategies to heal and prevent harm. This dual approach is essential for sustainable personal and societal change. Examples include preemptive educational campaigns and responsive support services for those affected by racial harm.

8 Conclusion

To address systemic racism and White supremacy, integrating Critical Race Theory (CRT) and Critical Whiteness Studies (CWS) into social work is essential. By examining principles like Interest Convergence and Critique of Liberalism, we can better understand power dynamics and move beyond zero-sum thinking in our approach to racial equity. This paper highlights the importance of supporting White individuals in understanding race by addressing Perpetration-Induced Traumatic Stress (PITS), moral injury, and White Shame Culture.

Self-reflection is crucial for White people in addressing racism. Morrison [ 86 ] and Baldwin [ 2 ] argue against the idea that people of color should be solely responsible for correcting or leading efforts to undo racial injustices. Menakem, a social worker, extends this argument by insisting that White people must reclaim and redefine Whiteness to embody responsibility and care [ 87 ]. He suggests building communities and supporting White leaders in anti-racism work rather than relying on Black individuals. Fred Jealous further extends this argument, challenging White people embedded in White Shame Culture with a poignant question: "Can you access the truth of your preciousness? And that's the starting place for the discussion. Can you access that? And if you can access that, can you stay there? Use it as a starting place from which to connect to all of life and from which to take a look at where you put your attention with other humans" [ 163 ].

White individuals must take a lead in preventing White supremacy. As demonstrated, these arguments are supported by the concept of Interest Convergence [ 29 , 164 ]. Various racial groups have developed strategies over centuries that meet the emotional, mental, and physical needs of White people, advocating for spaces where White individuals can heal independently—and communally—without interference [ 87 , 165 ]. This paper calls for White individuals to actively engage in collective liberation efforts, emphasizing the importance of internal community engagement before extending these efforts to broader societal interactions.

Integrating CWS offers a novel, preventative strategy to address modern White supremacy. It aims to explore the motivations behind White supremacy without justifications, tone policing, or diminishing the impact on colleagues of color. The ethos of this paper come from Audre Lorde's insight that new tools—compassion, patience, and respect—are essential in dismantling the house of White supremacy [ 166 ].

Social workers play a crucial role in applying an interpersonal approach to systemic racism. Understanding that systems and institutions are groups of individuals, this paper highlights the role of social workers in reflective practice, advocacy for systemic change, and fostering trauma-informed intergroup dialogues. Through these methods, social workers can make significant strides in preventing systemic racism.

This paper envisions a future where social work actively leads efforts toward an equitable and inclusive society. This vision is based on collective efforts, grounded in compassion, understanding, and a commitment to justice. Recognizing that liberation from oppressive systems is best achieved through collaborative efforts, social work must move beyond merely confronting White supremacy. Let’s prevent it.

8.1 Concluding positionality

A key challenge is motivating White social workers to address our racialized mental health needs. Over the years, I have focused on understanding White individuals through a trauma-informed lens. The most formidable challenge has been inspiring White social workers to consistently acknowledge and address our mental health needs related to race. I have experienced firsthand the reluctance of White colleagues—from standing faculty in schools of social work to direct service providers—to confront their racialized fears and insecurities, reflecting the pervasiveness of White Shame Culture in the helping professions. This culture leaves a significant imprint on contemporary social work practice. Confronting and addressing White Shame Culture is crucial for advancing social work toward its true potential. I acknowledge the emotional impact this discussion may have had on you, dear reader. I see you, precious friend. Me, too.

Data availability

This perspective piece primarily discusses and reviews existing literature, puts forward controversial positions or speculative hypotheses, or highlights work from one or a few research groups. Therefore, it does not involve the collection or analysis of original data, which is why this type of article does not include a data set.

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Acknowledgements

My deepest gratitude to Ben Jealous, Ariel Schwartz, Amy Hillier, Jessie Harper, Erin Cross, Jerry Bourjolly, Danna Bodenheimer, Jenny Skinner, Fred Jealous, and Lynn Burnett for their invaluable contributions in reviewing and cultivating the initial ideas of this paper. I am deeply grateful for those who, even in their pain, could only support my work privately. Their struggle with White shame taught me that it can be stronger than love, and that lesson has been profound. For Meade, Elizabeth, and Matthew.

This work was self-funded with no external support.

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Grishow-Schade, L. Preventing White supremacy: an applied conceptualization for the helping professions. Discov glob soc 2 , 52 (2024). https://doi.org/10.1007/s44282-024-00084-2

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v.7(4); Fall 2003

An Overview of Empathy

Empathy is a powerful communication skill that is often misunderstood and underused. Initially, empathy was referred to as “bedside manner”; now, however, authors and educators consider empathetic communication a teachable, learnable skill that has tangible benefits for both clinician and patient: Effective empathetic communication enhances the therapeutic effectiveness of the clinician-patient relationship. Appropriate use of empathy as a communication tool facilitates the clinical interview, increases the efficiency of gathering information, and honors the patient.

Introduction

That the medical care experience is enhanced by effective communication between clinicians and their patients is a well established fact. Byproducts of this enhanced communication include improved health outcomes, 1 better patient compliance, 2 reduction in medical-legal risk, 3 – 5 and improved satisfaction of clinicians and patients. 6 , 7 Of all the elements involved in effective communication, empathy seems to be the component that is most powerful yet is easily overlooked—and some commentators have asserted that in medical practice the importance of empathy cannot be overemphasized. 8

What is Empathy?

The origin of the word empathy dates back to the 1880s, when German psychologist Theodore Lipps coined the term “einfuhlung” (literally, “in-feeling”) to describe the emotional appreciation of another’s feelings. Empathy has further been described as the process of understanding a person’s subjective experience by vicariously sharing that experience while maintaining an observant stance. 9 Empathy is a balanced curiosity leading to a deeper understanding of another human being; stated another way, empathy is the capacity to understand another person’s experience from within that person’s frame of reference. 10

Even more simply stated, empathy is the ability to “put oneself in another’s shoes.” In an essay entitled “Some Thoughts on Empathy,” Columbia University psychiatrist Alberta Szalita stated, “I view empathy as one of the important mechanisms through which we bridge the gap between experience and thought.” A few sentences earlier in her essay, she had emphasized that … “[empathy is] consideration of another person’s feelings and readiness to respond to his [or her] needs … without making his [or her] burden one’s own.” 11:p151

Can Empathy Be Taught?

Unfortunately, many physicians were trained in the world of “Find it and Fix it” medicine, a world where empathetic communication was only an afterthought—if this behavior was considered at all. Empathy was known as “bedside manner,” a quality considered innate and impossible to acquire—either you were born with it or you weren’t. More recently, greater emphasis has been placed on empathy as a communication tool of substantial importance in the medical interview, and many experts now agree that empathy and empathetic communication are teachable, learnable skills. 12 , 13 As we might therefore expect, empathy is the cornerstone of several communication models, including “The Four Habits” model (Invest in the Beginning, Elicit the Patient’s Perspective, Demonstrate Empathy, Invest in the End) developed by The Permanente Medical Group’s Terry Stein with Richard Frankel; 14 “The 4 E’s” (Engage, Empathize, Educate, and Enlist) model used by the Bayer Institute for Health Care Communication; 15 the “PEARLS” (Partnership, Empathy, Apology, Respect, Legitimization, Support) framework adopted by the American Academy on Physician and Patient; 16 and other models. 17 , 18

Many medical schools have developed curricula with a strong focus on physician-patient communication and empathy. Delivery of these curricula begins early in the students’ training. At the University of Colorado Health Sciences Center, this curriculum is known as the “Foundations of Doctoring” program, a curriculum whose teaching staff includes several physicians and trainers from the Colorado Permanente Medical Group (CPMG). CPMG has also developed an eight-hour clinician-patient communication course based on The Four Habits model which is offered to all newly hired physicians in the Kaiser Permanente (KP) Colorado Region. In this course, plenty of time is set aside to explore empathy and to practice empathetic communication with patients selected according to standard criteria.

Practical Empathetic Communication

Making practical use of an otherwise esoteric concept such as empathy requires division of the concept into its simplest elements. As outlined by Frederic Platt, 19 key steps to effective empathy include:

recognizing presence of strong feeling in the clinical setting (ie, fear, anger, grief, disappointment);
pausing to imagine how the patient might be feeling;
stating our perception of the patient’s feeling (ie, “I can imagine that must be …” or “It sounds like you’re upset about …”);
legitimizing that feeling;
respecting the patient’s effort to cope with the predicament; and
offering support and partnership (ie, “I’m committed to work with you to …” or “Let’s see what we can do together to …”).

Being a psychiatrist or mental health expert is not necessary for using empathetic communication; the only requirement is an awareness of opportunities for empathy as they arise during the interview with a patient. This type of opportunity arises from a patient’s emotion (either directly expressed or implied): This emotion creates the opportunity for an empathetic response by the physician. In a study by Wendy Levinson et al, 20 116 office visits to primary care and surgical physicians were audiotaped and transcribed to look at the frequency of empathy opportunities or “clues.” More than half of visits in each setting included one or more clues. In more than half of cases, patients presented these clues not overtly but in more subtle ways. Unfortunately, physicians responded to those clues in only 38% of surgical cases and in only 21% of primary care cases and frequently missed opportunities to adequately acknowledge a patient’s feelings. 20 Clues are often hidden in the fabric of discussion about medical problems and thus may be easily missed by physicians who are busy attending to biomedical details of diagnosis and management. In fact, when opportunities for empathy are missed by physicians, patients tend to offer them again, sometimes repeatedly. This phenomenon can lead to longer, more frustrating interviews, return visits, and “doctor shopping” by patients who feel dismissed or alienated.

After an opportunity for empathy has been presented, the clinician should consider offering a gesture or statement of empathy. Statements that facilitate empathy have been categorized as queries, clarifications, and responses. 21 Examples of each are as follows:

“Can you tell me more about that?”
“What has this been like for you?”
“How has all of this made you feel?”
“Let me see if I’ve gotten this right … ”
“Tell me more about … ”
“I want to make sure I understand what you’ve said … ”
“Sounds like you are … ”
“I imagine that must be … ”
“I can understand that must make you feel … ”

Ideally, after perceiving the clinician’s statement of empathy, the patient expresses agreement or confirmation (“You got it, Doc!” or “Yeah, that’s exactly how I feel”). When we have not understood the patient’s experience exactly, we must allow the patient to correct our perception. Use of the Hypothesis-Test-Feedback Loop allows the patient to clarify his or her experience and thus allow the physician to restate an empathetic statement that originally missed its mark. The following exchange is an example of this Hypothesis-Test-Feedback Loop used in the doctor-patient encounter:

Patient: I am sick and tired of living with these headaches. No one has been able to help me, and none of the medications are working. Doctor (stating the hypothesis): I can see that you are frustrated by the lack of improvement in your symptoms. Patient (giving feedback): Yeah, but I’m really more worried that we’re missing something serious. I’ve got a wife and kids who are depending on me. Doctor (correcting the hypothesis): So, it sounds like you’re really more concerned that something serious could be going on that is causing these headaches. Patient (closing the empathy loop): Yes, exactly.

In this example, the physician makes an empathetic statement (hypothesis) about what he or she surmises is the chief aspect of the patient’s experience: frustration about an unrelenting headache. When the hypothesis is tested, the patient clarifies that although frustrated, he is mainly experiencing worry about the situation. Armed with this feedback, the physician restates the hypothesis back to the patient, who lets the physician know that he or she “got it exactly right.”

Barriers to Giving Empathy

Because empathy is such a powerful communication skill, we might suppose that clinicians would scramble to learn about and use it at every available opportunity. However, this is not necessarily the case. Clinicians have many reasons for not offering empathy to patients. An informal survey of practicing clinicians participating in a recent clinician-patient communication course revealed misgivings (and misconceptions) about empathetic communication. Concerns mentioned included:

“There is not enough time during the visit to give empathy.”
“It is not relevant, and I’m too busy focusing on the acute medical problem.”
“Giving empathy is emotionally exhausting for me.”
“I don’t want to open that Pandora’s box.”
“I haven’t had enough training in empathetic communication.”
“I’m concerned that if I use up all my empathy at work I won’t have anything left for my family.”

In our experience, empathy facilitates the clinical interview, increases efficiency of gathering information, and honors the patient. Empathy need not be awkward nor emotionally exhausting; unlike sympathy, empathy does not require emotional effort on the part of the clinician. An appropriate statement or gesture of empathy takes only a moment and can go a long way to enhance rapport, build positive relationships, and even improve difficult ones. Studies have shown that when opportunities for empathy were repeatedly missed, visits tended to be longer and more frustrating for both physician and patient. 18 , 20 Conversely, empathy may save time and expense and often is a cost-effective method of facilitating early diagnosis and proper treatment. 10

Empathy Versus Sympathy (and Versus Pity)

Despite some divergent opinion on the matter, we may propose a subtle but important distinction between empathy and sympathy.

Whereas empathy is used by skilled clinicians to enhance communication and delivery of care, sympathy can be burdensome and emotionally exhausting and can lead to burnout. Sympathy implies feeling shared with the sufferer as if the pain belonged to both persons: We sympathize with other human beings when we share and suffer with them. It would stand to reason, therefore, that completely shared suffering can never exist between physician and patient; otherwise, the physician would share the patient’s plight and would therefore be unable to help.

Empathy is concerned with a much higher order of human relationship and understanding: engaged detachment. In empathy, we “borrow” another’s feelings to observe, feel, and understand them— but not to take them onto ourselves. By being a participant-observer, we come to understand how the other person feels. An empathetic observer enters into the equation and then is removed.

Harry Wilmer 22 summarizes these three emotions—Empathy, Sympathy, and Pity—as follows:

Pity describes a relationship which separates physician and patient. Pity is often condescending and may entail feelings of contempt and rejection.
Sympathy is when the physician experiences feelings as if he or she were the sufferer. Sympathy is thus shared suffering.
Empathy is the feeling relationship in which the physician understands the patient’s plight as if the physician were the patient. The physician identifies with the patient and at the same time maintains a distance. Empathetic communication enhances the therapeutic effectiveness of the clinician-patient relationship.

Empathy is a powerful, efficient communication tool when used appropriately during a medical interview. Empathy extends understanding of the patient beyond the history and symptoms to include values, ideas, and feelings. Benefits of improved empathetic communication are tangible for both physician and patient.

Acknowledgments

Ilene Kasper, MS, and Andrew M Lum, MD of Kaiser Permanente Colorado; and Brian Dwinnell, MD, and Frederic W Platt, MD, FACP, of the University of Colorado Health Sciences Center, reviewed the article.

James T Hardee, MD , Obtained his medical degree from the University of New Mexico School of Medicine, where he also completed his Internal Medicine residency. He joined the Colorado Permanente Medical Group in 1998 and is currently on the CPMG Board of Directors. He is the physician lead for Clinician-Patient Communication in the Colorado Region. E-mail: [email protected] .

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Two Things Stand

Life is mostly froth and bubble, Two things stand like stone, Kindness in another’s trouble, Courage in your own. Adam Lindsay Gordon, 1833–1870, poet

COMMENTS

The Science of Empathy
In the past, empathy was considered an inborn trait that could not be taught, but research has shown that this vital human competency is mutable and can be taught to health-care providers. The evidence for patient-rated empathy improvement in physicians has been demonstrated in pilot and retention studies (3,4) and a randomized controlled trial .
Cultivating empathy
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EMPATHY AND INTERPERSONAL BEHAVIOUR. The social functions of empathy may be an even more important factor than affect. To the extent interpersonal behaviour is goal-directed (Horowitz et al., 2006), research showing associations between empathy and interpersonal behaviour reveals an individual's motives within an interaction.Consistent pairing of empathy and motives, in turn, is suggestive ...
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Evidence to date indicates that compassion and empathy are health-enhancing qualities. Research points to interventions and practices involving compassion and empathy being beneficial, as well as being salient outcomes of contemplative practices such as mindfulness. Advancing the science of compassion and empathy requires that we select measures best suited to evaluating effectiveness of ...
The Neurodevelopment of Empathy in Humans
Given the complexity of what encompasses the phenomenological experience of empathy, investigation of its neurobiological underpinnings would be worthless without breaking down this construct into component processes (fig. (fig.1). 1).In spite of reports in the popular press that give the appealing, yet wrong, notion that the organization of psychological phenomena maps in a 1:1 fashion into ...
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Using a scoping review technique, we provide a comprehensive overview of empathy definitions by highlighting the multidimensional nature of empathy. Drawing from multiple lines of research on empathy, we underscore the role of culture in researching empathy and highlight the strengths and weaknesses of existing research on empathy and culture. In general, this review article supports the ...
Understanding Empathy: Current State and Future Research Challenges
Future empathy research by socially and scholastically responsible scientists must overcome a long history of Euro-ethnocentric biases and integrate social justice into the understanding of this important construct. The scholarship and application of empathy will continue to be an important source of positivity for humans and for society as a ...
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Abstract. Empathy is one of the most consistent outcome predictors in contemporary psychotherapy research. The function of empathy is particularly important for the development of a positive therapeutic relationship: patients report positive therapeutic experiences when they feel understood, safe, and able to disclose personal information to ...
A systematic review of research on empathy in health care
Grants and funding. U18 HS016978/HS/AHRQ HHS/United States. Empirical research provides evidence of the importance of empathy to health care outcomes and identifies multiple changeable predictors of empathy. Training can improve individuals' empathy; organizational-level interventions for systematic improvement are lacking.
'I Feel Your Pain': The Neuroscience of Empathy
Claus Lamm, University of Vienna, investigates the processes that regulate firsthand pain and those that cause empathy for pain through numerous studies on the influence of painkillers. In these experiments, participants who took a placebo "painkiller" reported lower pain ratings after receiving a shock than did those in the control group.
A systematic review of research on empathy in health care
Principal Findings. Of the 2270 articles screened, 455 reporting on 470 analyses satisfied the inclusion criteria. We found that most studies have been survey‐based, cross‐sectional examinations; greater empathy is associated with better clinical outcomes and patient care experiences; and empathy predictors are many and fall into five categories (provider demographics, provider ...
The Psychology of Emotional and Cognitive Empathy
Empathy is a broad concept that refers to the cognitive and emotional reactions of an individual to the observed experiences of another. Having empathy increases the likelihood of helping others and showing compassion. "Empathy is a building block of morality—for people to follow the Golden Rule, it helps if they can put themselves in ...
Medical training: emotions, empathy, and belonging
In the work of the Lancet Commission on the emotional determinants of health, 2 we consider the trajectory of medical school education from a "hidden curriculum" 3 that has historically cultivated detached concern, to an era where empathy is encouraged, 4 yet senior physicians in clinical encounters might model emotional detachment, or worse, harsh or humiliating treatment. 5 Especially in ...
Declining empathy trends throughout medical curriculum and association
A physician's empathy level substantially impacts clinical competence, patient relationships, and treatment outcomes. Yet, understanding empathy trends from medical students to resident doctors within a single institution is limited. This study delves into empathy trends within a single-center academic setting and identifies factors associated with low empathy.
The Role of Empathy in Health and Social Care Professionals
The current article is an integrative and analytical literature review on the concept and meaning of empathy in health and social care professionals. Empathy, i.e., the ability to understand the personal experience of the patient without bonding with them, constitutes an important communication skill for a health professional, one that includes ...
The Role of Empathy and Compassion in Conflict Resolution
Empathy and empathy-related processes, such as compassion and personal distress, are recognized to play a key role in social relations. ... Research article. First published online July 2, 2019. The Role of Empathy and Compassion in Conflict Resolution. Olga M. Klimecki [email protected] View all authors and affiliations. Volume 11, Issue 4 ...
A 25-Year Study Reveals How Empathy is Passed from Generation to
Our new research shows that parents who express empathy toward their teenagers may give teens a head start in developing the skill themselves. In addition, adolescents who show empathy and support toward their friends are more likely to become supportive parents, which may foster empathy in their own offspring.
Meditation and Mindfulness: Effectiveness and Safety
In a 2012 U.S. survey, 1.9 percent of 34,525 adults reported that they had practiced mindfulness meditation in the past 12 months. Among those responders who practiced mindfulness meditation exclusively, 73 percent reported that they meditated for their general wellness and to prevent diseases, and most of them (approximately 92 percent) reported that they meditated to relax or reduce stress.
Full article: Replicability and reproducibility of data-intensive
1. Introduction. Design research suffers from a lack of replicability and reproducibility compared to several other fields. This is partly due to the highly contextual nature of design but also due to the lack of standard practices, replication, and open-access data (Cash Citation 2018).Replication, traceability, or reproducibility are necessary for building knowledge and theory; they help ...
Effectiveness of empathy in general practice: a systematic review
In general, authors consider empathy as the competence of a physician to understand the patient's situation, perspective, and feelings; to communicate that understanding and check its accuracy; and to act on that understanding in a helpful therapeutic way. It has an affective, a cognitive, and a behavioural dimension. 1, 21 - 24.
The Influence of Emotion and Empathy on Decisions to Help Others
For instance, research has found that affective and cognitive empathy can predict self-reported prosocial tendencies (Lockwood et al., 2014). In addition, evidence from laboratory studies have also shown that empathy motivates prosocial helping decision and behavior.
Preventing White supremacy: an applied conceptualization for the
This perspective paper synthesizes insights from social work research, Critical Race Theory (CRT), and Critical Whiteness Studies (CWS) to develop a strategy for preventing White supremacy and promoting racial justice. It examines the intricate feelings of White guilt and shame, advocating for introspection, comprehension, and active engagement by White individuals toward systemic reform. The ...
An Overview of Empathy
Empathy is a powerful, efficient communication tool when used appropriately during a medical interview. Empathy extends understanding of the patient beyond the history and symptoms to include values, ideas, and feelings. Benefits of improved empathetic communication are tangible for both physician and patient. 1.

Cultivating empathy

The right kind of empathy

Be willing to grow

Expose yourself to differences

Read fiction

Harness the power of oxytocin

Identify common ground

Ask questions

Understand your blocks

Second-guess yourself

Further reading

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Measures of empathy and compassion: A scoping review

Introduction

Conceptualizing compassion and empathy

Eligibility criteria

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Full text screening

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Measure development and validation studies

Measures of empathy and compassion

Interactive data visualization

Self-report measures

Peer/corollary and behavioral/expert coder measures

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Selecting measures

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Supporting information

S2 Table. Measures with 8+ psychometric assessments.

S3 Table. Measures of compassion and empathy.

Acknowledgments

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